Changing fruit and vegetable consumption among children: the 5-a-Day Power Plus program in St. Paul, Minnesota

The Norwegian School Fruit Programme: evaluating paid vs. no-cost subscriptions

BACKGROUND

This study reports the effect of providing Norwegian school children with free fruit or vegetables every school day and the effect of an existing fee-based School Fruit Programme.

METHODS

Seventh grade pupils and their parents completed questionnaires at baseline (autumn 2001) and at follow-up (spring 2002). Nine schools participated in the School Fruit Programme for free (Free fruit), nine schools took part at standard conditions (Paid fruit), and 20 schools did not take part in the subscription programme (No fruit). A total of 795 7th graders (11 or 12 years old at baseline) participated both at baseline and at follow-up.

RESULTS

At follow-up, pupils attending the Free fruit schools had significantly higher intake of fruit and vegetables at school than the pupils at the Paid fruit and No fruit schools (P < 0.001, mean intakes were 1.1, 0.4 and 0.2 portions, respectively). Subscribers at the Paid fruit schools had significantly higher intake than the non-subscribers at the same schools.

CONCLUSIONS

Providing a free piece of fruit or a vegetable is an effective strategy to increase school children's fruit and vegetable intake. The existing School Fruit Programme appears to increase the intake among the subscribers, but thereby also tends to increase an existing difference in consumption patterns among subscribers and non-subscribers.

Promoting healthful diets and exercise: efficacy of a 12-week after-school program in urban African Americans

This study examined the effectiveness of a unique extracurricular after-school initiative designed to promote healthy diets and exercise in urban African Americans. The Students and Parents Actively Involved in Being Fit after-school program was offered for 12 weeks to students and their parents/guardians at an urban middle school. Specific aims of the intervention were to increase participants' vegetable and fruit intake by using established 5 A Day for Better Health educational resource materials/activities and to affect their health-related fitness through dance, games, and fitness activities. Fifty-six children and 25 parents/guardians completed a standard battery of evaluations before and after the program. Pre-post pairwise t test revealed that both children and their parents/guardians showed an increase in fruit consumption and a reduction in diastolic blood pressure (P <.05). Moreover, children showed improvements in systolic blood pressure and fruit juice, salad, and nonfried potato consumption while parents/guardians showed a decrease in body fat, body mass index, and endurance walk/run time (P <.05). Overall, findings indicate that children tended to gain more diet-related benefits while parents/guardians tended to derive more fitness-related benefits. After-school programs like the Students and Parents Actively Involved in Being Fit initiative can potentially contribute to improved health levels in urban African Americans.

A site-specific literature review of policy and environmental interventions that promote physical activity and nutrition for cardiovascular health: what works?

OBJECTIVE

To review the literature to determine whether policy and environmental interventions can increase people's physical activity or improve their nutrition.

DATA SOURCES

The following databases were searched for relevant intervention studies: Medline, Chronic Disease Prevention File, PsychInfo, Health Star, Web of Science, ERIC, the U.S. Department of Transportation, and the U.S. Department of Agriculture.

STUDY SELECTION

To be included in the review, studies must have (1) addressed policy or environmental interventions to promote physical activity and/or good nutrition; (2) been published from 1970 to October 2003; (3) provided a description of the intervention; and (4) reported behavioral, physiological, or organizational change outcomes. Studies that had inadequate intervention descriptions or that focused on determinants research, individual-level interventions only, the built environment, or media-only campaigns were excluded.

DATA EXTRACTION

We extracted and summarized studies conducted before 1990 (n = 65) and during 1990-2003 (n = 64).

DATA SYNTHESIS

Data were synthesized by topic (i.e., physical activity or nutrition), by type of intervention (i.e., point-of-purchase), and by setting (i.e., community, health care facility, school, worksite). Current studies published during 1990-2003 are described in more detail, including setting and location, sample size and characteristics, intervention, evaluation period, findings, and research design. Findings are also categorized by type of intervention to show the strength of the study designs and the associations of policy and environmental interventions with physical activity and nutrition.

CONCLUSIONS

The results of our review suggest that policy and environmental strategies may promote physical activity and good nutrition. Based on the experimental and quasi-experimental studies in this review, the following interventions provide the strongest evidence for influencing these behaviors: prompts to increase stair use (N = 5); access to places and opportunities for physical activity (N = 6); school-based physical education (PE) with better-trained PE teachers, and increased length of time students are physically active (N = 7); comprehensive work-site approaches, including education, employee and peer support for physical activity, incentives, and access to exercise facilities (N = 5); the availability of nutritious foods (N = 33), point-of-purchase strategies (N = 29); and systematic officer reminders and training of health care providers to provide nutritional counseling (N = 4). Further research is needed to determine the long-term effectiveness of different policy and environmental interventions with various populations and to identify the steps necessary to successfully implement these types of interventions.

Associations between parental report of the home food environment and adolescent intakes of fruits, vegetables and dairy foods

OBJECTIVE

This study examines parental report of household food availability, parent dietary intake and associations with adolescent intakes of fruits, vegetables and dairy foods.

DESIGN

Cross-sectional study. Adolescents completed the Project EAT survey and the Youth Adolescent Food Frequency Questionnaire at school. Parents of adolescents were interviewed by telephone about the home food environment, eating habits and weight-related behaviours. General linear modelling was used to compare dietary intakes of adolescents across different levels of household food availability and parental intakes.

SUBJECTS/SETTING

The study sample included 902 adolescents and their parent or guardian.

RESULTS

Many parents were not consuming the minimum number of daily recommended fruit (44.5%), vegetable (69.9%) or dairy (46.9%) servings. While most parents reported that fruits and vegetables were available at home (90.3%) and vegetables were usually served at dinner (87.0%), fewer parents reported milk was served at meals (66.6%). Soft drinks were usually available at home (56.8%). Among girls, household availability was positively associated with fruit and vegetable intake (ttrend=2.70, P<0.01) and soft drink availability was inversely associated with dairy intake (ttrend=2.08, P=0.04). Among boys, serving milk at meals was positively associated with dairy intake (ttrend=3.65, P<0.01). Parental intakes were positively associated with dairy intake for boys (ttrend=2.04, P=0.04), and with dairy (ttrend=2.43, P=0.01), vegetable (ttrend=3.72, P<0.01) and fruit (ttrend=3.17, P<0.01) intakes for girls.

CONCLUSIONS/APPLICATIONS

Interventions designed to help adolescents improve consumption of fruits, vegetables and dairy foods may be enhanced by including a parental component aimed at increasing household availability and parents' intake of healthful food choices.

Multiple tailored messages are effective in increasing fruit and vegetable consumption among callers to the Cancer Information Service

Results are reported from a large (n = 3,402) four-group randomized trial to increase fruit and vegetable consumption among callers to the National Cancer Institute's (NCI's) Cancer Information Service (CIS) using tailored print materials. Following a baseline telephone interview, which included a brief educational message (BEM), participants were assigned randomly within CIS offices to one of four groups: single untailored (SU) group-one untailored set of materials; single tailored (ST) group-one tailored booklet; multiple tailored (MT) group-four tailored materials; and multiple retailored (MRT) group-four tailored materials with retailoring based on new information obtained at 5 months follow-up. Follow-up telephone interviews were conducted at 5 (n = 2,233) and 12 months (n = 1,927) after baseline. The main outcome measure was self-reported fruit and vegetable consumption using a seven-item food frequency questionnaire. At 12 months follow-up, there was a significant linear trend across groups of 0.21 servings (p = 0.0002). Specific nested hypotheses then were tested and revealed significant mean serving differences between SU (5.07) vs. MT (5.64) (p = 0.002) and SU vs. MRT (5.71; p < 0.001). Although the mean for ST (5.40) was greater than that for SU (5.07), the difference was not statistically significant (p = 0.07), and no difference was found between MT vs. MRT (p = 0.69). A higher proportion of recipients of tailored materials reported reading all of the materials and believing that they were written especially for them. No differences by experimental condition were found for the perceived usefulness or motivational impact of the print materials. In this trial, MT print materials were more effective at increasing fruit and vegetable (FV) consumption than were SU materials. The intervention mechanisms responsible for this effect merit further research. Retailoring did not produce a significant difference when compared with longitudinal baseline tailoring.

Reported willingness among adolescent nonsmokers to help parents, peers, and others to stop smoking

BACKGROUND

This study of 1025 adolescent nonsmokers aged 11-19 years examined level of interest and factors associated with reported willingness to help someone stop smoking.

METHODS

Data were collected from a survey distributed primarily in the schools at four geographic and ethnically diverse study sites.

RESULTS

A total of 692 adolescents identified someone close to them who smokes whom they thought should quit. Of these, 90% reported that they would be willing to help this person stop smoking. Multivariate predictors of willingness to help were female gender, less difficulty reading English, and greater level of comfort with talking to the smoker about their smoking. The smoker that the adolescents were willing to help was most often a parent or same age friend.

CONCLUSIONS

If this strong interest among adolescents could be tapped, engaging teens as support persons could be a novel public health approach to reaching parents, adolescents, and other smokers in the population.

Quality control for interviews to obtain dietary recalls from children for research studies

Quality control is an important aspect of a study because the quality of data collected provides a foundation for the conclusions drawn from the study. For studies that include interviews, establishing quality control for interviews is critical in ascertaining whether interviews are conducted according to protocol. Despite the importance of quality control for interviews, few studies adequately document the quality control procedures used during data collection. This article reviews quality control for interviews and describes methods and results of quality control for interviews from two of our studies regarding the accuracy of children's dietary recalls; the focus is on quality control regarding interviewer performance during the interview, and examples are provided from studies with children. For our two studies, every interview was audio recorded and transcribed. The audio recording and typed transcript from one interview conducted by each research dietitian either weekly or daily were randomly selected and reviewed by another research dietitian, who completed a standardized quality control for interviews checklist.Major strengths of the methods of quality control for interviews in our two studies include: (a) interviews obtained for data collection were randomly selected for quality control for interviews, and (b) quality control for interviews was assessed on a regular basis throughout data collection. The methods of quality control for interviews described may help researchers design appropriate methods of quality control for interviews for future studies.

Increasing children's fruit and vegetable consumption: a peer-modelling and rewards-based intervention

OBJECTIVE

To evaluate a peer-modelling and rewards-based intervention designed to increase children's fruit and vegetable consumption.

DESIGN

Over a 5-month period, children in an experimental and a control school were presented with fruit and vegetables at lunchtime. Children aged 5-7 y also received fruit at snacktime (mid-morning). The intervention was implemented in the experimental school and levels of fruit and vegetable consumption were measured at baseline, intervention and at 4-month follow-up.

SETTING

Two inner-city London primary schools.

SUBJECTS

In total, 749 children aged 5-11 y.

INTERVENTION

Over 16 days children watched video adventures featuring heroic peers (the Food Dudes) who enjoy eating fruit and vegetables, and received small rewards for eating these foods themselves. After 16 days there were no videos and the rewards became more intermittent.

MAIN OUTCOME MEASURES

Consumption was measured (i) at lunchtime using a five-point observation scale; (ii) at snacktime using a weighed measure; (iii) at home using parental recall.

RESULTS

Compared to the control school, lunchtime consumption in the experimental school was substantially higher at intervention and follow-up than baseline (P<0.001), while snacktime consumption was higher at intervention than baseline (P<0.001). The lunchtime data showed particularly large increases among those who initially ate very little. There were also significant increases in fruit and vegetable consumption at home (P<0.05).

CONCLUSIONS

The intervention was effective in bringing about substantial increases in children's consumption of fruit and vegetables.

Effects of a peer modelling and rewards-based intervention to increase fruit and vegetable consumption in children

OBJECTIVE

To measure children's consumption of, and liking for, fruit and vegetables and how these are altered by a peer modelling and rewards-based intervention.

DESIGN

In this initial evaluation of the programme, children's consumption of fruit and vegetables were compared within and across baseline and intervention phases.

SETTING

Three primary schools in England and Wales.

SUBJECTS

In total, 402 children, aged from 4 to 11 y.

INTERVENTION

Over 16 days, children watched six video adventures featuring heroic peers (the Food Dudes) who enjoy eating fruit and vegetables, and received small rewards for eating these foods themselves.

MAIN OUTCOME MEASURES

Fruit and vegetable consumption was measured (i) in school at lunchtime and snacktime using a five-point observation scale, with inter-rated reliability and weighed validation tests; and (ii) at home using parental recall. A questionnaire measured children's liking for fruit and vegetables before and after the intervention.

RESULTS

Consumption during the intervention was significantly higher than during baseline at lunchtime and at snacktime (P<0.001 in all instances). Consumption outside school was significantly higher during the intervention on weekdays (P<0.05) but not weekend days. Following the intervention, children's liking for fruit and vegetables also showed a significant increase (P<0.001).

CONCLUSIONS

The peer modelling and rewards-based intervention was shown to be effective in bringing about substantial increases in children's consumption of, and expressed liking for, fruit and vegetables.

SPONSORSHIP

: Horticultural Development Council, Fresh Produce Consortium, ASDA, Co-operative Group, Safeway, Sainsbury, Somerfield, Tesco and Birds Eye Wall's.

School-based approaches to affect adolescents' diets: results from the TEENS study

This article reports on the outcomes of the Teens Eating for Energy and Nutrition at School (TEENS) study, a 2-year intervention study conducted in 16 middle schools with a goal of increasing students' intakes of fruits, vegetables, and lower fat foods. Despite positive interim results for students randomized to intervention schools, the positive effects of the intervention were not seen for the primary outcomes at the end of the 2nd year. Positive effects were seen only for a food choice score (suggesting that the students usually choose lower versus higher fat foods) and not for measures of food intake. Future studies may need to take a step back toward more controlled efficacy studies in working with this age-group. In addition, future work may consider the use of peer leaders, more intensive teacher training, ongoing formative assessment, and the testing of more powerful environmental change intervention strategies.

Design and analysis of group-randomized trials: a review of recent practices

We reviewed group-randomized trials (GRTs) published in the American Journal of Public Health and Preventive Medicine from 1998 through 2002 and estimated the proportion of GRTs that employ appropriate methods for design and analysis. Of 60 articles, 9 (15.0%) reported evidence of using appropriate methods for sample size estimation. Of 59 articles in the analytic review, 27 (45.8%) reported at least 1 inappropriate analysis and 12 (20.3%) reported only inappropriate analyses. Nineteen (32.2%) reported analyses at an individual or subgroup level, ignoring group, or included group as a fixed effect. Hence increased vigilance is needed to ensure that appropriate methods for GRTs are employed and that results based on inappropriate methods are not published.

Availability, accessibility, and preferences for fruit, 100% fruit juice, and vegetables influence children's dietary behavior

The relationships among home fruit (F), 100% fruitjuice (J), and vegetable (V) availability and accessibility separately, as reported by 225 fourth- through sixth-grade children and their parents (n = 88), separately, and FJV preferences to child-reported FJV consumption were assessed. For girls, child-reported FJV availability and accessibility accounted for 35% of the variability in FJV consumption. Child-reported availability and parent-reported accessibility were significantly correlated with child FJV consumption in a combined model. For children with high FJV preferences, FJV availability was the only significant predictor, whereas both availability and accessibility were significantly related to consumption for children with low FJV preferences. Interventions targeting child dietary behaviors may need to tailor to the home environment, separately by gender. Extra efforts are necessary by parents to enhance accessibility among children who do not like FJV.

The impact of the Pathways intervention on psychosocial variables related to diet and physical activity in American Indian schoolchildren

BACKGROUND

The purpose of this study was to examine the impact of the Pathways intervention on pychosocial variables related to physical activity and diet in American Indian children.

METHODS

Schools serving American Indian children were randomized to a multicomponent intervention or control condition. At baseline (fall of third grade) and in the spring semester of third, fourth, and fifth grades 755 boys and 692 girls completed a classroom-administered questionnaire. The questionnaire assessed self-efficacy, knowledge, and behavioral intentions related to diet and physical activity, as well as weight loss behaviors and body image.

RESULTS

Knowledge of nutrition and physical activity messages increased in both boys and girls in the intervention group compared to controls; however, knowledge of which foods contained more fat did not increase consistently. Compared to controls, self-efficacy to be physically active increased among girls in intervention schools, but not among boys, whereas self-efficacy to make more healthy food choices did not increase more than in controls in either gender. In the intervention group, compared to controls, healthy food intentions and participation in physically active behaviors increased in both boys and girls. Perception of healthy body size and weight loss attempts did not differ in the intervention and control groups.

CONCLUSION

The Pathways intervention program had a positive impact on several aspects of obesity-related knowledge, attitudes, and behaviors.

Impact of the Pathways intervention on dietary intakes of American Indian schoolchildren

BACKGROUND

The Pathways study was a randomized, 3-year trial of obesity prevention in American Indian Children. An important goal of the Pathways intervention was to significantly decrease the percentage of calories eaten as fat by the intervention children, relative to controls. This paper reports the effects of the Pathways intervention on dietary intake.

METHODS

Two types of dietary data were analyzed from random samples of children in 41 schools: direct observation of school lunch intake at baseline (2nd grade) and follow-up (5th grade) (n=470), and 24-hour dietary recalls at follow-up only (n=620). Nutrient contents of school meals and recalls were calculated by NDS and NDS-R software (University of Minnesota), using vendor products and recipes from each school.

RESULTS

Based on lunch observations, the intervention was associated with significant decreases in mean percentage of calories from total fat (3.6%) and saturated fat (2.1%) relative to controls, and a significant increase in the percentage of calories from total carbohydrate (3.7%). Compared with the control children, intervention children reported significantly smaller 24-hour intakes of energy (263 kcal), protein (9.5 g), total fat (15.1 g), saturated fat (6.0 g), and polyunsaturated fat (2.3 g); and as a percent of calories, total fat (2.5%) and saturated fat (1.1%). Mean intake of carbohydrates as a percentage of calories was significantly greater in intervention children by 2.5%, compared with controls.

CONCLUSIONS

The Pathways intervention successfully reduced the intake of percent calories from fat and saturated fat, at school lunch and over the whole day.

Sentence Completion to Assess Children's Views About Aging

PURPOSE

Sentence completion exercises require students to give open-ended responses to prompts. The first purpose of this article is to describe the method of sentence completion to assess middle-school children's attitudes and beliefs about aging. The second purpose is to describe the patterns of characteristics that children associate with aging.

DESIGN AND METHODS

Two middle schools in San Antonio, TX agreed to have their students participate in the sentence completion exercises at the beginning of the 1998-1999 school year. Teachers asked students to write responses to the following prompts: "Old is.," "You know you are old when.," "You know your parents are old when.," "When I am old, I.," and "Old people." We coded the responses for their characteristics and whether they were positive, negative, or neutral.

RESULTS

Of the 2,476 students, 1,874 (75.6%) wrote responses to at least one prompt. Overall, we collected 3,700 responses and coded 9,438 characteristics (2.6 characteristics per response). The most common characteristics of aging were having wrinkles (21.1%), having gray hair or being bald (20.0%), and being less active (17.5%). Students had a much more positive view of their future (55.4%) compared with their view of aging elicited by the other prompts (range of 4.9-25.7% positive responses). Students infrequently associated old age with specific conditions; only 4.6% mentioned diseases, 6.0% mentioned being ill or taking medications, and 5.7% mentioned sensory problems.

IMPLICATIONS

Middle-school students view their futures much more positively than the changes they observe in their parents and other elders. Students infrequently identified specific diseases or impairments as responsible for the changes they observe with aging. These observed responses provide a starting point for educators to develop and deliver gerontologically based materials that teach about healthful habits to maintain independence across a life span.

Environmental interventions to promote vegetable and fruit consumption among youth in school settings

BACKGROUND

This paper reviews the available literature on the school food environment with a focus on identifying effective strategies to promote vegetable and fruit (VF) consumption among youth in school settings.

METHODS

Studies were identified through a search of electronic databases as well as references cited within published articles. Seven studies were identified that evaluated changes in VF intake and included a control group. Four additional school-based interventions were reviewed that focused on changes in VF intake as part of a multibehavior intervention.

RESULTS

Multicomponent school interventions have been effective in increasing F intake, with reported increases ranging from 0.2 to 0.6 servings per day. Impact on V intake has been less effective, with increases ranging from 0 to 0.3 servings per day. Total VF increases ranged from 0 to 0.6 servings per day. Results of environmental-only, school-based interventions have shown positive effects on students' choice of targeted foods.

CONCLUSIONS

Environmental change interventions in schools show potential for positively affecting VF consumption among youth.

Reverse versus forward order reporting and the accuracy of fourth-graders' recalls of school breakfast and school lunch

BACKGROUND

Do children recall school breakfast and school lunch intake during 24-h recalls more accurately when prompted to report meals and snacks in reverse versus forward order?

METHODS

One hundred twenty-one fourth-graders stratified by race (Black, White) and gender were each observed and interviewed twice (once per order) regarding the previous day's intake. Omission and intrusion rates determined accuracy for reporting items. Total inaccuracy determined accuracy for reporting items and amounts.

RESULTS

Results failed to indicate significant effects of interviewer, weekday, sequence (first or second recall), or race on omission rates, intrusion rates, or total inaccuracy. A significant order by gender interaction was found for omission rates, which were lower (i.e., better) for males for reverse (53%) versus forward recalls (62%), but not females (61 versus 53%) (P < 0.008). Intrusion rates were acceptable for males for 54% of reverse recalls and 40% of forward recalls (P = 0.095). Means were 57 and 32%, and 6.4 servings for omission rate, intrusion rate, and total inaccuracy for reverse recalls, and 56 and 39%, and 6.9 servings for forward recalls.

CONCLUSIONS

Prompting children to report in reverse versus forward order improved omission and intrusion rates for males more so than females. Regardless of reverse or forward order, children reported <50% of items observed; furthermore, >30% of items reported were not observed. Research is needed to enhance accuracy of children's dietary recalls.

Increasing children's acceptance of vegetables; a randomized trial of parent-led exposure

Despite considerable epidemiological evidence of the health benefits of a diet high in fruit and vegetables, consumption in pre-school children remains well below recommended levels. This study evaluated the effectiveness of an exposure-based intervention, carried out by parents in the home, in increasing children's liking for a previously disliked vegetable. 156 parents of 2-6 year old children were randomly assigned to Exposure, Information or Control groups after a pre-intervention taste test at which a 'target' vegetable was selected. Parents in the Exposure group gave their child a taste of this vegetable daily for 14 days, parents in the Information group were given nutritional advice and a leaflet, and parents in the Control group received no further intervention. All participants took part in a post-intervention taste test. Greater increases in liking, ranking and consumption of the 'target' vegetable from pre- to post-intervention occurred in the Exposure group than in either of the other two groups. Only the Exposure group showed significant increases across all three outcomes. It can be concluded that a parent-led, exposure-based intervention involving daily tasting of a vegetable holds promise for improving children's acceptance of vegetables. These findings suggest a parental advice strategy which could be disseminated directly to parents or by health professionals.

Leading the Way in Exercise and Diet (Project LEAD): intervening to improve function among older breast and prostate cancer survivors

The U.S. population is aging, bringing with it an increased prevalence of chronic disease and concomitant declines in physical function. The risk of developing cancer increases significantly with age, and functional decline is much more likely once a cancer diagnosis is rendered. Thus, functional status in later life is a key concern, one that is heightened among elders who have been diagnosed with cancer. To date, however, there have been few trials that have exclusively addressed issues related to cancer survivorship among older cancer patients, and to our knowledge, none has focused on preserving or enhancing physical functioning. This paper describes the study design and methodological considerations of a randomized controlled trial to determine if a personally tailored workbook and telephone counseling program can positively affect physical activity and dietary behaviors and ultimately the physical functioning of up to 420 older men and women newly diagnosed with breast or prostate cancer. This trial is unique because the cancer diagnosis is used not only as a marker of risk for functional decline, but also as a "teachable moment" - an opportune time when elders may be more receptive to making beneficial lifestyle changes. Undoubtedly, as cure rates for cancer increase and intersect with ever-growing numbers of elderly, there will be numerous opportunities to provide and test interventions within this vulnerable population and to target functional status as a primary outcome. In reporting our methods, we hope to give others "a leg up," so that they can hurdle with greater ease the barriers we experienced, and thus advance the field more rapidly.

Modifying children's food preferences: the effects of exposure and reward on acceptance of an unfamiliar vegetable

OBJECTIVE

The aim of this study was to evaluate two interventions (one reward-based and one exposure-based) for increasing children's acceptance of an unfamiliar vegetable compared with a no-treatment control. It was predicted that the exposure condition would increase liking for, and consumption of, the vegetable relative to either the reward or control group.

DESIGN

Using a randomized controlled design, participants were assigned to one of two intervention groups (exposure or reward) or to a no-treatment control condition, for a 2 week period. Liking for, and consumption of, red pepper was assessed before and after the treatment period.

SETTING

The study was conducted in three primary schools in London.

SUBJECTS

Parental consent was obtained for 49 out of a possible 72 children.

INTERVENTIONS

Interventions comprised eight daily sessions during which participants in the exposure group were offered a taste of sweet red pepper and told that they could eat as much as they liked. Participants in the reward group were shown a sheet of cartoon stickers and told that they could choose one of them on condition that they ate at least one piece of the pepper.

RESULTS

The exposure-based intervention significantly increased both liking (P=0.006) and consumption (P=0.03) compared with the control group. The outcome of the reward intervention was intermediate and did not differ significantly from the exposure or control conditions.

CONCLUSIONS

Repeated exposure to the taste of unfamiliar foods is a promising strategy for promoting liking of previously rejected foods in children.

Correlates of unhealthy weight-control behaviors among adolescents: implications for prevention programs

This study aimed to identify correlates of unhealthy weight-control behaviors in adolescents to guide the development of programs aimed at the primary prevention of disordered eating. A model explaining unhealthy weight-control behaviors was tested among 4,746 adolescents using structural equation modeling. Models fit the data well and explained 76% of the variance in unhealthy weight-control behaviors among girls and 63% among boys. Weight-body concerns were a strong correlate of unhealthy weight-control behaviors in both girls and boys. Models also emphasized the importance of weight-specific social norms within the adolescent's proximal environment. Findings suggest the importance of addressing weight-body concerns within prevention programs and extending interventions beyond classroom settings to ensure changes in weight-related norms among peer groups and family members.

Differences in Fourth-Graders' Participation Rates Across Four School-Based Nutrition Studies

Federal policy has encouraged researchers to include children in research studies; thus, it is important to report experiences recruiting children to participate in studies. This article compares fourth-graders' participation rates across four school-based nutrition studies conducted in one school district in a southeastern state. For each study, children were observed eating school meals (breakfast and lunch); interviewed regarding dietary intake; and weighed and measured. For Study 1, children from 11 schools received $10 per interview for up to two interviews conducted in the morning at school. For Study 2, children from 10 schools received $25 if interviewed once in the evening, either by telephone or in a van parked outside the child's home. For Study 3, children from three schools received $10 per interview for up to three interviews held in the evening by telephone. For Study 4, children from six schools received $15 per interview for up to two interviews conducted either in the morning or afternoon at school, or in the evening by telephone. Recruitment procedures were similar for all studies.Participation rates were 73% (n=635) for Study 1, 57% (n=432) for Study 2, 66% (n=158) for Study 3, and 71% (n=296) for Study 4. Logistic regression was used to determine whether study (1, 2, 3, 4), race (black, white), or gender (male, female) were significant predictors of participation (agreed, denied). The results indicated that study (p<0.0001), race (p=0.0198), and gender (p=0.0188) were significant predictors, however, no two-factor interactions among these effects were significant. Post hoc pairwise comparisons with Bonferroni adjustment indicated that agreement to participate for Study 2 was lower (p<0.0001) than that for Studies 1, 3, and 4, which did not differ. Agreement to participate across all four studies was higher for black (69%) than white (63%; p=0.0054) children and for females (69%) than males (64%; p=0.0209). Schools provide a natural environment for nutrition research because school foodservice programs feed millions of children one or two meals (breakfast and/or lunch) each school day. Observations of children eating school meals provide a convenient and relatively unobtrusive means of validating children's dietary recalls. Thus, at some point, most child nutrition professionals are likely to be involved in research either directly (i.e. by conducting studies themselves) or indirectly (i.e. by allowing others access to their school cafeterias to collect data).This paper references the following data:Table 1. Similarities and Differences in the Designs for Each of the Four Studies.Table 2. Number and Percent of Fourth-Grade Children Who Agreed or Denied to Participate by Race and Gender Across all Four Studies Combined.Table 3. Number and Percent of Fourth-Grade Children Who Agreed or Denied to Participate by Gender and Race for Each of the Four Studies Separately.

Assessing the dietary environment: examples from school-based nutrition interventions

OBJECTIVE

The objectives of this paper are to (1) introduce the concept of upstream and downstream public health approaches and discuss diet assessment issues in that context, and (2) provide examples of diet assessment methods and challenges in assessing environmental factors influencing eating patterns.

DESIGN

Dietary assessment of environmental factors is discussed as they relate to nutrition interventions for school-aged children, although the issues transcend population characteristics. Examples of assessment challenges in measuring 'dietary environments' are drawn from the Child and Adolescent Trial for Cardiovascular Health (CATCH), Teens Eating for Energy and Nutrition at School (TEENS) and Trying Alternative Cafeteria Options in Schools (TACOS) studies.

RESULTS/CONCLUSIONS

The healthfulness of our 'dietary environments' (which may include food availability, social norms around food choice and the effect of pricing, policy and promotion on food choice) may be more important in determining what people consume than their individual decision-making about food choice. There is a dearth of published information to inform us on how to assess these 'dietary environments'.

Do food-related experiences in the first 2 years of life predict dietary variety in school-aged children?

OBJECTIVE

To determine if food-related experiences in the first 2 years of life predict dietary variety in school-aged children.

DESIGN/SETTING

Child/mother pairs were interviewed 7 or 8 times when children were 2 to 24 months using a randomized incomplete block design to schedule interviews. Each child/mother pair was interviewed when the child was ages 6, 7, and 8 years.

PARTICIPANTS

Child/mother pairs (n = 70) were continuous participants in the longitudinal study.

MAIN OUTCOME MEASURES

Dependent variables were children's vegetable and fruit dietary variety, assessed from 3 days of dietary data at ages 6, 7, and 8 years. Independent variables from the first 2 years of life were selected from the longitudinal data set.

ANALYSES

General linear models. Adjustments for age that vegetables (or fruits) were introduced in the diet.

RESULTS

Vegetable variety in the school-aged child was predicted by mother's vegetable preferences, R2 =.084. Fruit variety in the school-aged child was predicted by breast-feeding duration and either early fruit variety (R2 =.254) or fruit exposure (R2 =.246).

CONCLUSIONS/IMPLICATIONS

Nutrition education messages for mothers should emphasize the importance of early food-related experiences to school-aged children's acceptance of a variety of vegetables and fruits.

Children's food preferences: a longitudinal analysis

OBJECTIVE

To compare children's food preferences longitudinally and identify factors related to food preferences.

DESIGN

Mothers completed the Food Preference Questionnaire for children at 2 to 3 years of age (T1), 4 years (T2), and 8 years (T3) and for themselves at T1 and T3. Both groups completed a Food Neophobia Scale at T3.

SUBJECTS

70 child/mother pairs who had participated continuously in the longitudinal study.

STATISTICAL ANALYSES PERFORMED

Changes in food preferences over time were tested with paired t tests and correlations. Consistency percentages were calculated by summing the consistent matches (like/like) for each food between two time periods. Similarly, concordance percentages were calculated for child/mother pairs by summing the concordant matches for each food. General linear models were developed to identify influences on children's food preferences.

RESULTS

Although children liked most foods, the number of liked foods did not change significantly during the 5 to 5.7 years of the study. The strongest predictors of the number of foods liked at age 8 years (R2=0.74) were the number liked at 4 years (P<.0001) and the food neophobia score (P=.0003). Newly tasted foods were more likely to be accepted between T1 and T2 than T2 and T3. Mothers' and children's food preferences were significantly but moderately related. Foods disliked by mothers tended not to be offered to children.

APPLICATIONS/CONCLUSIONS

The important role of children's early food preferences is confirmed by this study. Mothers influence children via their own preferences, which may limit foods offered to children.

A home-based nutrition intervention to increase consumption of fruits, vegetables, and calcium-rich foods in community dwelling elders

OBJECTIVE

To increase fruit, vegetable, and calcium-rich food consumption in community-dwelling, functionally impaired elderly.

DESIGN

Six-month, home-based nutrition intervention study.

SUBJECTS

Seventy men and women older than age 69 years were randomized to either a nutrition education intervention (n = 38) or a control group that received an exercise intervention (n = 32).

INTERVENTION

Nutrition education was designed to increase fruit, vegetable, and calcium-rich food consumption.

MAIN OUTCOME MEASURES

Food intake was assessed by a food frequency questionnaire. Fasting blood measures of nutrients and carotenoids were performed. Statistical Analysis Two-group randomized controlled trial with pre-test and post-test design and intention-to-treat analysis. Analysis of covariance to was used to assess differences between the two groups. Baseline and change partial correlation coefficients were performed between intake and blood nutrient levels. Paired t tests were conducted to test within-group changes.

RESULTS

Compared with the exercise group, subjects in nutrition group increased their self-reported intake of fruits by 1.1 +/- 0.2 (mean +/- SEM) servings per day (2.8 to 3.9, P = .01), vegetables 1.1 +/- 0.2 servings per day (2.3 to 3.4, P = .001), and milk/dairy 0.9 +/- 0.2 servings per day (3.0 to 3.9, P = .001). There was an increase in the dietary intake of alpha-carotene and beta-carotene in the nutrition group and this correlated with the increase in blood concentrations of alpha-carotene and beta-carotene (P < or = .02; r = 0.33 and r = 0.33, respectively).

CONCLUSION

The results of this study suggest that it is possible to improve the dietary intake of community dwelling elders to include more fruits, vegetables, and calcium-rich foods. Recommendations for increasing consumption of fruits, vegetables, and calcium-rich foods should be specific and individualized to meet the dietary pattern and lifestyle of the individual. Compliance should be encouraged with record keeping as well as through continuous monitoring and positive reinforcement.

Health and nutrition education in primary schools of Crete: changes in chronic disease risk factors following a 6-year intervention programme

The effectiveness of a health and nutrition education programme, in changing certain chronic disease risk factors, was assessed after the 6 years intervention period was completed. The school-based intervention programme was applied to all children registered in the first grade (age 5.5-6.5 years) in 1992 in two counties of Crete, while the children from a third county served as a control group. In order to assess the effectiveness of the intervention, a variety of biological and behavioural parameters were measured before and following completion of the intervention in a randomly selected school-based sample of 602 intervention group (IG) and 444 control group (CG) pupils. At the end of the 6-year period, it was found that biochemical indices generally improved significantly more in the IG compared with the CG (mean change for IG v. CG was -0.27 v. -0.12 mmol/l for total cholesterol (TC); -0.07 v. +0.24 for TC:HDL and -0.13 v. +0.14 for LDL:HDL). Similarly, the changes observed in the anthropometric variables in the two groups were in favour of the IG (+3.68 v. +4.28 kg/m2 for BMI; +2.97 v. +4.47 mm for biceps skinfold). Total energy intake and consumption of total fat and saturated fat increased significantly less in the IG compared with the CG (+747.7 v. 1534.7 kJ (+178.7 v. +366.8 kcal); +5.9 v. +18.8 g and +0.8 v. +5.1 g respectively), while time devoted to leisure time physical activity and cardiovascular run test performance increased significantly more in the IG (+281 v. +174 min/week and +2.5 v. +1.2 stages respectively). The findings of the present study underline the importance of such programmes in health promotion and disease prevention. Although the long-term effects of these programmes can only be assessed by tracking this population through to adolescence and adulthood, these programmes seem to have the potential to lead to a healthier lifestyle and thus a reduction in risk factor levels.

Patient-centered interventions

Patient-centered care is valued in nursing. However, until recently, nurse-researchers have focused on testing the effects of standardized rather than patient-centered interventions (PCIs). The latter are those interventions that are altered to address selected patient characteristics (e.g., beliefs, habits, or goals). PCIs have been well received, and in some studies they have been associated with improved health outcomes. In this article we describe briefly the concept patient centered, summarize the development of research on PCIs, discuss kinds of PCIs, provide examples of PCIs and how they have been derived and implemented, and raise issues for theory and future research.

Are differences in exposure to a multicomponent school-based intervention associated with varying dietary outcomes in adolescents?

Multicomponent interventions are recommended for health behavior change among adolescents. However, it is difficult to disentangle the effects of multiple intervention components. This article reports outcomes associated with varying levels of exposure to a school-based nutrition intervention. Teens Eating for Energy and Nutrition at School (TEENS). Four incremental exposures were possible: (1) control group, (2) school environment interventions only, (3) classroom plus environment interventions, and (4) peer leaders plus classroom plus environment interventions. Pattems suggesting dose response were observed, with peer leaders reporting the largest increases in fruit, vegetable, and lower fat food consumption. Students exposed to classroom plus environment interventions also improved, whereas students exposed only to school environment interventions showed trends toward choosing lower fat foods and declining fruit intake and no change in vegetable intake. Control students' choices remained stable. Future studies may investigate mechanisms for peer leaders' changes, maximizing curriculum effectiveness, and improving environmental interventions.

Evaluation of a theater production about eating behavior of children

This study evaluated "All's Well That Eats Well," a theater production performed in 20 schools in the Twin Cities, Minn., metropolitan area in winter 2000. The production sought to change food-related knowledge and food choices concerning fruits and vegetables among children in grades 1-6. The study used a pretest-posttest design with two randomly-assigned, sequential intervention-control groups (N = 4,093). All students completed surveys prior to and then following the theater production and the classroom and home activities. No differences existed between the groups at pretest. Significant differences occurred in food-related knowledge, food choices, and food recall from pretest to posttest for all students. Significant differences also occurred between intervention groups in food-related knowledge and food choices. The study indicates that professional theater productions in schools can create at least a short-term effect on children's nutrition knowledge and behavior.

The efficacy of behavioral interventions to modify dietary fat and fruit and vegetable intake: a review of the evidence

BACKGROUND

The evidence suggesting that nutrition, particularly dietary saturated fat and fruit and vegetable intake, is related to chronic disease risk has prompted considerable research on behavioral interventions focusing on dietary change. No clear understanding has emerged, however, of the degree to which these interventions can materially influence dietary change, or the types of intervention that are most effective and for whom. Therefore, the primary objective of the current study was to evaluate the overall effectiveness of behavioral dietary interventions in promoting dietary change related to chronic disease risk reduction. A secondary goal was to explore the relative effectiveness of specific intervention features and among different population subgroups.

METHODS

We conducted an evidence-based review and secondary analysis of existing literature. Our data sources included reports of randomized controlled trials and other study designs identified from multiple searches of MEDLINE, EMBASE, PsycINFO, CINAHL, AGELINE, and AGRICOLA. We included all studies on humans (including children, adolescents, and adults) published in English since 1975 that had been conducted in North America, Europe, or Australia; that had sample sizes of at least 40 subjects at follow-up; that were not based on controlled diets; and that otherwise met inclusion criteria. Through dual review, we abstracted detailed information on study characteristics, methodology, and outcomes relating to consumption of fruits, vegetables, and fats.

RESULTS

From 907 unduplicated articles originally identified, we retained 104 articles reporting on 92 independent studies. The studies were similarly successful in reducing intake of total and saturated fat, and increasing fruit and vegetable intake. More than three-quarters of the studies (17 of the 22 reporting results for fruit and vegetable intake) reported significant increases in fruit and vegetable intake, with an average increase of 0.6 servings per day. Similar consistent decreases were seen in intake of saturated fat and total fat (7.3% reduction in the percentage of calories from fat). Interventions appeared to be more successful at positively changing dietary behavior among populations at risk of (or diagnosed with) disease than among general, healthy populations. Two intervention components seemed to be particularly promising in modifying dietary behavior-goal setting and small groups.

CONCLUSIONS

The majority of the interventions reviewed resulted in meaningful improvements in dietary factors behaviors associated with the prevention of chronic disease, particularly among individuals at elevated disease risk. The lack of similarity across studies in outcome measures, study design, analysis strategy, and intervention technique hampered our ability to draw broad conclusions about the most effective behavioral dietary interventions, but our findings offer insight into intervention components that may hold promise for future research efforts.

Changes in vegetable and fruit consumption and awareness among US adults: results of the 1991 and 1997 5 A Day for Better Health Program surveys

OBJECTIVE

The purpose of this study is to assess population-based changes in vegetable and fruit consumption and psychosocial correlates.

DESIGN

Two nationally representative random digit dial surveys conducted in 1991 and 1997; respondents were queried regarding consumption of and attitudes and knowledge about vegetables and fruit.

SUBJECTS/SETTING

Respondents were 2,755 and 2,544 adults (in 1991 and 1997, respectively) older than 18 years.

STATISTICAL ANALYSIS PERFORMED

Vegetable and fruit consumption and message awareness were measured using weighted-only and regression model-adjusted analyses to assess changes.

RESULTS

Mean vegetable and fruit consumption was significantly (P=.007) higher in 1997 than in 1991 using weighted-only analyses, but remained significant only for Hispanic (P=.03) and nonsmoker (P=.004) subgroups when adjusted for demographic shifts. Significantly higher percentages were found in the model-adjusted analyses for those consuming 5 or more (daily servings (23.4% to 25.8%), message awareness (7.7% to 19.2%), and knowledge of the 5 A Day Program (2.0% to 17.8%).

APPLICATIONS/CONCLUSIONS

A significantly positive change in vegetable and fruit consumption occurred between 1991 and 1997 according to traditional methods of survey data analysis, but null findings resulted when the data were adjusted for demographic shifts. Nutrition professionals should continue targeting specific demographic subgroups with tailored interventions to move all Americans toward achievement of dietary guidelines for vegetable and fruit consumption.

The Team Nutrition pilot study: lessons learned from implementing a comprehensive school-based intervention

Team Nutrition (TN) is an educational and promotional initiative developed by the US Department of Agriculture to change children's eating behaviors through social marketing techniques. This article reports on the process evaluation of a TN pilot project targeting students in kindergarten to grade 4 and systematically documents the implementation experience. Even with a very short start-up period, schools implemented most components of this multichannel nutrition intervention and formed new, supportive relationships with local media and community partners. School teachers and administrators, along with foodservice professionals, generally expressed support for and satisfaction with TN, citing the positive experience and gains for students. The lessons learned from this study highlight the management and organizational issues involved in a comprehensive intervention. These include the importance of local coordinators to support and create a bridge between teachers and cafeteria staff and to forge links with key external partners. To function effectively, coordinators themselves may need training in coalition building and working with media. Relationships formed with parents, local businesses, other educational institutions, health organizations, and the media offer promise for helping to sustain nutrition education efforts. The TN process evaluation identified multiple ideas for pursuing these partnerships more successfully.

Behavioral science research in the prevention of diabetes : status and opportunities

Recent studies show diabetes can be prevented. Growing knowledge of its biological bases opens further prevention opportunities. This article focuses on behavioral science research that may advance these opportunities. An ecological model guides attention to how prevention research may be pursued at the individual, group, or community levels. Three key areas are reviewed: risk communication, screening, and preventive interventions. Research on diabetes risk communication is limited but suggests that many are relatively unaware of risks and may have misconceptions about the disease. Amid policy debates and research regarding the potential benefits and costs of screening, identification of diabetes may itself be risky in terms of psychological and social consequences. The Diabetes Prevention Program and other studies make clear that diabetes can be prevented, both by the combination of weight loss and physical activity and by medications. Research needs to address promoting these methods to individuals as well as to groups and even whole communities. Fundamental as well as applied research should address how risks of diabetes are understood and may be communicated; how to enhance benefits and minimize psychological and other risks of screening; how to promote healthy eating and weight loss, physical activity, and appropriate use of medications to prevent diabetes; and how to reduce socioeconomic and cultural disparities in all these areas.

Designing effective nutrition interventions for adolescents

By altering dietary behaviors, nutrition interventions during adolescence have the potential of affecting children at that time and later in life. The majority of interventions implemented in the teen years have occurred in schools, but other intervention sites have included after-school programs, summer camps, community centers, libraries, and grocery stores. Programs with successful outcomes have tended to be behaviorally based, using theories for the developmental framework; included an environmental component; delivered an adequate number of lessons; and emphasized developmentally appropriate strategies. One planning method that can be used in the development of nutrition interventions is Intervention Mapping. The steps of Intervention Mapping include conducting a needs assessment, developing proximal program objectives, mapping appropriate strategies and methods to address the objectives, planning the program design, planning program adoption and implementation, and evaluation. The use of intervention-planning techniques, coordination of nutrition and physical education interventions, using technological advances such as CD-ROMs, incorporation of policy changes into intervention efforts, and dissemination of effective programs are all trends that will influence the future development of effective nutrition programs for adolescents.

Low accuracy and low consistency of fourth-graders' school breakfast and school lunch recalls

OBJECTIVE

To determine the accuracy and consistency of fourth-graders' school breakfast and school lunch recalls obtained during 24-hour recalls and compared with observed intake.

DESIGN

Children were interviewed using a multiple-pass protocol at school the morning after being observed eating school breakfast and school lunch.

SUBJECTS

104 children stratified by ethnicity (African-American, white) and gender were randomly selected and interviewed up to 3 times each with 4 to 14 weeks between each interview.

STATISTICAL ANALYSIS

Match, omission, and intrusion rates to determine accuracy of reporting items; arithmetic and/or absolute differences to determine accuracy for reporting amounts; total inaccuracy to determine inaccuracy for reporting items and amounts combined; intraclass correlation coefficients (ICC) to determine consistency.

RESULTS

Means were 51% for omission rate, 39% for intrusion rate, and 7.1 servings for total inaccuracy. Total inaccuracy decreased significantly from the first to the third recall (P=0.006). The ICC was 0.29 for total inaccuracy and 0.15 for omission rate. For all meal components except bread/grain and beverage, there were more omissions than intrusions. Mean arithmetic and absolute differences per serving in amount reported for matches were -0.08 and 0.24, respectively. Mean amounts per serving of omissions and intrusions were 0.86 and 0.80, respectively.

APPLICATIONS/CONCLUSIONS

The low accuracy and low consistency of children's recalls from this study raise concerns regarding the current uses of dietary recalls obtained from children. To improve the accuracy and consistency of children's dietary recalls, validation studies are needed to determine the best way(s) to interview children.

Review and analysis of evaluation measures used in nutrition education intervention research

The purpose of this review is to provide a summary of the kinds of evaluation measures used in 265 nutrition education intervention studies conducted between 1980 and 1999 and an analysis of psychometric issues arising from such a review. The data are summarized in terms of tables for interventions with each of six key population groups: preschool children, school-aged children, adults, pregnant women and breast-feeding promotion, older adults, and inservice preparation of professionals and paraprofessionals. Measures evaluating knowledge and skills or behavioral capabilities were most widely used in studies with preschool, school-aged, and inservice populations (50%-85%) and less widely used in studies with the other groups, particularly breast-feeding promotion (5%). Measures of potential psychosocial mediators or correlates of behavior such as outcome expectancies, self-efficacy, or behavioral intention were used in 90% of behaviorally focused studies with school-aged children and in about 20% of studies with adults. Dietary intake measures were used in almost all studies, primarily food recalls, records, and quantitative food frequency questionnaires. Short frequency instruments involving only foods targeted in the intervention such as fruits and vegetables are increasingly being used. Measures of specific observable behaviors are also increasingly being used. Physiologic parameters were used in about 33% of behaviorally focused interventions with school-aged children and adults, 20% with older adults, and 65% with pregnant women and/or their infants. Criterion validity of newly developed intake instruments and content validity of instruments measuring mediating variables were reported in the majority (range 50%-90%) of studies. Reliability and stability of measures of mediating variables were reported in 50% to 75% of studies, with reliability coefficients mostly about .6 to .7. Two major conclusions from this review are that evaluation measures should be appropriate to the purpose, duration, and power of the intervention and that measures should have adequate validity and reliability in relation to both the outcomes and characteristics of the target audience. Major implications are that considerable preliminary work needs to be done before any intervention study to develop and test evaluation instruments so that they are appropriate and have adequate psychometric properties, and cognitive testing of published instruments with each new target audience is essential. We will then be better able to make judgments about the effectiveness of nutrition education.

A randomized trial of a brief intervention to increase fruit and vegetable intake: a replication study among callers to the CIS

BACKGROUND

Results are reported from a large randomized trial designed to increase fruit and vegetable consumption among callers to the National Cancer Institute's Cancer Information Service (CIS) (n = 1,717).

METHODS

CIS callers assigned to the intervention group (n = 861) received a brief proactive educational intervention over the telephone at the end of usual service, with two follow-up mailouts. Key educational messages and print material derived from the NCI 5 A Day for Better Health program were provided to intervention participants. Participants were interviewed by telephone at 4 weeks (n = 1,307), 4 months (n = 1,180), and 12 months for follow-up (n = 1,016).

RESULTS

Results obtained from a single-item measure of fruit and vegetable consumption indicate a significant intervention effect of 0.88 servings per day at 4 weeks follow-up (P < 0.001), 0.63 servings per day at 4 months follow-up (P < 0.001), and 0.43 servings per day at 12 months follow-up (P < 0.001). Using a 7-item food frequency measure, an intervention effect of 0.63 servings per day was obtained at 4 weeks follow-up (P < 0.001), compared with 0.39 servings per day at 4 months follow-up (P = 0.002) and 0.44 servings per day at 12 months follow-up (P = 0.002). A 24-h recall assessment included in the 4-month interviews also yielded a significant intervention effect of 0.67 servings per day (P = 0.015). The vast majority of callers (90%) endorsed the strategy of providing 5 A Day information proactively within the CIS.

CONCLUSIONS

This brief educational intervention was associated with higher levels of self-reported fruit and vegetable intake at both short- and long-term follow-up. Additional research is recommended to test this or a similar intervention in diverse populations.

Preventing obesity in children and adolescents

In this review, we address the natural history of obesity in children, the most promising family- and school-based approaches to the prevention of obesity, and the barriers and opportunities associated with secondary prevention. In childhood, the most important periods of risk appear to be the periods of adiposity rebound and adolescence. Caution regarding the period of adiposity rebound is still warranted, because it is not yet clear that early rebound is attributable to changes in body fat. Families and schools represent the most important foci for preventive efforts in children and adolescents. One productive approach is to proceed from an examination of factors that affect energy balance to the identification of more proximal influences on those factors. This approach may help to narrow the strategies necessary to prevent or treat childhood obesity. For example, television viewing affects both energy intake and energy expenditure, and therefore represents a logical target for interventions. Anticipatory guidance by pediatricians may offer an effective mechanism by which to change parental attitudes and practices regarding television viewing. A similar process is used to emphasize the potential influence of school-based interventions directed at changes in food choices and sedentary behavior.

The school setting: an opportunity for the implementation of dietary guidelines

Nutrition, physical activity and health related promotion programmes in schools have developed into a mature field of research over the past decades. A number of success factors have been identified and evidence-based interventions have been performed. However, the school setting as an arena for evidence-based health promotion programmes, is still not used to its full potential. Schools provide an excellent arena for reaching large segments of the population, such as young people, school staff, families and the surrounding community. There is a need for an overview regarding the current status of nutrition, physical activity, related health as well as support structures in the EU member states. Based upon such an analysis, a consensus report should be written, pointing out the major problems at hand. Self-assessment tools for national as well as for school level should be produced, in order to guide changes, but also to include an element of continuous assessment of change, for evaluation purposes.

School-based nutrition education: lessons learned and new perspectives

Nutrition is a major environmental influence on physical and mental growth and development in early life. Food habits during infancy can influence preferences and practices in later life and some evidence suggests fair to moderate tracking of food habits from childhood to adolescence. Studies support that good nutrition contributes to improving the wellbeing of children and their potential learning ability, thus contributing to better school performance. Children and young people who learn healthy eating habits, are encouraged to be physically active, to avoid smoking and to learn to manage stress, have the potential for reduced impact of chronic diseases in adulthood. Nutrition education is a key element to promoting lifelong healthy eating and exercise behaviours and should start from the early stages of life; it should also address the specific nutritional needs associated with pregnancy, including reinforcing breastfeeding. Food habits are complex in nature and multiple conditioning factors interact in their development. Young children do not choose what they eat, but their parents decide and prepare the food for them. During infancy and early childhood the family is a key environment for children to learn and develop food preferences and eating habits. As they grow and start school, teachers, peers and other people at school, together with the media and social leaders, become more important. Progressively children become more independent and start making their own food choices. The peer group is very important for adolescents and has a major influence in developing both food habits and lifestyles. Community trials suggest that nutrition education is an accessible effective tool in health promotion programmes with a focus on the development of healthy eating practices.