Abstract
Parents, families and schools play key roles in influencing the eating habits of children. This article reviews several factors that can influence the intake of fruits and vegetables in children. Families that eat together have better overall diets, including intakes of fruits and vegetables. When parents serve as positive role models and make fruits and vegetables more available and accessible to children intakes increase. Schools, through their food and nutrition programs, have increased the amounts of fruits and vegetables offered to children. Assisting parents with simple messages about increasing fruits and vegetables in the home and at meal time for their children can improve health and reduce disease risk.
‘By eating more whole fruits, reducing intake of 100% fruit juice, and eating more vegetables of a variety of colors, USDA recommendations can be met.’
Fruits and vegetables supply vitamins and minerals, are usually low in calories if prepared without sugar or sauce, and are associated with a reduced risk of many chronic diseases including cardiovascular disease. The US Department of Agriculture (USDA) recommends in general that adults consume 4½ cups and children up to age 10 consume 2 to 3½ cups of fruits and vegetables per day, based on age, gender, and activity level. 1 Unfortunately, both adults and children in the United States are not consuming recommended levels of fruits and vegetables. Enns et al 2 reviewed data from 3 national surveys covering a span of 25 years and found that intakes of total vegetables were lower than recommendations: intakes of legumes and dark green vegetables were very low whereas the intake of fried white potatoes increased over time. Total fruit consumption has remained low over this time frame, with only 24% of girls and 23% of boys consuming recommended amounts. 2 The National Cancer Institute data for children ages 2 to 18 shows similar findings.3,4
What to do? By eating more whole fruits, reducing intake of 100% fruit juice, and eating more vegetables of a variety of colors, USDA recommendations can be met. The purpose of this article is to examine 4 factors that have been shown to increase children’s intake of fruits and vegetables, with a focus on the key role of the family, parents, and schools.
Factor 1: Family Mealtime
Families that eat together have better overall diets, including intakes of fruits and vegetables. In a study of more than 2300 children attending primary school in London, Christian et al 5 found that children who always or sometimes ate with a family consumed more fruits and vegetables than those reporting never eating a family meal. Moreover, when parents ate fruits and vegetables every day, so did their children. In addition, children who had access to cut-up vegetables and fruit every day consumed, on average, 0.5 more fruit and vegetable portions than those who only had these items available on occasion. This research showed that the children who ate meals with their families consumed 1.5 more fruit and vegetable portions than those reporting never eating as a family.
The findings of Christian et al were validated in older children. Neumark-Sztainer et al 6 studied 4746 middle and high school students from the Minneapolis/St Paul public schools. They found a strong positive association between the quality of the students’ diets and frequency of family meals. Adolescents reported eating an average of 4.5 meals with their family over the course of the week, with 27% eating 5 or more meals per week with their family. Youth who ate 7 or more meals with their families had higher consumption of fruits, vegetables, and calcium-rich foods and lower consumption of soft drinks, compared to youth who never or rarely ate with their families. 6
In a 5-year longitudinal study of 1710 high school students, Larson et al 7 found that the greater the number of meals eaten as a family during adolescence, the higher the intake of fruits, vegetables, dark green and orange vegetables and the lower the intake of soft drinks in young adulthood. Teens who reported eating 7 or more family meals a week consumed approximately 0.7 more servings of fruits and vegetables per day as young adults. 7
Factor 2: Availability of Fruits and Vegetables
Parents make the majority of the food buying decisions in the family. Increasing the availability of fruits and vegetables in the home starts with encouraging parents to purchase more fruits and vegetables in place of foods that do not offer the same nutrient quality. If foods of lower quality are not present in the home, then children do not have them available to eat.
In her book How to Get Your Kid to Eat . . . But Not Too Much, Ellyn Satter 8 outlines the feeding relationship between parents and children. Satter maintains that it is the parent’s job to choose healthy foods to prepare and serve at appropriate times for their child. It is the child’s job to decide how much to eat and whether to eat at all.
USDA’s MyPlate visual shows fruits and vegetables covering half the plate, with grains and protein foods on the other half. Food budgets can accommodate more fruits and vegetables if smaller amounts of protein foods and foods with lower diet quality are purchased. Working with parents to find lower cost fruits and vegetables to purchase could help them achieve their goal of including more fruits and vegetables in their daily meal plans. In addition, parents can benefit from information on fruits and vegetables in season, which are generally lower in cost, 9 even though most foods can be purchased year-round.
In a study comparing the home food environment and fruit and vegetable intake of adolescents and children, Ding et al 10 found that the availability and accessibility of fruits and vegetables in the home has a positive effect on fruit and vegetable consumption. Furthermore, having fruits and vegetables cut-up and ready to eat, and having more healthful foods and fewer unhealthful foods in the home, further increases healthy eating. 10
Behan 11 recommends that health care providers offer a simple message to patients, especially parents with children. The message is: offer fruits and vegetables at every meal and snack, and eat meals together as a family. She suggests that our message to families be clear, simple, and quick, in order to lead to behavior change.
Factor 3: Parents as Role Models
Parents’ habits play an important role in influencing their children’s eating habits. Children imitate what their parents do: when parents eat fruits and vegetables with their children, there is an increased likelihood that children will be more accepting of these foods and more likely to eat them.
Parental modeling was examined in Washington-Baltimore schools of fourth and fifth grade students and their parents. 12 Students whose parents reported eating fruits and vegetables the previous day consumed 0.5 servings more than students whose parents did not consume any fruits and vegetables. Food preference was also a factor, underscoring the importance of exposing children to a variety of fruits and vegetables. 12
In a review of 98 articles of children 6 to 18 years of age, Rasmussen et al 13 noted that 2 key determinants of fruit and vegetable intake of children were (a) parental intake and (b) home availability/accessibility. In addition, the authors noted that low socioeconomic position is associated with low or less frequent intake of fruits and vegetables, while preference and shared family meals were associated with more frequent intake of fruits and vegetables and preference. Recommendations by Rasmussen et al include targeting efforts to reach youth from lower socioeconomic backgrounds and creating opportunities for more frequent exposure to fruits and vegetables via parental modeling and increased home availability. 13
Factor 4: Schools
Children consume at least one third of their daily food intake at school and often more if they eat snacks and breakfast at school. Schools can play an important role in providing foods of high quality. Schools are actively seeking ways to improve the intake of fruits and vegetables in their students, using lessons, Web sites, and government initiatives. Many states have implemented the USDA Fresh Fruit and Veggies Program in schools where a high percentage of children are eligible to receive free and reduced priced meals. This program offers fresh fruits and vegetables 2 to 5 times per week as a snack for school-aged children. A recent study of the USDA Fresh Fruit and Veggie Program 14 showed that children who participated in the program increased consumption of fruits and vegetables by 0.32 cups compared to a comparison group: fruit consumption accounted for 0.26 of the increase and consumption of fruits and vegetables increased at home by a small but significant amount.
A study conducted in Canada on the Northern Fruit and Vegetable Pilot Programme with children in grades 5 to 8 showed an increase of 0.5 cups of fruits and vegetables by children through their intake at school. 15 A second study, 16 which examined perceptions of this Pilot Programme, suggested that children changed their views about fruits and vegetables, with children indicating that they ate more fruits and vegetables at school, at home, or both. The results further suggest that children influenced their parents to buy and serve more fruits and vegetables. 16
In a study of 263 preschool-aged children before and after completing a series of lessons designed for child care settings, children showed an increase of fruit snack by 21% and veggie snack by 33% from baseline to 3 months. 17 An important finding of this intervention was that the children maintained the increase in consumption 3 months after the end of the intervention. 17
In addition, recent changes to the school meals program through the 2010 Hunger Free Children’s Act 18 have increased the amount of fruits and vegetables offered to children in the school lunch program. This legislation aligned the USDA school meals programs with the Dietary Guidelines for Americans. Schools are required to offer ¾ to 1 cup of vegetables and ½ to 1 cup of fruits each day, doubling the requirement from previous standards. 19
Practical Tips for Parents
Parents can benefit from practical tips to help children eat more fruits and vegetables; encouraging parents to focus on one goal at a time increases their chances for success.
Plan most meals based on MyPlate recommendations, making half your plate fruits and vegetables
Purchase fruits and vegetables regularly
Have fruits and vegetables ready to eat and accessible for children
Plan to eat more meals together as a family
Get children involved in choosing and preparing fruits and vegetables
Be a good role model and eat plenty of fruits and vegetables
Involve children in the choice and preparation of fruits and vegetables to increase acceptance
Have a child choose 1 new fruit or vegetable each week
Offer a variety of fruits and vegetables often
Include a fruit and vegetable with every meal
Visit “Blast-Off” with your children at http://teamnutrition.usda.gov/Resources/blastoff.htm to help them plan healthy food for their take off
Download the Auburn University’s free “Body Quest: Food of the Warrior” series apps (http://www.aces.edu/family-health/health-nutrition/bodyquest/iPadApps.php) to encourage children to eat more fruits and vegetables
Summary
Evidence is plentiful that eating fruits and vegetables improves health and reduces disease risk. Family mealtime and parental role modeling are important for increasing intake of fruits and vegetables in children, and having fruits and vegetables accessible and available at home will increase children’s intake. Asking parents about their home environment is key to assisting families in maximizing opportunities and minimizing obstacles for increasing fruit and vegetables in daily meals.