Abstract
Concerns about childhood obesity and chronic disease make most primary care providers willing to address diet. Lack of time and knowledge are cited as obstacles. This article reviews the evidence for selecting one simple message to share with patients. Substantial evidence indicates increasing fruit and vegetable intake can reverse the rising trend is diet-related disease. Eating shared family meals leads to better food choices and lower calories. Recommending family meals and including a fruit or vegetable with every meal and snack, is easy to understand and the health benefits can be significant.
When there is only one opportunity to share a message with a parent interested in improving the family diet, the most powerful recommendation a health care provider can share is, “Include a fruit or vegetable with every meal and snack, and eat meals together.” Why? The message is simple, easy to understand, and effective.
A Simple Message May Be the Best Message
When families hear clear nutrition messages from their health care provider, research indicates that such messages can lead to positive change. In a survey of adults receiving routine health care, those who were asked by their doctor about diet were more likely to have changed their fat or fiber intake and somewhat more likely to have lost weight than those who were not asked about diet. 1 Simple interventions that address diet and weight, such as diagnosing overweight in patients or asking about food choices, leads to weight loss attempts. 2
. . . a health message needs to be both simple and clear to be effective.
Concerns about childhood obesity and chronic disease make parents hungry for guidance, and there is an enormous amount of nutrition information that could be integrated into care; but a health message needs to be both simple and clear to be effective. An example of a successful, effective, and simple health message can be found in the recommendations made to reduce sudden infant death syndrome (SIDS). In 1992, 70% of parents were putting their infants to bed face down. When the prone sleep position was identified as a risk factor for SIDS, pediatric health care providers changed their sleep advice to include the clear, specific message: “put your baby to sleep on his back.” The Back to Sleep Campaign began in 1994. Since that time, the percentage of infants placed on their backs to sleep has increased dramatically, and the overall SIDS rate has declined by over 50%. 3 It would not have been adequate to advise parents to “put your child to bed safely” just as it is not adequate to tell individuals “to eat a little better.” The simple recommendation to “ include a fruit or vegetable or both with every meal and snack, and eat together as often as you can,” could be effective at moving parents toward action just as the Back to Sleep campaign did, because it is simple and easy to understand.
“Eat Right” Versus “Eat More”: Messages That Children Hear
Most physicians believe that it is their responsibility to address diet, but barriers such as lack of time, compensation, knowledge, and resources are all cited as obstacles. 4 The American Academy of Pediatrics, recognizing the rise in obesity among children and its eventual accompanying health consequences, has also recommended that nutrition be addressed as part of well-child visits. Because most Americans visit their primary care provider or are in contact with their provider at least once in any year, and twice a year for children, the non–acute care visit, particularly the adult and well-child visit, provide an ideal opportunity to offer information about diet. Integrating health messages into primary care is particularly important for young children where it is needed to balance the messages heard from the American food industry. Half of all ads on children’s television shows are for food. The average 2- to 7-year-old child views12 food ads per day or approximately 4400 per year, and 8- to 12-year-olds are exposed to 7600 food ads per year. Public service announcements promoting fitness and better nutrition are far fewer; children aged 2 to 7 years see an average of 164 public service announcements in a year, and for 8- to 12-year-olds, that number is 158. 5
More Fruit and Vegetables: The Nutrition Message of Choice
Substantial evidence indicates that increasing fruit and vegetable intake to the recommended levels can reverse the rising trend in all diet-related disease, including cardiovascular disease, stroke, hypertension, diabetes, weight management, and some cancers.6,7 Fruits and vegetables are high in water content, low in calories, and require chewing—factors that improve satiety and increase meal volume. When fruits and vegetables are incorporated into meals and recipes, portions look large, but the caloric density is lower, and the large volume of food helps people feel full. Thus, portions can be the same with fewer calories, and those calories are not replaced at subsequent meals. 8
Health benefits from a high intake of fruits and vegetables apply to all family members. Along with a diet that includes dairy products, eating a menu rich in fruit and vegetables reduces blood pressure in adults, and the same benefits have been found in children who consumed 4 servings of fruit and vegetables during the preschool years. 9 Including the recommended servings of fruits and vegetables also offers the potential benefit of slowing the rate of cognitive decline with age, an important selling factor as the US population ages. 10 The benefit of incorporating a fruit and vegetable message over other nutrition messages is that it is quick and effective. When fruits and vegetables substitute for the foods currently overrepresented in the US diet, a menu is more likely to come in line with the US dietary guidelines designed to promote optimal health.
Recognizing low intake of fruits and vegetables as a major risk factor for chronic disease, health care providers in the United Kingdom have taken a novel nutrition approach to help their patients. In one community, primary care providers hand over a prescription providing discounts on fruit and vegetable purchases. The intervention takes less than 1 to 2 minutes to deploy, and the clinicians anecdotally find it to be effective. 11
In the United States, offering discounts is not an available treatment tool, but prescribing family meals and recommending parents include a fruit or vegetable with every meal and most snacks is practical and simple to understand. The message does not require any special resources or knowledge and little interpretation, and it could go a long way in improving diet and, thus, reducing obesity, heart disease, diabetes, and even some forms of cancer.
Knowing Is Not Doing
Since the National Cancer Institute (NCI) initiated the “five a day” campaign to increase fruit and vegetable intake in 1991, the percentage of Americans who know that they should eat 5 or more servings of fruit and vegetables a day has more than quadrupled, from 8% to 36%, and the overall consumption of fruits and vegetables has increased. 12
A phone survey after the release of the 2005 Dietary Guidelines for Americans conducted by Opinion Dynamics Corporation found that about one third of consumers surveyed were unclear about portion sizes, but they were aware of the fruit and vegetable recommendation made in the guidelines.
Despite being aware of the recommendations and the health benefits associated with eating fruits and vegetables, we are not on target for consuming what we need. The September 2010 report assessing state consumption of fruits and vegetables included in the CDC’s Morbidity and Mortality Weekly Report finds fruit and vegetable consumption to be far short of the Healthy People 2010 goals. In fact, no state in the United States met the targeted goals.
The 2010 Dietary Guidelines recommend that female adolescents, participating in less than 30 minutes of daily physical activity, consume 1.5 cups of fruit and 2.5 cups of vegetables daily, and males 2 cups of fruit and 3 cups of vegetables daily. However, consumption has been found to be considerably below this level. 13 To increase consumption, it is more effective for parents to serve fruits and vegetables more frequently than it is to increase portion size at meals.14,15 Making the recommendation to include a fruit or vegetable at every eating opportunity would in theory guarantee at least 1 serving at each eating event, and because snacking among children aged 2 to 18 years and adults aged 19 years and more has increased during the past decade, this would almost certainly move young people and their parents closer to the recommended servings they need. 16
French Fries: Our Most Popular Vegetable
The foods we feed in the early stages of life can have an impact on a child’s preferences for life.
The Feeding Infants and Toddler Study (FITS), sponsored by Gerber Products Company, updates our understanding of the food and nutrient intake of infants and toddlers in the United States. The survey asked the parents or caregivers about the feeding habits of their children aged 4 months to 24 months. It provides a look into what families are feeding their kids, and illustrates how quickly young parents are forced to make decisions about how and what they feed their children.
Through phone interviews, questions were asked about food choices, feeding practices, growth, and development, and conclusions about nutrient intake were determined. The 2004 FITS found that half of all 7- to 8-month-olds were eating dessert daily, replacing the recommended fruits and vegetables they actually need. One third of 7- to 24-month-old babies ate no vegetables at all, and by 15 months of age, French fries became the most popular vegetable. 17
The 2008 FITS nutrient assessment found that toddler and infant intake of fiber and potassium was below recommended levels. 18 This coincided with the finding that the diets of all infant, toddler, and preschool age groups were low in fruit and vegetable intake—foods that are rich in fiber and potassium.19,20 Alarmingly, French fries remain the most commonly consumed vegetable among preschoolers. 20 Once infants move to table food, potatoes become the vegetable of choice. The trend of not meeting the recommendations for fruit and vegetables starts as early as 9 to 11 months of age, and as the FITS babies transition to table food, 25% of 19- to 24-month-olds are consuming chips or other salty snacks on any given day.
Combine the fact that parents have complex food choices with the phenomenon of the “picky eater,” and you have a source of real stress for new parents. As many as 50% of babies 4 to 24 months of age are described by their parents as “picky eaters.” Most parents offer a food 3 to 5 times, and 25% of parents surveyed only offer a food 1 to 2 times before deciding that their child does not like it; yet research indicates that children may need 8 to 15 tries before accepting a new food. 21 Many parents are giving up too soon. A campaign to include a fruit or vegetable with every meal and snack could help the picky eater. It would increase the frequency with which they are exposed to new fruits and vegetables, allowing children to become familiar with them and stimulating consumption.
Recommend Food, Not Nutrients
Mozaffarian and Ludwig 22 advise that we move from a nutrient-based to a food-based approach when making food recommendations to improve health. A nutrient-based approach can sway parents toward choosing a highly processed and heavily marketed food because it is fortified with desirable nutrients such as fiber or because it is advertised as being low in fat. Currently, the USDA’s Healthier US School Challenge Competitive Food Criteria for packaged snack foods provides specific recommendations based on total fat, saturated fat, sugar, sodium, and calories. Cereal bars, baked chips, reduced-sugar cereal, and flavored fruit snacks can all make the “acceptable list” because they meet the defined nutrient requirements. However, these snacks will do nothing to move children toward the goal of eating more produce.
Increasing fruits and vegetables has been identified as a behavioral target to prevent obesity in infants and young children. Optimal child development is associated with those parents who provide clear guidance about healthy food choices. Asking parents to include a fruit or vegetable at meals and every snack can displace foods currently overrepresented in the US diet. The 2010 Dietary Guidelines revealed grain-based desserts, yeast bread, chips, and crackers to be among the top sources of calories in the US diet. Using a food-based approach and the recommendation to include a fruit or vegetable with every meal and/or snack, children would be snacking on more fruits and vegetables helping them reach the goal of 1 to 2.5 cups of fruit and 1 to 3 cups of vegetables every day advised for children aged 2 to 18.
The Power of the Family Table
Eating shared family meals 3 or more times per week can lead to better food choices and reduce the risk of being overweight.23,24 Meals prepared at home include larger portions of fruit and vegetables, help children increase fruit and vegetable intake, and provide the opportunity to sample a new food.25,26 Sampling is a technique food marketers use to introduce a new product or change an image, and the same technique can be used at the table to “market” new foods at home.
More meals at home obviously lead to fewer restaurant meals. Food surveys reveal that eating at restaurants or meals based on take-out foods from restaurants include little, if any, servings of fruit or vegetables. Fried potatoes make up 35% of vegetables eaten away from home compared with 10% of at-home consumption. 27 Encouraging family meals can improve the diet for many children by lowering calorie consumption and lead to an increase in fruit and vegetable intake.
No one cares about an individual child more than his or her parent. Help parents teach good nutrition in their own home, at the family table, where it will be most effective by providing them with 1 clear, effective message. The most powerful recommendation a health care provider could share with a parent interested in improving the family’s diet just might be, “Include a fruit or vegetable with every meal and snack, and eat family meals as often as you can.”
Use these resources to help increase fruit and vegetable consumption and family meals:
For the Love of Food Project at www.fortheloveoffood.org: provides ideas and inspiration for increasing fruit and vegetable intake;
Choose My Plate at www.choosemyplate.gov: find the Daily Food Plans under SuperTracker & Other Tools and using your child’s age, gender, height, weight, and activity and learn how many servings of fruits and vegetables your child needs;
Fruits and veggies more matters: www.fruitsandveggiesmorematters.org has ideas for increasing consumption of fruits and vegetables and includes activities and recipes; and
Family Day: A day to eat dinner with your children: www.casafamilyday.org.