Interventions in schools to increase Fruit and Vegetable consumption

Promoting Fruit and Vegetable Consumption through Increased Availability and Accessibility at School: A Strategy to Reduce Childhood Obesity

Obesity is an epidemic affecting nearly all countries (high-income and low-income alike) worldwide1. In the more affluent countries not only is adult obesity on the rise, but childhood obesity is emerging as a major public health challenge. While the causes for childhood obesity are complex, poor diet plays a major role. Focusing on interventions to promote healthy eating early in life is one way to reduce the obesity burden by instituting behaviors that result in life-long healthy habits. Adequate daily fruit and vegetable intake is one such healthy eating behavior. It sometimes requires up to 10-15 taste exposures to a food before a child accepts it2-3. Increasing access and availability of fruit and vegetables sets up opportunities for children to have repeated exposures to fruit and vegetables, and this impacts preferences4. Availability and accessibility of fruit and vegetables, and taste preferences are the consistently and positively related to fruit and vegetable consumption among children5.

Fruits and vegetables should be available and accessible both at home and school since these are the places children usually spend most of their time. To date, there are a limited number of studies evaluating schoolbased environmental interventions in the cafeteria to increase availability and accessibility of fruit and vegetables for children5-6. One cafeteriabased intervention in the United States increased opportunities to eat a variety of fruit and vegetables during school lunch, provided new healthful role models, and instituted social support for children to eat fruit and vegetables at lunch7. This intervention significantly increased fruit consumption from 0.14 to 0.17 servings during lunch. Although this seems like a small change, it could have public health significance if this intervention was applied to a large population of children. An important limitation of this study is the children were fairly homogenous with 90% of the children being White and only 21% of the children participating in the free or reduced price school meal, a proxy for low-household income.

An observational study with a more diverse student population (non-White population ranging from 45-67%, and 52-59% participation in free or reduced lunch) found no differences in 6-12 year old children’s fruit and vegetable consumption among those children who attended schools with self-service salad bars compared to those children who attended schools with pre-portioned fruit and vegetable servings8. They did find a positive relationship between fruit and vegetable consumption and the number of fruit and vegetable items offered on the salad bars. However, the study did not control for student ethnicity or participation in free or reduced lunch.

More recently, an evaluation of a pilot salad bar intervention in 3 elementary schools in Southern California showed promising results comparing fruit and vegetable frequencies between a cross sectional sample of pre- and post-intervention children (2.97 to 4.09, p<0.001)9. Concurrent with the increase in fruit and vegetable consumption was a statistically significant decrease in cholesterol, saturated fat, percent energy from fat, and overall energy intake. The schools in this study served children who were predominately of Latino, African American or Asian, and lived in low-income households. This pilot salad bar program inspired a public private research partnership between Los Angeles Unified School District Food Services (the second largest school district in the US), University of California, Los Angeles, Department of Pediatrics and Blue Cross of California (the largest private health insurer in the US). This partnership is rigorously evaluating the fruit and vegetable bar intervention in combination with nutrition education in elementary schools.

Promoting fruit and vegetable consumption is listed by the WHO as one of the 9 main strategies for the prevention of childhood obesity1. Offering fruits and vegetables to children during the school day offers promise as a step to promote fruit and vegetable consumption and in turn prevent obesity and improve overall health. The following outlines the WHO complete list of strategies for the prevention of obesity in infants, young children, children and adolescents.

The main strategies for the prevention of obesity in infants and young children are:

  • The promotion of exclusive breastfeeding.
  • Avoiding the use of added sugars and starches when feeding formula.
  • Instructing mothers to accept their child’s ability to regulate energy intake rather than feeding until the plate is empty.
  • Assuring the appropriate micronutrient intake needed to promote optimal linear growth.

The main strategies for the prevention of obesity in children and adolescents are:

  • Promote an active lifestyle.
  • Limit television viewing.
  • Promote the intake of fruits and vegetables.
  • Restrict the intake of energy-dense, micronutrient-poor foods (e.g. packaged snacks).
  • Restrict the intake of sugars-sweetened soft drinks.
  1. WHO, Diet, Nutrition and the prevention of chronic diseases. Report of a Joint WHO/FAO Expert consultation. WHO Technical Report Series 916. Geneva; 2003.
  2. Skinner JD, Carruth, BR, Bounds W, Ziegler PJ. Children’s Food Preferences: A Longitudinal Analysis – Research. J Am Diet Assoc. 2002; 102(11): 1638-1647.
  3. Hendy H, Williams K and Camise T. “ Kids Choice” School lunch program increases children’s fruit and vegetable acceptance. Appetite 2005; 45:250-263.
  4. Bere E, and Klepp K. Changes in accessibility and preferences predict children’s future fruit and vegetable intake. International Journal of Behavioral Nutrition and Physical Activity 2005; 2:15-23
  5. Blanchette L, and Brugg J. Determinants of fruit and vegetable consumption among 6-12 year old children and effective interventions to increase consumption. J. Hum Nutr Dietet. 2005;18:431-443.
  6. Knai C, Pomerleau J, Lock K, McKee M. Getting children to eat more fruit and vegetables: A systematic review. Preventive Medicine 2006; 42(2):85-95.
  7. Perry CL, Bishop DB, Taylor GL, Davis M, Story M, Gray C, Bishop SC, Mays RA, Lytle LA, Harnack L.A randomized school trial of environmental strategies to encourage fruit and vegetable consumption among children. Health Educ Behav. 2004; 31(1):65-76.
  8. Adams M, Pelletier RL, Zive M and Sallis J. Salad bars and fruit and vegetable consumption in elementary schools: a plate waste study. J Am Diet. Assoc. 2005; 105: 1789-1792.
  9. Slusser, WM, Cumberland B, Browdy B, Lange L, Neumann C (2007). A school salad bar increases frequency of fruit and vegetable consumption among children living in low-income households. Public Health Nutr. Jul 5:1-7
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