Getting children to eat fruits and vegetables – lessons from the English School Fruit and Vegetable Scheme

There is nothing more endearing than watching a young child’s face expand in wonder as they taste a strawberry picked straight from a plant or a pea popped straight from a pod. Yet for many children the experience of eating fresh fruits and vegetables is unusual. Research in the UK has revealed that some children don’t eat fruits and vegetables during a typical week and others eat so little they compromise their current and future health.

Fruits and vegetables provide a wide range of nutrients and bioactive components which play an important role in keeping children healthy and preventing disease in later life. These foods are low in fat and displace energy dense foods helping to avert the onset of obesity – a disease becoming more common in children in the UK. Fruit and vegetables also provide an important source of non-starch polysaccharides which are useful for promoting gut health.

A national 5 A DAY programme has been introduced in England to encourage eating five daily portions of fruit and vegetable as an essential and enjoyable part of a healthy diet. Part of this programme includes the school fruit and vegetable scheme (SFVS). The SFVS is the largest scale intervention in English children’s diet since the introduction of free school milk in 1946.

Since November 2004, a free piece of fruit or vegetable has been provided to children aged four to six years on each school day. The scheme aims to distribute 440 million pieces of fruit and vegetables each year to over two million children in 18 000 schools. It has cost £42 million to set up and the scheme has received a further £77 million from the Department of Health.

By providing free fruits and vegetables for schoolchildren, it was hoped their overall consumption of fruit and vegetables would be increased by up to one portion a day, with subsequent associated improvement in nutrient intake.

We were commissioned to evaluate the impact of this intervention on children’s intake of fruit, vegetables, and key nutrients. The evaluation was undertaken using a non – randomised control design. Two random samples were drawn from English primary schools. Fifty schools were recruited from the North East (Intervention) and 45 schools from Yorkshire and Humberside (Control) comprising a sample of 3703 children aged between four to six years (reception, year 1, and year 2).

Diet was assessed using The Child and Diet Evaluation Tool (CADET). CADET is completed by an adult on behalf of the child and records dietary intake over 24 hours. Diet was assessed at baseline (March 2004), June and November 2004.

Multilevel modelling was used to measure the impact of the SFVS on diet. This type of statistical analysis is important because it allows for any effects that may influence children’s intake of fruits and vegetables at the class, school and local authority level and adjusts for these where necessary.

This analysis showed the SFVS was associated with an increase in fruit intake across reception and year 1 pupils of 0.4 portions (95% confidence interval, 0.2 to 0.5) and 0.6 portions (0.4 to 0.9), respectively, at three months, which fell to 0.2 (0.1 to 0.4) and 0.3 (0.1 to 0.6) at seven months. In year 2 it was associated with an increase of 0.5 portions (0.2 to 0.7) of fruit at three months, which fell to baseline values at seven months when these children were no longer eligible for the scheme. Overall, at seven months there were no changes in vegetable consumption, no associations between the SFVS and energy, fat, or salt intake, and small changes in carotene and vitamin C intake.

We concluded the SFVS promoted an increase in fruit intake after three months but at seven months the effect remained significant but reduced, and it returned to baseline in year 2 pupils when they entered year 3 and were no longer part of the scheme.

Following the publication of our results in the Journal of Epidemiology and Community Health earlier this year, researchers from the University of Nottingham published similar results in the International Journal of Epidemiology. They too concluded that the SFVS appeared to be an effective means of increasing dietary fruit intake in young children while they participated in the scheme, but when the scheme ends the effect was lost. Clearly the take home message from this research is that further intervention is required to sustain an increased intake of fruit and vegetables in children.

We are currently being funded to explore ways in which we can optimise the effects of the SFVS and sustain its effects. The results of which will be available in 2008.