Getting children to eat more fruit and vegetables: A systematic review
Introduction
The most recent evidence for the importance of nutritional factors in preventing disability and death in Europe suggests that 4.4% of the overall burden of disease in the region could be attributed to low fruit and vegetable intake (WHO, 2002). Fruit and vegetables are important sources of a wide range of vital micronutrients, and there is now strong evidence that fruit and vegetable consumption can prevent a number of chronic non-communicable diseases including cardiovascular disease and some cancers (IARC, 2003, Klerk et al., 1998, Robertson et al., 2004, WCRF/AICR, 1997, WHO, 2003). Although most of the research on this association has focused on adults, some studies have examined the influence of childhood diet on disease in later life, such as a recent follow-up of the Boyd Orr cohort, initiated in the 1930s (Gunnell et al., 1996, Rowett, 1955), which found that childhood fruit consumption appeared to be protective against cancer in adulthood (Maynard et al., 2003). There is also growing evidence that fruit and vegetable consumption in children may protect against a range of childhood illnesses. In a study of over 20,000 children in six Central European countries, an association was found between respiratory symptoms and low fruit and vegetable consumption (Antova et al., 2003).
While evidence for the public health benefits of consuming more fruit and vegetables grows, nutritional surveys show that children and adults in most regions of the world are not meeting the minimum suggested consumption goals of 400 g/day (Health Behaviour in School-aged Children (HBSC) study, 2001, Pomerleau et al., 2004, WHO, 2003). Furthermore, children and adolescents are particularly at risk because of their often erratic eating behavior, including snacking on energy-dense foods instead of fruits and vegetables (Cavadini et al., 1999, Chauliac and deBeco, 1996, Neumark-Sztainer et al., 1998, Sharma, 1998). Consequently there are compelling reasons to develop and implement effective programmes and policies that will increase consumption of fruit and vegetables among children and adolescents.
This is, to our knowledge, the first systematic review of the worldwide evidence of interventions to promote children's fruit and vegetable consumption. Earlier reviews were generally limited in scope or geographical setting (Ammerman et al., 2002, Burchett, 2003, Ciliska et al., 1999, Contento, 1995, Miller and Stafford, 2000, Pignone et al., 2003). A number of studies have also been conducted since these reviews were published, creating the need for a new systematic review of fruit and vegetable promotion initiatives worldwide and across all settings.
Section snippets
Materials and methods
A systematic review was conducted to collect and summarize worldwide evidence from published and “grey” literature on current evaluations of all interventions and programmes which promote fruit and vegetable consumption in children and adults (results for adults are reported elsewhere (Pomerleau et al., 2005)).
Retrieval of papers
Of the 3499 unduplicated papers identified for review, 306 reported on interventions designed to increase fruit and vegetable intake (Fig. 1). A further 229 papers were excluded as they did not meet our eligibility criteria. Of the remaining 77 articles, 8 were rated as weak on the quality criteria and excluded from the review. Of the final pool of 59 studies (reported in 69 articles), 15 studies (reported in 17 articles) focused on 5- to 18-year-old children and adolescents, the results of
Discussion
The findings of this review contribute to the growing body of evidence of how best to promote fruit and vegetable in the critical age group of children and adolescents. Of the fifteen studies reviewed, ten had a significant effect, ranging from +0.3 to +0.99 servings/day. Translated into broad population interventions and optimizing the most effective intervention components, such change in fruit and vegetable intake could have an important long-term public health impact, particularly in terms
Conclusion
Lessons learned from other areas of public health (e.g., Swinburn et al., 2004) point to the importance of creating an enabling environment within which public health can be promoted. It is important that an enabling environment for fruit and vegetable consumption by children be generated. This might include a range of macro-level interventions such as increasing access to fruit and vegetables through targeted government subsidies of production; agricultural policies that support healthy diets (
Acknowledgments
Ms Ingrid Keller and Ms Vanessa Candeias at the World Health Organization are sincerely thanked for their support and help with identifying experts and obtaining research papers, and the contribution of the many people world wide who helped with this review by supplying information is gratefully acknowledged. This review was funded by the World Health Organization. However, WHO cannot accept any responsibility for any information provided or views expressed. The authors have no conflict of
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