State of the art intervention strategies?

Extensive reviews of previous school-based fruit and vegetable interventions tell us that, in order to be successful, behavioural interventions should consist of multiple components (such as including both school and home environments), include education directed at behavioural change, be of adequate time and duration, include messages specifically targeting fruit and vegetable intake (as opposed to healthy eating in general) and be based on an appropriate theoretical framework. Study 1^[1] evaluated a multicomponent intervention consisting of a classroom homeeconomics curriculum, newsletters sent home to parents and parent meetings at schools. The intervention was delivered in seven sessions over a seven-month period and each session lasted for a duration of three school lessons (i.e. 3 x 45 minutes). A total of six newsletters were sent home to parents. The intervention was directed at behavioural change, it included messages specifically targeting fruit and vegetable intake and it was based on the framework of Social Cognitive Theory.

Although the intervention in study 1 was based on what was perceived as state of the art intervention strategies, it did not have any effect in increasing school children’s intake of fruits and vegetables.

Free school fruit is effective

Study 2^[2] included the same intervention as in study 1, but in addition it also included participation in the Norwegian School Fruit Programme at no cost to the parents for a whole school year. The standard Norwegian School Fruit Programme is a subscription programme that currently is offered in all Norwegian elementary schools (www.skolefrukt.no). The pupils who subscribe receive a piece of fruit or a carrot each school day, usually in connection with their lunch (school children in Norway bring their own lunch, usually sandwiches, to school). Very few elementary schools have canteens, and fruit and vegetables have traditionally not been available at school. The cost for the parents is usually NOK 2.50 per school day (approximately EUR 0.30). The programme is subsidised by the Norwegian Government by NOK 1.00 per pupil per school day. A problem with the programme is low participation. Only 41% of the schools participate (spring 2006), and at participating schools, only 28% of the pupils subscribed. Totally, only 12% of the Norwegian school population (grades 1-10) subscribed, and therefore, the effect of the paid programme is limited^[3]. A second problem is that participating pupils tend to be a healthier group than nonparticipating pupils; they eat more fruit and vegetables before the programme starts, they eat fewer unhealthy snacks and their parents are less likely to smoke^[3]. Therefore, study 2 included subscription to the Norwegian school fruit programme for free for a full school year.

Results of study 2 showed that fruit and vegetable intake increased in pupils at intervention schools compared to pupils at control schools, both at school and all day. The mean difference was 0.6 portion both measured at school and all day. The effect was sustained also one year after the end of the intervention (mean difference was 0.5 portion). This sustained effect can partly be explained by a higher subscription rate in the standard (paid) School Fruit Programme in the intervention group than the control group the year following the intervention year.

Concluding remarks

Why did study 1, based on state of the art intervention strategies, not increase children’s fruit and vegetable intake while the free school fruit clearly did? An important point is that most fruit and vegetable interventions reviewed have not been especially successful. Therefore, the “state of the art messages” from the review articles are based on studies that are only slightly better than other studies. Interventions that really have an impact on children’s consumption of fruits and vegetables are dearly lacking from the literature. The present results evaluating a free school fruit programme are very promising^[2;3]. It seems to be an effective strategy for reaching all pupils, especially those that need it the most: boys, pupils of low SES families, and pupils with low habitual intake and preferences.