Regular articleEnvironmental interventions to promote vegetable and fruit consumption among youth in school settings
Introduction
Despite the well-documented health benefits of a diet rich in vegetables and fruits (VF) [1], [2], fewer than one-third of U.S. adults and only about 20% of children and adolescents meet national recommendations for VF intake [3], [4], [5], [6]. The importance of a diet rich in VFs is increasingly reflected in federal government dietary guidelines, and is being translated into programmatic and funding priorities [7]. For example, the 5-A-Day program began as an initiative of the California State Department of Health Services and became a national program in 1991, jointly sponsored by National Cancer Institute (NCI) and the Produce for Better Health Foundation [8], [9], [10], [11]. The goal of the 5-A-Day program is to increase the population's consumption of VF to five or more servings a day using four major components: retail, community, media, and research [8], [9], [10], [11]. In April, 2002, the NCI, Centers for Disease Control and Prevention (CDC), and the U.S. Department of Agriculture (USDA) signed a commitment to partner to enhance and coordinate their programmatic and funding efforts in the area of national VF promotion, including national 5-A-Day programs [7]. Several federal advisory committees have recommended increasing behavioral research efforts to better understand the motivations for healthy food choices and characteristics of effective VF promotion interventions.
Public health approaches for eating behavior change in populations have primarily focused on increasing individual knowledge and awareness through educational approaches using the mass media in settings such as schools, worksites, and grocery stores [12], [13], [14]. Recently, greater attention has been given to the role of environmental influences on food choices and to policies that might affect environmental variables [15], [16], [17]. Environmental influences include food availability, price, promotion, and social influences such as social norms and role models. Environmental interventions are those that do not require the individual to select him/herself into an intervention program. Typical environmental strategies include changes in food availability (physical access or environmental opportunity) or price (economic access, incentives), or promotional, advertising, and point-of-purchase information [12].
Youth are an important group to target for VF intervention efforts. Eating behaviors such as VF intake are established in youth and track into adulthood [18], [19]. Thus, behavioral interventions that establish adequate levels of VF intake among youth have the potential to prevent adulthood chronic disease related to low VF intake, as well as to yield current nutritional and health benefits that result from healthful levels of VF intake [18], [19].
School-based nutrition interventions have been an important setting for examining environmental strategies to increase healthy food choices among youth, including those that have specifically targeted VF intake. Schools provide high access to youth of diverse ethnic/race and socioeconomic groups and provide a significant proportion of total daily energy intake for most students, both through the federally reimbursable school meals program and through competitive food sources such as a la carte areas and vending machines [20], [21], [22], [23].
Section snippets
Rationale and methods of literature review
The purpose of this report is to provide a review of the available literature on the school food environment with a focus on identifying effective strategies to promote VF consumption among youth in school settings. The literature reviewed as part of this report focused on VF promotions in school-based settings, with a specific interest in environmental interventions, or interventions that included an environmental component as part of a multicomponent intervention program. The literature
Description of the current school food environment
Currently, about 84,000 U.S. public schools participate in the National School Lunch Program (NSLP) [20]. The NSLP has federal guidelines that specify the nutritional standards school meals must meet in order to be eligible for federal reimbursement [20]. Schools vary in the proportion of students who participate in the NSLP, with a general decline from elementary through secondary school [20], [21]. NSLP participation is associated with higher average intake of many nutrients and greater
School-based vegetable and fruit interventions: overview of theoretical models and intervention components
The school-based interventions to increase VF intake among students are reviewed below in the following order: (1) multicomponent interventions to increase VF intake; (2) stand-alone environmental interventions to increase VF intake; (3) multicomponent intervention programs that targeted several eating behaviors, including VF consumption; (4) stand-alone environmental interventions that targeted food choices other than VF (e.g., high fat foods).
Vegetable and fruit interventions: multicomponent programs
Five multicomponent school-based interventions were located in the literature [25], [33], [34], [35], [36] Table 1, Table 1. All of these studies were conducted in the United States and were funded as part of the NCI's 5-A-Day program [8], [9]. Most of these interventions were framed in terms of Social Cognitive Theory [37] or the transtheoretical model [38]. However, the interventions were not specifically designed to explicitly test these theories. These theories were used as frameworks to
Summary of multicomponent vegetable and fruit interventions
To summarize the school-based, multicomponent VF intervention trials, two randomized controlled trials in 4th and 5th graders reported significant increases in VF intake, and one reported somewhat mixed results. A nonrandomized short-term school-based intervention reported significant positive increases in VF intake in the same age group (4th and 5th graders). One randomized study in high schools reported somewhat positive results that were not maintained over the entire 3-year intervention
Environmental interventions for vegetable and fruit intake
Three studies were located that evaluated environmental-only interventions [40], [41], [42] (Table 1). One study was a group-randomized trial that examined several environmental strategies to increase VF consumption among elementary school children [42]. Two studies were located that focused on a single environmental change strategy to increase VF intake in school settings [40], [41]. The first study examined the effects on VF intake of increases in the availability of low cost VF in elementary
School-based multibehavioral interventions including vegetables and fruits
Several school-based multicomponent nutrition interventions targeted change in VF intake as one of several behavior changes Table 2, Table 2 .Two randomized trials [43], [44] and two nonrandomized trials [45], [48] are discussed below. Consistent with the VF-specific, multicomponent interventions reviewed above, no independent evaluation of the environmental components is available, so the relative impact of the environmental component on change in VF intake is unclear.
Perry et al. [43]
Summary of multibehavioral interventions including vegetables and fruits
The results of the four non-VF-specific multibehavioral nutrition interventions do not present a consistent picture of the impact of these types of interventions on changes in VF intake. One large multicenter randomized trial that included a food service cafeteria intervention component did not significantly increase VF intake among 3rd, 4th, and 5th graders [43]. One randomized trial that did not include a food service cafeteria intervention component significantly increased VF intake among
Environmental interventions for eating behavior change
Four studies have examined the effects of changes in the cafeteria food availability or food prices on changes in students' purchase of targeted foods (Table 2). While these interventions did not specifically target changes in VF intake, they are included here as innovative examples of environmental intervention strategies that have potential for application to changing VF intake. Two studies were conducted to examine the effects of increases in availability of lower fat school meal entrees on
Summary
Five multicomponent school-based interventions that primarily targeted VF intake were identified. Most of these interventions were framed in terms of Social Cognitive Theory, and included classroom-based educational or behavior change curricula, food service cafeteria intervention, parent outreach/home-based activities, and in some cases, community-based components. The environmental component is typically defined in terms of changes in VF availability as part of the school lunch program. Food
Conclusion
The results of several multicomponent school-based programs to increase VF intake have shown effective results on F intake, with increases ranging from 0.2 to 0.6 servings per day. V intake has proven more difficult to change. Most of these programs included classroom education and behavior change curricula, food service changes, and a parent home activity component. Because no separate evaluation of the environmental intervention components was done, evaluation of the relative impact of
Research recommendations
- 1.
Identification of environmental strategies to increase the availability of vegetables and fruits and to support their choice by students.
- 2.
Separate evaluation of the environmental intervention components of multicomponent vegetable and fruit intervention programs.
- 3.
Direct comparison of environmental-only and multicomponent interventions to promote vegetable and fruit intake.
- 4.
Direct comparison of school-based and school-plus-community-based interventions to promote vegetable and fruit intake.
- 5.
Acknowledgements
This research was supported by the National Cancer Institute.
References (52)
- et al.
Changes in fruit and vegetable consumption and awareness among U.S. adultsresults of the 1991 and 1997 5 A Day for Better Health Program surveys
J Am Dietetic Assoc
(2002) - et al.
5 A Day for better health: a new research initiative
J Am Dietetic Assoc
(1994) - et al.
Development and evaluation of a school intervention to increase fruit and vegetable consumption among 4th and 5th grade students
J Nutr Educ
(1993) - et al.
Fat and sugar levels are high in snacks purchased from student stores in middle schools
J Am Diet Assoc
(2000) - et al.
Effect of a la carte and snack bar foods at school on children's lunchtime intake of fruits and vegetables
J Am Diet Assoc
(2000) - et al.
Availability of foods in high schoolsIs there cause for concern?
J Am Diet Assoc
(1996) - et al.
Increasing fruit and vegetable consumption of fourth-gradersresults from the High 5 Project
Prev Med
(2000) - et al.
Pricing strategy to promote fruit and vegetable purchase in high school cafeterias
J Am Diet Assoc
(1997) - et al.
Effects of the Child and Adolescent Trial for Cardiovascular Health (CATCH) on fruit and vegetable intake
J Nutr Educ
(1998) - et al.
Changes in the nutrient content of school lunchesresults from the CATCH Eat Smart food service intervention
Prev Med
(1996)
The Cookshop Programoutcome evaluation of a nutrition education program linking lunchroom food experiences with classroom cooking experiences
J Nutr Educ
Randomized intervention to increase children's selection of low-fat foods in school lunches
J Pediatrics
Diet and healthimplications for reducing chronic disease risk
Vegetables, fruit and cancer Iepidemiology
Cancer Causes Control
Fruit and vegetable intakes of children and adolescents in the U.S
Arch Pediatr Adol Med
Dietary behavior changethe challenge of recasting the role of fruit and vegetables in the American diet
Am J Clin Nutr
The National 5 A Day for Better Health Programan American nutrition and cancer prevention initiative
The National 5 A Day for Better Health Programa large-scale nutrition intervention
J Public Health Manage Pract
Environmental interventions to promote healthy eatinga review of models, programs, and evidence
Health Educ Q
Obesity as a public health problem
Nutrition education for school-aged children
J Nutr Educ
Environmental influences on eating and physical activity
Annu Rev Public Health
Environmental and policy approaches to cardiovascular disease prevention through nutritionopportunities for state and local action
Health Educ Q
Cited by (178)
Taste Exposure Increases Intake and Nutrition Education Increases Willingness to Try an Unfamiliar Vegetable in Preschool Children: A Cluster Randomized Trial
2019, Journal of the Academy of Nutrition and DieteticsSystematic review and meta-analysis of strategies to increase vegetable consumption in preschool children aged 2–5 years
2018, AppetiteCitation Excerpt :It is important to understand which strategies are most successful in early years to promote liking and intake of vegetables, as eating habits developed during childhood track into adulthood (Harris, 2008; Ventura & Worobey, 2013). Evidence from previous reviews suggests that interventions to encourage fruit and vegetable intake are selectively beneficial for fruits (Evans, Christian, Cleghorn, Greenwood, & Cade, 2012; French & Stables, 2003). For example, the meta-analysis by Evans et al. (2012) in children aged 5–12 years revealed only a small effect of intervention on daily fruit intake (+0.24 portion) and no effect on daily vegetable consumption (+0.07 portion).
Fresh Fruit and Vegetable Program and Requests for Fruits and Vegetables Outside School Settings
2018, Journal of the Academy of Nutrition and Dietetics