Increasing fruit and vegetable consumption among British primary schoolchildren: a review

Interventions for increasing fruit and vegetable consumption in children aged five years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future non-communicable diseases, including cardiovascular disease. Testing the effects of interventions designed to increase children's consumption of fruit and vegetables, including those focused on specific child-feeding strategies or broader multicomponent interventions targeting the home or childcare environment, is required to assess the potential to reduce this disease burden.

OBJECTIVES

To assess the benefits and harms of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 March 2023. We searched Proquest Dissertations and Theses in December 2022. We reviewed reference lists of included trials and contacted authors of the included trials to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), including cluster-randomised controlled trials (C-RCTs) and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both amongst children aged five years and under compared to no-intervention control, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risks of bias of included trials; a third review author resolved disagreements. We used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the certainty of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included 53 trials with 120 trial arms and 12,350 participants. Sixteen trials examined the impact of child-feeding practice interventions only (e.g. repeated food exposure) in increasing child vegetable intake. Twenty trials examined the impact of multicomponent interventions primarily conducted in the childcare setting (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. Seventeen trials examined the impact of parent nutrition education only in increasing child fruit and vegetable intake. Two trials examined the effect of a nutrition education intervention delivered to children only in increasing child fruit and vegetable intake and one each examined a child-focused mindfulness intervention or providing families with fruit and vegetable interventions. We judged nine of the 53 included trials as free from high risks of bias across all domains. Performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining trials. There is moderate-certainty evidence that child-feeding practice interventions versus no-intervention control probably have a small positive effect on child vegetable consumption, equivalent to an increase of 15.5 grams as-desired consumption of vegetables (SMD 0.44, 95% confidence interval (CI) 0.24 to 0.65; 15 trials, 1976 participants; mean post-intervention follow-up = 12.3 weeks). No trials in this comparison reported information about intervention costs. One trial reported no harms or serious unintended adverse consequences (low-certainty evidence). Multicomponent interventions versus no-intervention control probably have a small effect on child consumption of fruit and vegetables (SMD 0.27, 95% CI 0.11 to 0.43; 14 trials, 4318 participants; moderate-certainty evidence; mean post-intervention follow-up = 4.0 weeks), equivalent to an increase of 0.34 cups of fruit and vegetables a day. One trial, which tested a multicomponent garden-based intervention, reported the installation of the garden as part of the intervention to be USD 1500 per childcare centre (low-certainty evidence). No trials in this comparison reported information about unintended adverse consequences of interventions. Parent nutrition education interventions may have little to no short-term impact on child consumption of fruit and vegetables versus no-intervention control (SMD 0.10, 95% CI -0.02 to 0.22; 14 trials, 4122 participants; low-certainty evidence; mean post-intervention follow-up = 6.4 weeks). One trial reported the total estimated cost of delivering a parent nutrition education intervention for infant feeding, physical activity and sedentary behaviours delivered by a dietitian as approximately AUD 500 per family (low-certainty evidence). One trial reported no unintended adverse consequences on family food expenditure following implementation of an intervention delivered over the telephone to improve parental knowledge and skills about the home food environment (low-certainty evidence). Trials reported receiving governmental or charitable funds, except for one trial reporting industry funding.

AUTHORS' CONCLUSIONS

There was moderate-certainty evidence that child-feeding practice interventions and multicomponent interventions probably lead to only small increases in fruit and vegetable consumption in children aged five years and under. Parent nutrition education interventions may have little or no effect on increasing fruit and vegetable consumption in children aged five years and under. Future research should be prioritised on assessment and reporting of both intervention cost and adverse effects, and development and evaluation of interventions in research gaps, including in a broader range of settings and in low- and middle-income countries. This review continues to be maintained as a living systematic review with monthly searches for new evidence and incorporation of relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future non-communicable diseases, including cardiovascular disease. Testing the effects of interventions to increase consumption of fruit and vegetables, including those focused on specific child-feeding strategies or broader multicomponent interventions targeting the home or childcare environment is required to assess the potential to reduce this disease burden.

OBJECTIVES

To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 January 2020. We searched Proquest Dissertations and Theses in November 2019. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included trials to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risks of bias of included trials; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included 80 trials with 218 trial arms and 12,965 participants. Fifty trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Fifteen trials examined the impact of parent nutrition education only in increasing child fruit and vegetable intake. Fourteen trials examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. Two trials examined the effect of a nutrition education intervention delivered to children in increasing child fruit and vegetable intake. One trial examined the impact of a child-focused mindfulness intervention in increasing vegetable intake. We judged 23 of the 80 included trials as free from high risks of bias across all domains. Performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining trials. There is low-quality evidence that child-feeding practices versus no intervention may have a small positive effect on child vegetable consumption, equivalent to an increase of 5.30 grams as-desired consumption of vegetables (SMD 0.50, 95% CI 0.29 to 0.71; 19 trials, 2140 participants; mean post-intervention follow-up = 8.3 weeks). Multicomponent interventions versus no intervention has a small effect on child consumption of fruit and vegetables (SMD 0.32, 95% CI 0.09 to 0.55; 9 trials, 2961 participants; moderate-quality evidence; mean post-intervention follow-up = 5.4 weeks), equivalent to an increase of 0.34 cups of fruit and vegetables a day. It is uncertain whether there are any short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.13, 95% CI -0.02 to 0.28; 11 trials, 3050 participants; very low-quality evidence; mean post-intervention follow-up = 13.2 weeks). We were unable to pool child nutrition education interventions in meta-analysis; both trials reported a positive intervention effect on child consumption of fruit and vegetables (low-quality evidence). Very few trials reported long-term effectiveness (6 trials), cost effectiveness (1 trial) or unintended adverse consequences of interventions (2 trials), limiting our ability to assess these outcomes. Trials reported receiving governmental or charitable funds, except for four trials reporting industry funding.

AUTHORS' CONCLUSIONS

Despite identifying 80 eligible trials of various intervention approaches, the evidence for how to increase children's fruit and vegetable consumption remains limited in terms of quality of evidence and magnitude of effect. Of the types of interventions identified, there was moderate-quality evidence that multicomponent interventions probably lead to, and low-quality evidence that child-feeding practice may lead to, only small increases in fruit and vegetable consumption in children aged five years and under. It is uncertain whether parent nutrition education or child nutrition education interventions alone are effective in increasing fruit and vegetable consumption in children aged five years and under. Our confidence in effect estimates for all intervention approaches, with the exception of multicomponent interventions, is limited on the basis of the very low to low-quality evidence. Long-term follow-up of at least 12 months is required and future research should adopt more rigorous methods to advance the field. This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future non-communicable diseases, including cardiovascular disease. Interventions to increase consumption of fruit and vegetables, such as those focused on specific child-feeding strategies and parent nutrition education interventions in early childhood may therefore be an effective strategy in reducing this disease burden.

OBJECTIVES

To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 August 2019. We searched Proquest Dissertations and Theses in May 2019. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included trials to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risks of bias of included trials; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included 78 trials with 214 trial arms and 13,746 participants. Forty-eight trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Fifteen trials examined the impact of parent nutrition education in increasing child fruit and vegetable intake. Fourteen trials examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. Two trials examined the effect of a nutrition education intervention delivered to children in increasing child fruit and vegetable intake. One trial examined the impact of a child-focused mindfulness intervention in increasing vegetable intake. We judged 20 of the 78 included trials as free from high risks of bias across all domains. Performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining trials. There is very low-quality evidence that child-feeding practices versus no intervention may have a small positive effect on child vegetable consumption equivalent to an increase of 4.45 g as-desired consumption of vegetables (SMD 0.42, 95% CI 0.23 to 0.60; 18 trials, 2004 participants; mean post-intervention follow-up = 8.2 weeks). Multicomponent interventions versus no intervention has a small effect on child consumption of fruit and vegetables (SMD 0.34, 95% CI 0.10 to 0.57; 9 trials, 3022 participants; moderate-quality evidence; mean post-intervention follow-up = 5.4 weeks), equivalent to an increase of 0.36 cups of fruit and vegetables per day. It is uncertain whether there are any short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.12, 95% CI -0.03 to 0.28; 11 trials, 3078 participants; very low-quality evidence; mean post-intervention follow-up = 13.2 weeks). We were unable to pool child nutrition education interventions in meta-analysis; both trials reported a positive intervention effect on child consumption of fruit and vegetables (low-quality evidence). Very few trials reported long-term effectiveness (6 trials), cost effectiveness (1 trial) and unintended adverse consequences of interventions (2 trials), limiting their assessment. Trials reported receiving governmental or charitable funds, except for four trials reporting industry funding.

AUTHORS' CONCLUSIONS

Despite identifying 78 eligible trials of various intervention approaches, the evidence for how to increase children's fruit and vegetable consumption remains limited. There was very low-quality evidence that child-feeding practice may lead to, and moderate-quality evidence that multicomponent interventions probably lead to small increases in fruit and vegetable consumption in children aged five years and younger. It is uncertain whether parent nutrition education interventions are effective in increasing fruit and vegetable consumption in children aged five years and younger. Given that the quality of the evidence is very low or low, future research will likely change estimates and conclusions. Long-term follow-up of at least 12 months is required and future research should adopt more rigorous methods to advance the field. This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Sensory variety in shape and color influences fruit and vegetable intake, liking, and purchase intentions in some subsets of adults: a randomized pilot experiment

Dietary variety increases food intake, but it is unclear if sensory differences elicit increases in eating-related behaviors. Using a 4×3 between-subject pilot experiment, we examined if increasing sensory variety (control, color, shape, both color and shape) and priming individuals to notice differences or similarities in the foods (positive, neutral, negative) influenced ad libitum proximal intake, liking, and willingness to purchase pears and peppers among 164 Greater Boston adults >18y/o. MANOVA was used to examine associations between sensory variety (independent variable) and six dependent measures. We tested for interactions between sensory variety condition and individual-level factors that may influence food intake. There was no main effect of sensory variety condition for any dependent measure. However, interactions between sensory variety condition and age, overweight status, and prime were detected. Adults with overweight (vs. adults of normal weight) ate more pear with color variety (7.2 vs. 4.4 oz, p=0.01). Pear intake was also higher among adults with overweight in the color variety (7.2 oz) vs. combination variety (4.4 oz) condition. Adults ≥36y/o ate more peppers (3.5 oz) in the color variety condition versus other conditions (2.1-2.2 oz, p=0.04). Participants primed to notice differences were more willing to purchase pears in the color variety (5.0 ± 0.5) versus control (3.7 ± 0.5) condition. Color variety may modestly increase proximal intake, liking, and purchase intentions for fruits and vegetables in some subsets of adults. Our preliminary findings encourage more research to determine if color variety can be used to improve diet quality of targeted populations.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future non-communicable diseases, including cardiovascular disease. Interventions to increase consumption of fruit and vegetables, such as those focused on specific child-feeding strategies and parent nutrition education interventions in early childhood may therefore be an effective strategy in reducing this disease burden.

OBJECTIVES

To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 January 2018. We searched Proquest Dissertations and Theses in November 2017. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included studies to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risks of bias of included studies; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included 63 trials with 178 trial arms and 11,698 participants. Thirty-nine trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Fourteen trials examined the impact of parent nutrition education in increasing child fruit and vegetable intake. Nine studies examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. One study examined the effect of a nutrition education intervention delivered to children in increasing child fruit and vegetable intake.We judged 14 of the 63 included trials as free from high risks of bias across all domains; performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining studies.There is very low quality evidence that child-feeding practices versus no intervention may have a small positive effect on child vegetable consumption equivalent to an increase of 3.50 g as-desired consumption of vegetables (SMD 0.33, 95% CI 0.13 to 0.54; participants = 1741; studies = 13). Multicomponent interventions versus no intervention may have a very small effect on child consumption of fruit and vegetables (SMD 0.35, 95% CI 0.04 to 0.66; participants = 2009; studies = 5; low-quality evidence), equivalent to an increase of 0.37 cups of fruit and vegetables per day. It is uncertain whether there are any short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.12, 95% CI -0.03 to 0.28; participants = 3078; studies = 11; very low-quality evidence).Insufficient data were available to assess long-term effectiveness, cost effectiveness and unintended adverse consequences of interventions. Studies reported receiving governmental or charitable funds, except for four studies reporting industry funding.

AUTHORS' CONCLUSIONS

Despite identifying 63 eligible trials of various intervention approaches, the evidence for how to increase children's fruit and vegetable consumption remains limited. There was very low- and low-quality evidence respectively that child-feeding practice and multicomponent interventions may lead to very small increases in fruit and vegetable consumption in children aged five years and younger. It is uncertain whether parent nutrition education interventions are effective in increasing fruit and vegetable consumption in children aged five years and younger. Given that the quality of the evidence is very low or low, future research will likely change estimates and conclusions. Long-term follow-up is required and future research should adopt more rigorous methods to advance the field.This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future chronic diseases, including cardiovascular disease.

OBJECTIVES

To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE and Embase to identify eligible trials on 25 September 2017. We searched Proquest Dissertations and Theses and two clinical trial registers in November 2017. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included studies to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risks of bias of included studies; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included 55 trials with 154 trial arms and 11,108 participants. Thirty-three trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Thirteen trials examined the impact of parent nutrition education in increasing child fruit and vegetable intake. Eight studies examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. One study examined the effect of a nutrition intervention delivered to children in increasing child fruit and vegetable intake.We judged 14 of the 55 included trials as free from high risks of bias across all domains; performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining studies.Meta-analysis of trials examining child-feeding practices versus no intervention revealed a positive effect on child vegetable consumption (SMD 0.38, 95% confidence interval (CI) 0.15 to 0.61; n = 1509; 11 studies; very low-quality evidence), equivalent to a mean difference of 4.03 g of vegetables. There were no short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.11, 95% CI -0.05 to 0.28; n = 3023; 10 studies; very low-quality evidence) or multicomponent interventions versus no intervention (SMD 0.28, 95% CI -0.06 to 0.63; n = 1861; 4 studies; very low-quality evidence).Insufficient data were available to assess long-term effectiveness, cost effectiveness and unintended adverse consequences of interventions. Studies reported receiving governmental or charitable funds, except for three studies reporting industry funding.

AUTHORS' CONCLUSIONS

Despite identifying 55 eligible trials of various intervention approaches, the evidence for how to increase children's fruit and vegetable consumption remains sparse. There was very low-quality evidence that child-feeding practice interventions are effective in increasing vegetable consumption in children aged five years and younger, however the effect size was very small and long-term follow-up is required. There was very low-quality evidence that parent nutrition education and multicomponent interventions are not effective in increasing fruit and vegetable consumption in children aged five years and younger. All findings should be considered with caution, given most included trials could not be combined in meta-analyses. Given the very low-quality evidence, future research will very likely change estimates and conclusions. Such research should adopt more rigorous methods to advance the field.This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future chronic diseases, including cardiovascular disease.

OBJECTIVES

To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE, Embase Classic and Embase to identify eligible trials on 30 September 2016. We searched CINAHL and PsycINFO in July 2016, Proquest Dissertations and Theses in November 2016 and three clinical trial registers in November 2016 and June 2017. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included studies to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risks of bias of included studies; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures.We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included 50 trials with 137 trial arms and 10,267 participants. Thirty trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Eleven trials examined the impact of parent nutrition education in increasing child fruit and vegetable intake. Eight studies examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. One study examined the effect of a nutrition intervention delivered to children in increasing child fruit and vegetable intake.Thirteen of the 50 included trials were judged as free from high risks of bias across all domains; performance, detection and attrition bias were the most common domains judged at high risk of bias of remaining studies.Meta-analysis of trials examining child-feeding practices versus no intervention revealed a positive effect on child vegetable consumption (SMD 0.38, 95% CI 0.15 to 0.61; n = 1509; 11 studies; very low-quality evidence), equivalent to a mean difference of 4.03 grams of vegetables. There were no short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.11, 95% CI -0.05 to 0.28; n = 3023; 10 studies; very low-quality evidence) or multicomponent interventions versus no intervention (SMD 0.28, 95% CI -0.06 to 0.63; n = 1861; 4 studies; very low-quality evidence).Insufficient data were available to assess long-term effectiveness, cost effectiveness and unintended adverse consequences of interventions.Studies reported receiving governmental or charitable funds, except for two studies reporting industry funding.

AUTHORS' CONCLUSIONS

Despite identifying 50 eligible trials of various intervention approaches, the evidence for how to increase fruit and vegetable consumption of children remains sparse. There was very low-quality evidence child-feeding practice interventions are effective in increasing vegetable consumption of children aged five years and younger, however the effect size was very small and long-term follow-up is required. There was very low-quality evidence that parent nutrition education and multicomponent interventions are not effective in increasing fruit and vegetable consumption of children aged five years and younger. All findings should be considered with caution, given most included trials could not be combined in meta-analyses. Given the very low-quality evidence, future research will very likely change estimates and conclusions. Such research should adopt more rigorous methods to advance the field.This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Implementation of a Cooking Bus intervention to support cooking in schools in Wales, UK

Purpose

The teaching of cooking is an important aspect of school-based efforts to promote healthy diets among children, and is frequently done by external agencies. Within a limited evidence base relating to cooking interventions in schools, there are important questions about how interventions are integrated within school settings. The purpose of this paper is to examine how a mobile classroom (Cooking Bus) sought to strengthen connections between schools and cooking, and drawing on the concept of the sociotechnical network, theorise the interactions between the Bus and school contexts.

Design/methodology/approach

Methods comprised a postal questionnaire to 76 schools which had received a Bus visit, and case studies of the Bus’ work in five schools, including a range of school sizes and urban/rural locations. Case studies comprised observation of Cooking Bus sessions, and interviews with school staff.

Findings

The Cooking Bus forged connections with schools through aligning intervention and schools’ goals, focussing on pupils’ cooking skills, training teachers and contributing to schools’ existing cooking-related activities. The Bus expanded its sociotechnical network through post-visit integration of cooking activities within schools, particularly teachers’ use of intervention cooking kits.

Research limitations/implications

The paper highlights the need for research on the long-term impacts of school cooking interventions, and better understanding of the interaction between interventions and school contexts.

Originality/value

This paper adds to the limited evidence base on school-based cooking interventions by theorising how cooking interventions relate to school settings, and how they may achieve integration.

Behavioural effects of a short school-based fruit and vegetable promotion programme

Purpose

– The purpose of this paper is to investigate the effects of the Cancer Society of Lower Saxony’s school-based nutrition education programme “5-a-day for kids”, designed to increase children’s fruit and vegetable consumption. Intervention: the programme included three parts (each 45 minutes): education-based classroom session; food knowledge in a local supermarket; and practical vegetable snack preparation. Additional promoting information materials for parents were provided.

Design/methodology/approach

– A pre-/post-test research design was used for the evaluation. In total, 1,376 pupils (age 7-14, 51 per cent female), their parents and 69 teachers of 35 schools in Lower Saxony participated in the study. The fruit and vegetable intake was measured with the KiGGS-Food Frequency Questionnaire.

Findings

– A Wilcoxon signed-rank test was used to determine the change in fruit and vegetable consumption over three measurements (baseline, one month, three months). No significant positive effect of the intervention was observed with the applied method for the daily intake of fruit and vegetables, neither at month 1 nor at month 3.

Research limitations/implications

– A 135 min school-based intervention does not seem to increase children’s fruit and vegetable consumption. To enhance its effectiveness, the programme may be improved by adding a longitudinal classroom component, extensive parental involvement and/or distribution of free fruit/vegetables every day.

Originality/value

– This is the first evaluation of a 5-a-day-intervention in Germany.

Teaching approaches and strategies that promote healthy eating in primary school children: a systematic review and meta-analysis

BACKGROUND

Healthy eating by primary school-aged children is important for good health and development. Schools can play an important role in the education and promotion of healthy eating among children. The aim of this review was to: 1) perform a systematic review of randomised controlled, quasi-experimental and cluster controlled trials examining the school-based teaching interventions that improve the eating habits of primary school children; and 2) perform a meta-analysis to determine the effect of those interventions.

METHODS

The systematic review was limited to four healthy eating outcomes: reduced food consumption or energy intake; increased fruit and vegetable consumption or preference; reduced sugar consumption or preference (not from whole fruit); increased nutritional knowledge. In March 2014, we searched seven electronic databases using predefined keywords for intervention studies that were conducted in primary schools which focused on the four healthy eating outcomes. Targeted internet searching using Google Scholar was also used. In excess of 200,000 possible citations were identified. Abstracts and full text of articles of potentially relevant papers were screened to determine eligibility. Data pertaining to teaching strategies that reported on healthy eating outcomes for primary school children was extracted from the 49 eligible papers.

RESULTS

Experiential learning strategies were associated with the largest effects across the reduced food consumption or energy intake; increased fruit and vegetable consumption or preference; and increased nutritional knowledge outcomes. Reducing sugar consumption and preference was most influenced by cross-curricular approaches embedded in the interventions.

CONCLUSIONS

As with most educational interventions, most of the teaching strategies extracted from the intervention studies led to positive changes in primary school children's healthy eating behaviours. However, given the finite resources, increased overcrowding of school curriculum and capacity of teachers in primary schools, a meta-analysis of this scope is able to provide stakeholders with the best evidence of where these resources should be focused.

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.

Interventions for increasing fruit and vegetable consumption in children aged 5 years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future chronic diseases including cardiovascular disease.

OBJECTIVES

To assess the effectiveness, cost-effectiveness and associated adverse events of interventions designed to increase the consumption of fruit and/or vegetables amongst children aged five years and under.

SEARCH METHODS

The Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library Issue 2, 2010, MEDLINE (1950 to 2010 April week 4), EMBASE (1947 to 2010 week 18), CINAHL (up to 12 May 2010), PsycINFO (up to 12 May 2010) and Proquest Dissertations and Theses (up to February 2011) were searched to identify eligible trials, as well as electronic trial registers (also up to February 2011). The reference lists of included trials were reviewed and handsearches of three international nutrition journals were also performed. Authors of all included trials were contacted in order to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), including cluster-randomised controlled trials, of any intervention primarily targeting fruit and/or vegetable consumption among children aged five years and under and incorporating a biochemical or dietary assessment of fruit and/or vegetable consumption. Two review authors independently screened the titles and abstracts of identified papers. A third review author with expertise in review methodology resolved any disagreements regarding study eligibility.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias of the included studies. A third reviewer resolved disagreements between review authors. Fixed-effect models were used to perform meta-analysis for the primary review outcomes where a sufficient number of trials with suitable data and homogeneity were identified.

MAIN RESULTS

Five trials, with 13 trial arms and 3967 participants were included in the review. Two trials examined the impact of specific feeding practices (e.g. repeated food exposure) in increasing child intake of a target vegetable. Two trials assessed the effectiveness of home visiting programs implemented in disadvantaged communities and one trial investigated the effect of a preschool-based intervention in increasing child fruit and vegetable intake. Risk of bias of included studies was low although three of the five trials were judged to be at high risk of performance bias. Meta-analysis of two trials examining repeated food exposure versus a no intervention comparison found no significant difference in target vegetable consumption in the short term (mean difference (MD) 1.37, 95% confidence interval (CI) -2.78 to 5.52). Coupling repeated food exposure with a tangible non-food or social reward, was effective in increasing targeted vegetable consumption in the short term based on one trial. Home visiting programs provided to disadvantaged groups did not significantly increase overall fruit intake in the short term (standardised mean difference (SMD) 0.01, 95% CI -0.09 to 0.11). Similarly, a multi-component preschool-based intervention failed to significantly increase child consumption of vegetables, but did report a small significant increase in mean child consumption of fruit, six months following baseline assessment. None of the trials investigated intervention cost-effectiveness or reported information regarding any adverse events or unintended adverse consequences of the intervention.

AUTHORS' CONCLUSIONS

Despite the importance of encouraging fruit and vegetable consumption among children aged five years and under, this review identified few randomised controlled trials investigating interventions to achieve this.

Community-based interventions for enhancing access to or consumption of fruit and vegetables among five to 18-year olds: a scoping review

BACKGROUND

Low fruit and vegetable ( FV) consumption is a key risk factor for morbidity and mortality. Consumption of FV is limited by a lack of access to FV. Enhanced understanding of interventions and their impact on both access to and consumption of FV can provide guidance to public health decision-makers. The purpose of this scoping review is to identify and map literature that has evaluated effects of community-based interventions designed to increase FV access or consumption among five to 18-year olds.

METHODS

The search included 21 electronic bibliographic databases, grey literature, targeted organization websites, and 15 key journals for relevant studies published up to May 2011. Retrieved citations were screened in duplicate for relevance. Data extracted from included studies covered: year, country, study design, target audience, intervention setting, intervention strategies, interventionists, and reported outcomes.

RESULTS

The search located 19,607 unique citations. Full text relevance screening was conducted on 1,908 studies. The final 289 unique studies included 30 knowledge syntheses, 27 randomized controlled trials, 55 quasi-experimental studies, 113 cluster controlled studies, 60 before-after studies, one mixed method study, and three controlled time series studies. Of these studies, 46 included access outcomes and 278 included consumption outcomes. In terms of target population, 110 studies focused on five to seven year olds, 175 targeted eight to 10 year olds, 192 targeted 11 to 14 year olds, 73 targeted 15 to 18 year olds, 55 targeted parents, and 30 targeted teachers, other service providers, or the general public. The most common intervention locations included schools, communities or community centres, and homes. Most studies implemented multi-faceted intervention strategies to increase FV access or consumption.

CONCLUSIONS

While consumption measures were commonly reported, this review identified a small yet important subset of literature examining access to FV. This is a critically important issue since consumption is contingent upon access. Future research should examine the impact of interventions on direct outcome measures of FV access and a focused systematic review that examines these interventions is also needed. In addition, research on interventions in low- and middle-income countries is warranted based on a limited existing knowledge base.

Effectiveness of a multi-strategy intervention in increasing the implementation of vegetable and fruit breaks by Australian primary schools: a non-randomized controlled trial

Background

Limited evidence exists describing the effectiveness of strategies in facilitating the implementation of vegetable and fruit programs by schools on a population wide basis. The aim of this study was to examine the effectiveness of a multi-strategy intervention in increasing the population-wide implementation of vegetable and fruit breaks by primary schools and to determine if intervention effectiveness varied by school characteristics.

Methods

A quasi-experimental study was conducted in primary schools in the state of New South Wales, Australia. All primary schools in one region of the state (n = 422) received a multi-strategy intervention. A random sample of schools (n = 406) in the remainder of the state served as comparison schools. The multi-strategy intervention to increase vegetable and fruit breaks involved the development and provision of: program consensus and leadership; staff training; program materials; incentives; follow-up support; and implementation feedback. Comparison schools had access to routine information-based Government support. Data to assess the prevalence of vegetable and fruit breaks were collected by telephone from Principals of the intervention and comparison schools at baseline (2006–2007) and 11 to 15 months following the commencement of the intervention (2009–2010). GEE analysis was used to examine the change in the prevalence of vegetable and fruit breaks in intervention schools compared to comparison schools.

Results

At follow-up, prevalence of vegetable and fruit breaks increased significantly in both intervention (50.3 % to 82.0 %, p < 0.001) and comparison (45.4 % to 60.9 % p < 0.001) schools. The increase in prevalence in intervention schools was significantly larger than among comparison schools (OR 2.36; 95 % CI 1.60-3.49, p <0.001). The effect size was similar between schools regardless of the rurality or socioeconomic status of school location, school size or government or non-government school type.

Conclusion

The findings suggest that a multi-strategy intervention can significantly increase the implementation of vegetable and fruit breaks by a large number of Australian primary schools.

The implementation and effectiveness of school-based nutrition promotion programmes using a health-promoting schools approach: a systematic review

Objective

To evaluate implementation and effectiveness of nutrition promotion programmes using the health-promoting schools (HPS) approach, to indicate areas where further research is needed and to make recommendations for practice in this field.

Design

The searched electronic databases included: CINAHL, Cochrane Library, Health Reference Center, Informit Search, MEDLINE, ProQuest, PsycINFO, PubMed, ScienceDirect, Scopus, Social Services Abstracts and Web of Science. Inclusion criteria were: (i) controlled or before-and-after studies evaluating a nutrition intervention and involving the HPS approach, either fully or in part; (ii) provision of information about components and delivery of the intervention; and (iii) report on all evaluated outcomes.

Setting

Schools.

Subjects

Students, parents and school staff.

Results

All included studies described intervention delivery and six reported on process evaluation. In intervention schools school environment and ethos were more supportive, appropriate curriculum was delivered and parents and/or the community were more engaged and involved. Students participated in interventions at differing levels, but the majority was satisfied with the intervention. The evidence indicates that nutrition promotion programmes using the HPS approach can increase participants’ consumption of high-fibre foods, healthier snacks, water, milk, fruit and vegetables. It can also reduce participants’ ‘breakfast skipping’, as well as reduce intakes of red food, low-nutrient dense foods, fatty and cream foods, sweet drinks consumption and eating disorders. It can help to develop hygienic habits and improved food safety behaviours.

Conclusions

More professional training for teachers in the HPS approach, further qualitative studies, longer intervention periods, improved follow-up evaluations and adequate funding are required for future school-based nutrition promotion programmes.

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.

Differences in fruit and vegetable intake and their determinants among 11-year-old schoolchildren between 2003 and 2009

BACKGROUND

Fruit and vegetable (FV) intake in children in the Netherlands is much lower than recommended. Recurrent appraisal of intake levels is important for detecting changes in intake over time and to inform future interventions and policies. The aim of the present study was to investigate differences in fruit and vegetable intake, and whether these could be explained by differences in potential determinants of FV intake in 11-year-old Dutch schoolchildren, by comparing two school samples assessed in 2003 and 2009.

METHODS

For 1105 children of the Pro Children study in 2003 and 577 children of the Pro Greens study in 2009 complete data on intake and behavioural determinants were available. The self-administered questionnaire included questions on children's ethnicity, usual fruit and vegetable intake, mother's educational level, and important potential determinants of fruit and vegetable intake.Multiple regression analysis was applied to test for differences in intake and determinants between study samples. Mediation analyses were used to investigate whether the potential mediators explained the differences in intake between the two samples.

RESULTS

In 2009, more children complied with the World Health Organization recommendation of 400 g fruit and vegetables per day (17.0%) than in 2003 (11.8%, p = 0.004). Fruit consumption was significantly higher in the sample of 2009 than in the sample of 2003 (difference = 23.8 (95%CI: 8.1; 39.5) grams/day). This difference was mainly explained by a difference in the parental demand regarding their child's intake (23.6%), followed by the child's knowledge of the fruit recommendation (14.2%) and parental facilitation of consumption (18.5%). Vegetable intake was lower in the 2009 sample than in the 2003 sample (12.3 (95%CI -21.0; -3.6). This difference could not be explained by the assessed mediators.

CONCLUSIONS

The findings indicate that fruit intake among 11-year-olds improved somewhat between 2003 and 2009. Vegetable intake, however, appears to have declined somewhat between 2003 and 2009. Since a better knowledge of the recommendation, parental demand and facilitation explained most of the observed fruit consumption difference, future interventions may specifically address these potential mediators. Further, the provision of vegetables in the school setting should be considered in order to increase children's vegetable intake.

Strategies for pediatric practitioners to increase fruit and vegetable consumption in children

High intake of fruits and vegetables (FV) is associated with a decreased risk for many chronic diseases and may assist in weight management, but few children and adolescents consume the recommended amounts of FV. The pediatric practitioner can positively influence FV consumption of children through patient-level interventions (eg, counseling, connecting families to community resources), community-level interventions (eg, advocacy, community involvement), and health care facility-level interventions (eg, creating a healthy food environment in the clinical setting). This article reviews the importance of FV consumption, recommended intakes for children, and strategies by which pediatric practitioners can influence FV consumption of children.

Vegetable and fruit breaks in Australian primary schools: prevalence, attitudes, barriers and implementation strategies

School-based vegetable and fruit programs can increase student consumption of vegetables and fruit and have been recommended for adoption by Australian schools since 2005. An understanding of the prevalence and predictors of and the barriers to the adoption of school-based vegetable and fruit programs is necessary to maximize their adoption by schools and ensure that the health benefits of such programs to children are realized. The aim of this study was to determine Australian primary school Principals' attitudes and barriers to the implementation of vegetable and fruit breaks; the prevalence of vegetable and fruit breaks in schools and the implementation strategies used and associated with their recommended adoption (daily in at least 80% of classes). A random sample of 384 school Principals completed a 20-min telephone interview. While Principals were highly supportive of vegetable and fruit breaks, only 44% were implementing these to a recommended level. When controlling for all school characteristics, recommended vegetable and fruit break adoption was 1.9 and 2.2 times greater, respectively, in schools that had parent communication strategies and teachers trained. A substantial opportunity exists to enhance the health of children through the adoption of vegetable and fruit breaks in schools.

Kid's Choice Program improves weight management behaviors and weight status in school children

The present study examined the effectiveness of the Kid's Choice Program (KCP) for increasing children's weight management behaviors, and decreasing body mass index percentile (BMI%) for overweight and average-weight children. It also evaluated KCP characteristics relevant to long-term application in schools. Participants included 382 children assigned to two groups: a KCP group that received token rewards for three "Good Health Behaviors" including eating fruits or vegetables first at meals (FVFIRST), choosing low-fat and low-sugar healthy drinks (HDRINK), and showing 5000 exercise steps recorded on pedometers (EXERCISE), or a control group that received token rewards for three "Good Citizenship Behaviors." School lunch observations and pedometer records were completed for one month under baseline and three months under reward conditions. The school nurse calculated children's BMI% one year before baseline, at baseline, at the end of KCP application, and six months later. The KCP increased FVFIRST, HDRINK, and EXERCISE from baseline through reward conditions, with ANCOVAs demonstrating that these increases were associated with both the offer of reward and nearby peer models. Overweight (n=112) and average-weight (n=200) children showed drops in BMI% after the three-month KCP, but overweight children re-gained weight six months later, suggesting the need for more ongoing KCP application. HDRINK choice was the behavior most associated with BMI% drops for overweight children. Small teams of parent volunteers effectively delivered the KCP, and school staff endorsed parent volunteers as the best personnel to deliver the KCP, which costs approximately two U.S. dollars per child per month of application.

Increasing fruit and vegetable intake among children: comparing long-term effects of a free distribution and a multicomponent program

The aim of this study was to evaluate and compare the effectiveness of two primary school-based interventions on children's fruit and vegetable (F&V) consumption on the long term (2 years after the start of the interventions). Six primary schools were recruited and randomly assigned to (i) a daily free distribution program for the whole school or (ii) a multicomponent program consisting of a classroom curriculum and parental involvement (without free F&V), and six schools served as controls. Follow-up measurements were conducted at the end of the intervention (Follow-up I) and 1 year later (Follow-up II). Random coefficient analyses for longitudinal data showed that the effects of both interventions did not differ between the two follow-up measurements. The results showed similar effects for the free distribution program and the multicomponent program in increasing children's fruit consumption over time (respectively, 7.2 and 15.2 g day(-1)). The distribution program also increased children's vegetable consumption over time (3.25 g day(-1)), even after repeating the analyses using a pessimistic scenario. Despite the large dropout and its consequences for generalizability of our results, the distribution program is considered as the preferred intervention of the two, and implementation on a larger scale should be investigated.

Examination of Weight Status and Dietary Behaviors of Middle School Students in Kentucky

OBJECTIVE

There is growing interest in understanding the roles that fruit, vegetable, milk, breakfast, and soft drink consumption play in relation to adolescents' weight status. This study examines the relationship between weight status and dietary practices of middle school students.

DESIGN

This study consists of secondary analysis of a cross-sectional survey given to 4,049 middle school students in central Kentucky.

METHODS

Students' self-reported height and weight data, as well as 7-day recall of fruits, vegetables, milk, soft drinks, and breakfast consumption prior to completion of the survey, were collected. Self-reported height and weight were converted to body mass index (BMI) percentile according to Centers for Disease Control and Prevention's classification criteria.

OUTCOME MEASURES

Measures included dietary consumption of fruits, vegetables, milk, soft drinks, and breakfast in relation to students' BMI percentile.

STATISTICAL ANALYSES PERFORMED

Descriptive statistics were extracted on demographics, BMI percentile, and food consumption. Bivariate analyses included chi2 tests of association and Spearman rank correlation.

RESULTS

Healthy weight was associated with consuming fruits, vegetables, breakfast, and milk. Underweight and healthy-weight students consumed more fruits than students who were at risk of being overweight and overweight. Healthy-weight students consumed more "other vegetables" than students who were at risk of being overweight and more "other vegetables" and carrots than overweight students. Underweight students consumed breakfast more often than all other students, and healthy-weight students consumed breakfast significantly more frequently than students at risk of being overweight and overweight. Finally, overweight students had a significantly lower consumption of milk than all other students.

CONCLUSIONS

Parents and school foodservice personnel should take these factors into consideration by developing menu strategies and tactics to encourage more healthful eating behaviors in children.

Increasing children's fruit and vegetable consumption: distribution or a multicomponent programme?

OBJECTIVE

To measure the effects of two school-based interventions on children's intake of fruit and vegetables (F&V).

DESIGN AND METHODS

A total of six primary schools were randomly assigned to (1) a free F&V distribution programme, or (2) a multicomponent programme, consisting of a classroom curriculum and parental involvement. The two interventions were evaluated on their effects and compared with six control schools in a pre-test-post-test design. Two methods were used for dietary assessment: a pre-structured food recall and a food-frequency questionnaire including only F&V.

SUBJECTS

A total of 939 parents of children aged 4-12 years filled out the questionnaire at both pre-test and post-test. The response rate was 54%.

RESULTS

Multilevel analyses showed that both programmes were equally effective in increasing children's fruit consumption by 0.2 portions per day. The free F&V distribution increased vegetable intake among non-native children and the oldest age group, and the multicomponent programme among the oldest children and girls. The distribution also caused an increased 24 h fruit, juice and vegetable intake among the youngest and the oldest age groups, and the multicomponent programme among all children.

CONCLUSION

The results of this study indicate that both interventions were shown to be effective for different subgroups regarding age, gender and ethnicity. When comparing both interventions, the distribution programme was shown to be more effective, especially in increasing vegetable consumption. An important next step will be to investigate which intervention has the greatest potential to be implemented in primary schools.

Getting children to eat more fruit and vegetables: a systematic review

BACKGROUND

There is growing recognition of the need to increase consumption of currently suboptimal levels of fruit and vegetables by children, given their known beneficial effects for health. There is, however, a need for a synthesis of the evidence on interventions that might achieve this policy goal.

METHODS

A systematic review of published and unpublished studies was carried out by searching 14 publication databases and contacting experts in the fields. All papers in eight languages were considered if they described individual- and population-based interventions and promotion programmes that encouraged the consumption of a diet relatively higher in fruit and/or vegetables in free-living, not acutely ill children of both genders, with follow-up periods of at least 3 months, measurement of change in intake and a control group.

RESULTS

Fifteen studies focusing on children met the criteria for inclusion in the systematic review. None of the studies reviewed had a detrimental effect on fruit and vegetable consumption. Ten studies had a significant effect, ranging from +0.3 to +0.99 servings/day.

CONCLUSIONS

More research is needed to examine in more depth, for longer follow-up periods, the effectiveness of interventions promoting fruit and vegetable consumption. The evidence is strongest in favor of multi-component interventions to increase fruit and vegetable consumption in children.

“Kids Choice” School lunch program increases children's fruit and vegetable acceptance

The "Kids Choice" school lunch program used token reinforcement, food choice, and peer participation to increase children's fruit and vegetable consumption without later drops in food preference sometimes found in past research and often called 'overjustification effects.' Participants included 188 school children (92 boys, 96 girls; mean age = 8.0; 95% Caucasian). After four baseline meals, children were randomly assigned for 12 meals to receive token reinforcement for eating either fruits or vegetables. Observers recorded fruit and vegetable consumption and provided token reinforcement by punching holes into nametags each day children ate their assigned foods, then once a week children could trade these tokens for small prizes. Fruit and vegetable preference ratings were gathered with child interviews during baseline, and during follow-up conditions two weeks and seven months after the token reinforcement program. Consumption increased for fruit and for vegetables and the increases lasted throughout reinforcement conditions. Two weeks after the program, preference ratings showed increases for fruit and for vegetables. Seven months later, fruit and vegetable preferences had returned to baseline levels, suggesting the need for an ongoing school lunch program to keep preferences high, but also showing no signs of "overjustification effects" from the token reinforcement used in the "Kids Choice" school lunch program.

Determinants of fruit and vegetable consumption among 6-12-year-old children and effective interventions to increase consumption

PURPOSE

To review the current literature about potential determinants of fruit and vegetable intakes and effective intervention strategies to increase the consumption of fruits and vegetables among 6-12-year-old children.

METHODS

A structured review of literature located in PubMed and Psychinfo electronic literature databases.

RESULTS

Of all determinants, the availability and accessibility of fruit and vegetables and taste preferences were most consistently and most positively related to consumption. There was some evidence that parental fruit and vegetable intakes, knowledge of intake recommendations and skills had a positive association with children's intakes, whereas television viewing, exposure to television advertisement, and having a snack bar at school were associated with lower intakes of fruit and vegetables. Multi-component school-based interventions that combined classroom curriculum, parent and food service components showed the greatest promise for fruit and vegetable promotion among children. School fruit and vegetable subscription programmes, scout-based interventions, and fruit and vegetables education via computer multi-media channels also appear promising.

CONCLUSIONS

Interventions should improve the availability and accessibility of fruit and vegetables to children, and should aim to improve their taste preferences for them. Such interventions should be of a multi-component nature, school-based or use other social channels and may include multi-media channels.

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

International recommendations advise increasing intakes of fruit and vegetables to help reduce the burden of chronic diseases worldwide. This project systematically reviewed evidence on the effectiveness of interventions and programs promoting fruit and/or vegetable intake in adults. In April 2004, we contacted experts in the field and searched 14 publication databases. We considered all papers published in English, French, Spanish, Portuguese, Russian, Danish, Norwegian, and Swedish, and reporting on interventions and promotion programs encouraging higher intakes of fruit and/or vegetables in free-living not acutely ill adults, with follow-up periods > or = 3 mo, that measured change in intake and had a control group. Forty-four studies (mainly from developed countries) were included in the review and stratified by study setting. Larger effects were generally observed in individuals with preexisting health disorders. In primary prevention interventions in healthy adults, fruit and vegetable intake was increased by approximately 0.1-1.4 serving/d. Consistent positive effects were seen in studies involving face-to-face education or counseling, but interventions using telephone contacts or computer-tailored information appeared to be a reasonable alternative. Community-based multicomponent interventions also had positive findings. This literature review suggests that small increases in fruit and vegetable intake are possible in population subgroups, and that these can be achieved by a variety of approaches. More research is required to examine the effectiveness of specific components of interventions in different populations, particularly less developed countries. There is also a need for a better assessment of the effectiveness and cost-effectiveness of large community-based interventions.