Pro Children: The intake of fruits and vegetables in Europe

Professor Knut-Inge KleppDepartment of Nutrition Faculty of Medicine University of Oslo, Norway

Nutrition: Basic Literature Data for the Projects of the Working Party ’Lifestyle’ of the EC SANCO

Dresden, November 26, 2004

Promoting and sustaining healththrough increased vegetable andfruit consumption among European Schoolchildren (QLK1-CT-2001-00547)

• University of Oslo, Norway (Co-ordinator)• Community Nutrition Unit Bilbao, Spain• University Hospital Reykjavík, Iceland• University of Copenhagen, Denmark• University of Porto, Portugal• University of Vienna, Austria• Royal Veterinary and Agricultural

University of Denmark• Erasmus Medical Centre Rotterdam, the

Netherlands• Karolinska Institute Stockholm, Sweden• University of Gent, Belgium

The Pro Children Project: 2002-2006

Pro Children: Main objectives

To develop effective strategies to promote adequate consumption levels of fruits and vegetables among school children (11-13 year olds) and their parents

National representative, cross-sectional surveys securing comparable data from pupils and their parents in all 9 countriesComprehensive intervention programs developed and tested in the Netherlands, Norway andSpain prior to broader dissemination

Specific research questions

How does reported fruit and vegetable intake differ by sex and country among 11-12 year old school children?To what extent do European children perceive fruits and vegetables to be available at home and outside their homes?To what extent is perceived availability associated with fruits and vegetables intake?How is increased availability being promoted within the Pro Children project?

Availability as a predictor of fruit and vegetable consumption

Review of studies investigating predictors of fruit and vegetable intake among children and adolescents shows that availability is associated with increased intake:

Cullen, Baranowski et al. (2003): Availability, accessibility, and preferences for fruit, 100% fruit juice, and vegetables influence children's dietary behaviour. Health Educ BehavNeumark-Sztainer et al. (2003): Correlates of fruit and vegetable intake among adolescents. Findings from Project EAT. Prev MedFrench & Stables (2003): Environmental interventions to promote vegetable and fruit consumption among youth in school settings. Prev Med

Fruits and Vegetables Make the Marks Study:Correlates of children's fruit and vegetable intake

0.35R2

<0.010.140.48Child's Preferences0.66-0.01-0.02Child's Accessibility<0.010.100.12Parent's Intake (FFQ)

Parents’ report

<0.010.120.59Awareness (of 5-a-day)<0.010.090.24Self-Efficacy (to eat 5-a-day)<0.010.210.40Preferences0.930.00-0.01Intention (to eat 5-a-day)0.030.050.13Modelling<0.010.260.50Accessibility

Students’ reportpbetaB

Bere & Klepp: Correlates of fruit and vegetable intake among Norwegian school children:parental and self-reports. Public Health Nutrition. In press.

Pro Children Study: Participating countries, language groups, and major data collection events

XSwedishSweden

XXXSpanish/ BasqueBilbao region

XBasque/ CatalanGalician/ Spanish

SpainXPortuguesePortugal

XXXNorwegianBuskerudXNorwegianNorway

XXXDutch/ TurkishRotterdam

XDutch/ TurkishNetherlandsXIcelandicIcelandXDanishDenmarkXFlemishBelgium

XGerman/ TurkishAustria

SecondFollow-upMay 2005

FirstFollow-upMay 2004

NationalSurveys

Oct-Nov -03

Baseline

Sept 2003

LanguageCountry

Pro Children: Data collected from 11-12 year old school children and their parents

FRUIT AND VEGETABLE INTAKE24-HOUR RECALL DATAFREQUENCY ITEMS (usual intake)

DEMOGRAPHIC DATASEXAGEFAMILY COMPOSITIONETHNICITYSOCIO-ECONOMIC STATUS

PERSONALSELF-RATED INTAKEKNOWLEDGEATTITUDESGENERAL SELF-EFFICACYINTENTIONHABITPREFERENCESPERCEIVED BARRIERS

PERCEIVED SOCIAL-ENVIRONMENTALSUBJECTIVE NORMACTIVE PARENTAL ENCOURAGEMENTFAMILY RULES

PERCEIVED PHYSICALENVIRONMENTALAVAILABILITY AT HOME AVAILABILITY AT SCHOOL & LEISURE

The Attitude-Social influence-Self-efficacy -(ASE) Model

Attitudes

Social influence

Self-efficacy

Intention Fruit-vegetable intake

Skills

Perceived Barriers – incl.

Availability

Kok et al., 1996

Pro Children:Cross-sectional samples* (preliminary data)

2 13447.452.6Portugal1 31353,746,3Spain

13 61350.349.7Overall1 44149.950.1Sweden

1 19550.749.3Norway1 38047.053.0Netherland1 20052.647.4Iceland1 91951.049.0Denmark1 34354.245.8Belgium1 68847.552.5Austria

N%%TotalBoysGirls

* 11-12 years old

Pro Children (preliminary data)Times per day children reporting eating fresh fruit

(mean values)

0

0,2

0,4

0,6

0,8

1

1,2

1,4

Austria Belgium Denmark Iceland Netherland Norway Portugal Spain Sweden

GirlsBoys

Pro Children (preliminary data)Children reporting eating fresh fruit every day (%)

52

42

51

40

48

35

59

48

41

45

33

38

32

37

26

54

46

32

0 10 20 30 40 50 60 70

Austria

Belgium

Denmark

Iceland

Netherland

Norway

Portugal

Spain

Sweden

Pro Children (preliminary data)Times per day children reporting eating vegetables

(mean values)

0

0,2

0,4

0,6

0,8

1

1,2

1,4

1,6

Austria Belgium Denmark Iceland Netherland Norway Portugal Spain Sweden

GirlsBoys

Pro Children (preliminary data)Children reporting eating vegetables every day (%)

52

74

63

51

75

58

64

42

60

46

60

50

38

60

42

52

39

47

0 10 20 30 40 50 60 70 80

Austria

Belgium

Denmark

Iceland

Netherland

Norway

Portugal

Spain

Sweden

Availability assessment in Pro Children

AVAILABILITY AT HOME (test-retest: 0.60/ 0.57) *

If you tell at home what fruit/vegetable you like to eat, will it be bought?Are there usually different kinds of fruits/vegetables available in your home?Is there usually fruit/vegetables available at home that you like?

AVAILABILITY AT SCHOOL & LEISURE TIME (test-retest: 0.68/ 0.71)

Can you get fruit/vegetables at school either by buying it or getting it for free?Can you get fruit/vegetables at your friends’ house, when you spend the afternoon there?Can you get fruit/vegetables at the place where you have your leisure time activity (e.g. club, sports place), either by buying it or getting it for free?

5-point scale from (1) yes, always to (5) never* Test-retest values: ICC (intraclass correlation coefficients)

Pro Children (preliminary data)Reported fruit availability at home (mean values; scale 1-5)

1

1,5

2

2,5

3

3,5

4

4,5

5

Austria Belgium Denmark Iceland Netherland Norway Portugal Spain Sweden

GirlsBoys

Pro Children (preliminary data)Reported fruit availability outside home (mean; scale 1-5)

1

1,5

2

2,5

3

3,5

4

4,5

5

Austria Belgium Denmark Iceland Netherland Norway Portugal Spain Sweden

GirlsBoys

Pro Children (preliminary data)Reported vegetable availability at home (mean; scale 1-5)

1

1,5

2

2,5

3

3,5

4

4,5

5

Austria Belgium Denmark Iceland Netherland Norway Portugal Spain Sweden

GirlsBoys

Pro Children (preliminary data)Reported vegetable availability outside home (mean; scale 1-5)

1

1,5

2

2,5

3

3,5

4

4,5

5

Austria Belgium Denmark Iceland Netherland Norway Portugal Spain Sweden

GirlsBoys

The Attitude-Social influence-Self-efficacy -(ASE) Model

Attitudes

Social influence

Self-efficacy

Intention Fruit-vegetable intake

Skills

Availability

Kok et al., 1996

?

Pro Children (preliminary data)Association between fruit and vegetable intake and perceived availability at home and outside home (r)

Overall Fruit VegetableAvaliability at home 0.25 0.29Avaliabilty outside home 0.14 0.13

Iceland Avaliability at home 0.25 0.32Avaliabilty outside home 0.07 0.12

Netherl Avaliability at home 0.19 0.25Avaliabilty outside home 0.13 0.18

Austria Avaliability at home 0.19 0.24Avaliabilty outside home 0.07 0.20

Pro Children (preliminary data)Reported fruit intake (times per day) according to deciles of

predicted value (based on availability at home and outside home)

0,50,60,70,80,9

11,11,21,31,41,51,6

1 2 3 4 5 6 7 8 9 10

Deciles of predicted intake

Rep

orte

d in

take

Pro Children (preliminary data)Reported vegetable intake (times per day) according to deciles of predicted value (based on availability at home and outside home)

0,50,60,70,80,9

11,11,21,31,41,51,61,7

1 2 3 4 5 6 7 8 9 10

Deciles of predicted intake

Rep

orte

d in

take

The Pro Children Intervention Programmes(http://www.univie.ac.at/prochildren/)

Classroom curriculum (Intervention Mapping)Computer tailoringFamily/parental involvementInterventions targeting the school environmentCommunity components: health care services, media, grocery stores

School

School-basedIntervention program

Family

Community

ClassroomOut-of-classroom

School meals

Whole School

Pro Children: InterventionPro Children: Intervention

Worksheets

EducationalActivities

ComputerTailoring

Web site

Fruit break

Special schoolEvents

School Projectcommittees

School Policy

Worksheets

Newsletters

School Events

Computertailoring

School Health

Mass Media

Grocery stores

Pro Children Bilbao:Increasing fruit & vegetable availability at school

In Spain, schools provide a school meal (the proportion of pupils participating varies) where fruits and/or vegetables are served;A ”fruit break” was introduced as part of Pro ChildrenBilbao fruit & vegetable wholesalers association initially provided free distribution of fruit two days per week: oranges, apples, bananas, tangerinesSubsequently schools asked children to bring the fruit from home

Pro Children Bilbao:Experiences from implementing the fruit break

In 78% of the classes, children brought fruit for the fruit break throughout the school year

The fruit break was organised everyday in 22% of the classes; two days per week in the rest

Average duration of the breaks: 5-10 minutes

The large majority of the teachers (77%) reported their experiences with the fruit break to be very good or good

Pro Children Rotterdam:Increasing fruit & vegetable availability at school

In the Netherlands, there is no organized school meal, and pupils usually do not eat at schoolA national School Fruit Programme is underway and is being tested as part of the Pro Children projectAll intervention school pupils receive a free fruit or vegetable once a week delivered by local retailers (pear, banana, tangerine, kiwi, tomato or carrot)

Pro Children Rotterdam:Experiences from implementing the fruit break

Some schools have introduced special fruit breaks. Others have the pupils eat the fruit/vegetable during their usual breaks between lessons, during lessons, and some let the pupils take it homeThe fruit distribution appear to be very well received by the teachers, and they report that it is well organisedThe children reported during focus group discussions that they enjoy the fruit breaksOne complain from both teachers and pupils was the lack of variation (too many apples)

The Norwegian School Fruit ProgrammeFor NOK 2,50 (€ 0.30) a day pupils get an apple, a pear, carrot, banana or orange at lunchtimeParents are invited by the school to subscribe for half a year or a whole year at the timeWholesalers ordinarily deliver the fruit and vegetables twice a week directly to each schoolThe schools/pupils are responsible for administering the program

Pro Children Oslo (Buskerud):Increasing fruit & vegetable availability at school

Schools had to commit to take part in the School Fruit programmeA rotating fruit/vegetable menu was introduced to secure increased variationSchools were given proper storage facilitiesSchools also received proper boxes for distributing the fruit/vegetables to the pupils in the classroomsInformation to parents trying to motivate them to sign up their children was distributed as part of the Pro Children project

Conclusions from the Pro Children project

Preliminary data indicate significant differences in reported frequency of fruit and vegetable intake between girls and boys across countriesNo strong north-south gradient in intake was seen in the frequency data among the school childrenThe majority of children reported fruits and vegetables to be easily available at home, but less so outside their homesPerceived availability (both at home and outside home) was significantly and consistently associated with reported intakeIncreasing the availability of fruits and vegetables for school children seem to be an important intervention objectiveFurther analyses will compare 24-hour recall data for the children and their parents across countries and socio-economic groups, and investigate the effects of the intervention program

Co-investigators & acknowledgementI De Bourdeaudhuij, Ghent UniversityM Wind & J Brug, EMC RotterdamC Perez Rodrigo, Community Nutrition Unit BilbaoÁG Kristjánsdóttir & Inga Thorsdottir, University Hospital ReykjavíkM Rasmussen & P Due, University of CopenhagenA Wolf & I Elmadfa, University of ViennaE Poortvliet, A Yngve & M Sjöström, Karolinska Institute StockholmMD Vaz de Almeida, University of Porto

Pro Children is funded under the Fifth Framework Programme of the European Commission, Thematic programme Quality of Life and Management of Living Resources, key action Food, Nutrition and Health (QLK1-CT-2001-00547)

This paper was produced for a meeting organized by Health & Consumer Protection DG and represents the views of its author on the subject. These views have not been adopted or in any way approved by the Commission and should not be relied upon as a statement of the Commission's or Health & Consumer Protection DG's views. The European Commission does not guarantee the accuracy of the data included in this paper, nor does it accept responsibility for any use made thereof.