Background
Adequate consumption of fruit and vegetables provides children with essential nutrients for healthy growth and development [
1] and may displace the consumption of energy-dense, nutrient-poor foods associated with childhood overweight and obesity [
2‐
6]. Given that childhood diet is a significant determinant of adult diet [
7] and higher fruit and vegetable consumption in childhood is associated with decreased risk of adult chronic disease [
8,
9], the benefits of adequate childhood fruit and vegetable consumption appear to extend throughout the lifespan. Despite this, internationally, a high proportion of children have inadequate fruit and vegetable intake [
10,
11]. Identifying factors associated with higher childhood fruit and vegetable consumption may assist in the development of interventions to address this public health issue.
Many factors influence the foods that children eat: the demographic and socio-economic characteristics of their families [
10,
11]; their individual preferences and genetic predispositions [
12,
13]; psychosocial factors [
14]; and characteristics of their environment [
15,
16]. Given the amount of time children spend in the home, this environment represents a potentially promising setting in which to improve young children's fruit and vegetable consumption. Rosenkranz's ecological model of the home food environment hypothesises that child diet in this setting is influenced by three domains: built and natural environments; political and economic environments; and socio-cultural environments [
17]. Of these, those most proximal to a child's life, such as home accessibility and availability of foods (built and natural environments) and parental diet, parenting practices and rules, and family eating patterns (socio-cultural environments) may be most amenable to intervention. As such, research investigating associations between these characteristics of the home environment and children's fruit and vegetable consumption is warranted.
Studies of school-aged children have found parental fruit and vegetable intake and the accessibility and availability of fruit and vegetables in the home [
12,
15,
16] to be consistently associated with children's consumption. However, research involving children of preschool age (children aged 3 to 5 years [
18]) is limited. For example, a 2007 systematic review that included environmental correlates of children's fruit and vegetable intake identified just three studies involving children of preschool-age, compared with 30 studies involving children aged 5-18 years [
16], while a more recent systematic review only included studies of children aged 6 years and older [
15]. The factors influencing dietary habits in early childhood be may distinct from those affecting school-aged children, due to preschoolers' earlier developmental stage and greater dependence on their family [
15]. The few studies that have investigated associations between such factors and fruit and vegetable consumption in preschool children found positive associations with parental fruit and vegetable intake [
19‐
21] and parental role-modeling [
22]; and negative associations with eating in front of the television [
23] and parental pressure to eat [
21,
23]. However, only a minority of these studies, have used both a comprehensive or validated assessment of child fruit and vegetable consumption and multivariate analyses to isolate the effect of individual variables and control for the influence of socio-demographic characteristics [
20,
21]. As such, this study sought to address these limitations, and identify characteristics of the home food environment associated with fruit and vegetable consumption in a sample of Australian preschool children.
Results
The sample consisted of 396 parents, recruited from 30 preschools across the Hunter region. Of the 57 preschools within the sampling frame, 30 consented, 19 were ineligible, seven refused to participate and one could not be contacted. Children from approximately 2,200 families attended the 30 preschools, and 417 parents consented to participate, with a further 178 returning a form indicating that they did not consent to participate. Of the consenters, ten refused to participate when contacted to complete the survey, six were ineligible and five could not be contacted, resulting in a total of 396 parents providing data for the analysis. The study sample and the characteristics of their home food environments are described in Table
1.
Table 1
Parent, child and home food environment characteristics of the 396 study participants
Parent characteristics
| |
Mean age (SD) - years | 35.5 (5.3) |
Gender - female | 96% |
Aboriginal and/or Torres Strait Islander | 2% |
Highest educational level | |
Years 7-9 | 2% |
Years 10 | 11% |
Year 11-12 | 10% |
TAFE (Technical and Further Education) | 30% |
University | 47% |
Annual household income* | |
< $20,000 | 4% |
$20,000 - $39,999 | 9% |
$40,000 - $59,999 | 11% |
$60,000 - $79,999 | 15% |
$80,000 - $99,999 | 19% |
$100,000 | 41% |
Child characteristics
| |
Mean age (SD) - years | 4.3 (0.6) |
Gender - female | 49% |
Mean daily serves of fruit (SD)#
| 2.3 (1.0) |
Mean daily serves of vegetables (SD)#
| 2.1 (1.1) |
Home food environment characteristics
| |
Parental role-modeling
| |
Daily serves of fruit & vegetables | 5.0 (1.8) |
Occasions/day modeled fruit & vegetable consumption | 2.3 (1.4) |
Pressure to eat
| |
Pressure to eat | 3.1 (0.7) |
Parent providing behaviour
| |
Times/day parent provides fruit & vegetables | 3.2 (1.3) |
Fruit and vegetable availability
| |
Different varieties of fruit & vegetables in home | 21.7 (4.8) |
Fruit and vegetable accessibility
| |
Fruit and vegetables kept in ready to eat format (% yes) | 39% |
Mealtime practices
| |
Always eat together as a family (7 nights per week) | 57% |
Never eat in front of TV (0 nights per week) | 47% |
Family eats most meals at table/bench (% who all or most of the time) | 87% |
Family eating policies (% who all or most of the time ...)
| |
Ask child to eat everything on their plate at dinner | 50% |
Restrict dessert if child does not eat dinner | 59% |
Reward with dessert if child finishes dinner | 29% |
Only allow child to eat at set mealtimes | 39% |
Allow child to help him/herself to snacks | 4% |
There were no significant differences between participants and those non-consenters who returned a form with respect to child age, gender, daily serves of fruit or vegetables, or level of disadvantage based on residential postcode [
44]. However, only a small proportion (approximately 10%) of the families who did not participate returned a completed consent form. In comparison with a regionally representative sample of children aged 2 to 4 years, a similar proportion of children in this study consumed at least one serve of fruit per day, but a higher proportion of children in the study consumed at least two serves of vegetables per day [
45].
Most parents (99%) lived with their child 7 days a week and most (74%) reported that they were 'always' responsible for their child's meals and snacks, with 22% and 5% reporting they were responsible 'most of the time' and 'half of the time' respectively. Parents consumed an average of five serves of fruit and vegetables each day and consumption levels approximated that of female adults of a similar age within the region [
45]. On average, parents ate fruit and vegetables in front of their children more than two occasions per day and provided their children with fruit and vegetables more than three times a day. While, on average, households had almost 22 different types of fruit and vegetables available in the house, fewer than half of those households (39%) kept both fruit and vegetables in a ready-to-eat, accessible format. On average, families ate together at a table 5.6 days a week (with 57% eating together 7 days a week) and children ate dinner in front of the television on an average of 2.2 days a week (with 47% not doing this at all, i.e. 0 days per week). The majority of families (87%) ate most meals at a table. Although 59% of parents indicated that they would restrict dessert 'most' or 'all of the time' when their child did not eat their dinner, 29% rewarded their child with dessert for finishing dinner. Only 4% of parents allowed their child to access snacks themselves.
The mean score for the fruit and vegetable subscale for children within the study was 14.8 (sd 4.6). Table
2 displays the strength of the associations between children's fruit and vegetable score and characteristics of the home food environment and socio-demographic characteristics in simple and multiple regression models.
Table 2
Associations between CDQ score and characteristics of the home food environment: simple and multiple regression
Parental role-modeling
| | | | |
Daily serves of fruit & vegetables (F&V) | 0.87 (0.64-1.11) | < 0.001 | 0.30 (0.09-0.50) | 0.005 |
Occasions/day modeled F&V consumption | 1.09 (0.78-1.40) | < 0.001 | | |
Pressure to eat
| | | | |
Pressure to eat | -0.78 (-1.40- -0.17) | 0.012 | | |
Parent providing behaviour
| | | | |
Times/day parent provides F&V | 2.22 (1.96-2.49) | < 0.001 | 1.80 (1.53-2.09) | < 0.001 |
Fruit and vegetable availability
| | | | |
Different varieties of F&V in home | 0.34 (0.25-0.43) | < 0.001 | 0.12 (0.03-0.20) | 0.006 |
Fruit and vegetable accessibility*
| | | | |
F&V kept in ready to eat format (Yes) | 1.80 (0.87-2.73) | < 0.001 | 0.90 (0.20-1.60) | 0.012 |
Mealtime practices*
| | | | |
Always eat together as a family (7 nights per week) | 0.90 (-0.02-1.82) | 0.055 | | |
Never eat dinner in front of TV (0 nights per week) | 0.87 (-0.04-1.79) | 0.061 | | |
Family eats most meals at table/bench (All or most of the time) | 0.48 (-0.86-1.82) | 0.480 | | |
Family eating policies*
| | | | |
(% who all of most of the time ...)
| | | | |
Ask child to eat everything on plate at dinner | -0.05 (-0.96-0.87) | 0.922 | | |
Restrict dessert if child does not eat dinner | -0.68 (-1.60-0.25) | 0.151 | | |
Reward with dessert if child finishes dinner | -0.79 (-1.79-0.21) | 0.121 | | |
Only allow child to eat at set mealtimes | 1.38 (0.46-2.31) | 0.003 | 1.00 (0.31-1.68) | 0.006 |
Allow child to help him/herself to snacks | -1.59 (-3.90-0.72) | 0.177 | | |
Socio-demographic characteristics
#
| | | | |
Parental education - University | 1.13 (0.22-2.05) | 0.015 | | |
Annual household income >$100,000 | 0.87 (-0.05-1.79) | 0.065 | | |
Child gender | 0.64 (-0.27-1.55) | 0.169 | | |
Child age | -0.12 (-0.87-0.64) | 0.765 | | |
Simple regression analysis found statistically significant positive associations (p < 0.003) between children's fruit and vegetable consumption and the following factors: parental fruit and vegetable intake; occasions per day where parents role-model fruit and vegetable consumption; provision of fruit or vegetables to children; variety of fruit and vegetables available in the home; keeping fruit and vegetables in a ready-to-eat format (e.g. washed and chopped); and only allowing children to eat at set meal times.
Twelve characteristics of the home food environment had a p-value less than 0.25 in the simple regression models and were entered into the backward stepwise regression along with parental education, household income and child gender. The assumptions of multiple regression were tested and found to be acceptable. The regression coefficients, 95% confidence intervals and p-values for the five significant variables (p < 0.05) that were retained in the final regression model are shown in the final two columns of Table
2.
Multiple regression analysis indicated that higher fruit and vegetable consumption in children was significantly associated with: higher fruit and vegetable intake in parents, more frequent provision of fruit and vegetables to children throughout the day, having a wider variety of fruits and vegetables available in the home, having fruit and vegetables stored in a ready-to-eat format, and generally only allowing children to eat at set mealtimes. These variables remained significant despite controlling for parental education, household income and the gender of the child. This model of the characteristics of the home food environments accounted for 48% of the variation in the child's fruit and vegetable score. The regression coefficients suggest that, all other factors held constant, each additional occasion that parents provide their children with fruit or vegetables throughout the day is associated with an average an increase in children's fruit and vegetable score of 1.80 points, and that ensuring that children generally only eat at set mealtimes is associated with an average increase of 1.00 points in the fruit and vegetable score. The coefficients of the remaining three significant variables within the model ranged from 0.12 to 0.90.
Discussion
This study is one of only a handful of studies examining associations between characteristics of the home food environment and the fruit and vegetable consumption of preschool-aged children, and among the first to investigate these relationships through multiple regression analysis and with a reliable and valid measure of fruit and vegetable intake. The study found that greater fruit and vegetable consumption in children was positively associated with parent's own fruit and vegetable consumption; the frequency with which parents provide these foods to their child; the availability and accessibility of these foods in the home; and with maintaining set mealtimes. Such findings provide insights into factors that influence young children's vegetable and fruit intake.
The positive association between child and parent fruit and vegetable intake is supported by studies involving preschool-aged children [
19‐
21] as well as older children and adolescents [
14,
18,
48,
49] and supports previous recommendations that modification of parent diet be a key strategy for interventions targeting children's eating habits [
5,
19,
21,
38,
46]. A lack of significant association between child fruit and vegetable intake and parental consumption of these foods in front of their children, however, suggests that the influence of parental role-modeling is complex [
47,
48]. Further research investigating the mechanisms by which parental intake may influence child consumption may yield important insights for intervention.
A unique aspect of this study was the examination of parental provision of fruit and vegetables as a correlate of child consumption. Although the reported positive association is somewhat intuitive for children of this age, the finding accentuates the critical role that parents play in facilitating fruit and vegetable consumption through provision of these foods. Within the study sample at least, the findings also suggest that there is considerable scope to further improve child fruit and vegetable intake through encouraging more frequent provision. On average, parents provided fruit or vegetables to their child on 3.2 occasions per day, with dinner being the most prevalent occasion for serving vegetables, and morning tea the most prevalent occasion for serving fruit. Given that it is recommended that children of this age have three meals and two to three small snacks daily [
49], introducing fruit and vegetables at additional occasions throughout the day, particularly the provision of vegetables for morning or afternoon teas, could represent an effective intervention strategy. Further, the findings of this, and other studies with older children [
50,
51] demonstrate a greater likelihood for children to eat fruits and vegetable if they are stored at home in a ready-to-eat form. As preparation time is a commonly cited barrier to fruit and vegetable consumption [
52,
53], having ready-to-eat fruit and vegetables on hand may increase the likelihood of parents feeding their preschool child these foods rather than convenient, pre-packaged, snack foods. As only 39% of parents in this study reported storing fruit
and vegetables in this way, strategies that make it easier for parents to purchase, prepare and store ready-to-eat fruits and vegetables are needed and likely to facilitate increased parent provision of these foods to their child.
These findings should be considered in the context of the study limitations. First, this data is cross-sectional, precluding conclusions regarding causality. Further research is warranted to determine if these associations are evident in longitudinal research, and if changes to such characteristics mediate the changes to child fruit and vegetable intake following intervention. Second, use of parent volunteers may have introduced selection-bias as study participants may not be representative of the broader population from which they were drawn. Compared to a random sample of 764 mothers of 2 to 5 year-olds in the broader study region, parents in this study were more educated (47% vs 36% with a university education) and from higher income households (41% vs 20% earning over $100,000 per year) [
33] and their children had higher levels of vegetable consumption than a regionally representative sample of children aged 2 to 4 years [
45]. The strength of the associations found in this study is therefore unknown among families from less advantaged backgrounds. Furthermore, most participants identified themselves as the parent that was primarily responsible for feeding their child, and only 4% of the participants were fathers, most likely due to fathers being less likely to drop children at childcare [
54] and being less likely to have primary responsibility for food within the household [
55]. This may restrict the generalisability of study findings to mothers, and the primary food provider, rather than parents more broadly. The inclusion of measures of the home food environment with unknown validity and reliability is a further limitation of this research and further research is required to develop and refine appropriate measures suitable for population-based investigation. Finally, this research examined the combined consumption of fruit and vegetables. The analyses did not allow for the identification of the relative associations of environmental characteristics with fruit and vegetable intake separately [
56]. Future research should seek to address these limitations.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
Author RW led the development of this manuscript. Authors RW, EC and LW determined the research design and the measures to be used. All authors decided upon the analyses conducted, and contributed to, read and approved the final version of this manuscript.