Most Effective Ways To Increase Children’s Fruit Consumption

How do children best learn about healthy eating habits? Not through education, according to a recent study. We examine an approach that did have long-lasting effects, and consider what the implications might be for improving our patients’ approach to food.

By Dr Jacob Schor

Reference
Perikkou A, Gavrieli A, Kougioufa MM, Tzirkali M, Yannakoulia M. A novel approach for increasing fruit consumption in children. J Acad Nutr Diet. 2013;113(9):1188-1193.

Design
A randomized controlled trial for evaluating the effectiveness of a school-based intervention to increase children’s fruit consumption. Dietary intake was assessed before the intervention began in October 2008 and then at the end of the intervention period (June 2009) and at 1-year follow-up (June 2010).

Participants
In this study, 218 nine-year-old elementary students were randomly assigned to 1 of 3 groups. Children in 2 groups were exposed to interventions aimed at increasing fruit consumption, while the third group served as a control.

Interventions
Two interventions were tested. The first was an educational curriculum designed to provide general information about a healthy lifestyle and to build skills for choosing healthful foods. The curriculum consisted of 29 lessons of 15 minutes each delivered in the students’ classroom by their own teacher once a week for the entire school year. The teachers were trained and provided with a curriculum and teaching materials. The second experimental group received no educational training; instead they were exposed to their teacher eating healthy snacks during the school day. The teachers merely acted as role models, bringing fruit to school at least 3 times a week. They kept the fruit on their desks and ate it during a break in the day. The control group of students received no intervention.

Outcome Measures
Parents of the children completed dietary records listing the foods children consumed at home or recalled eating away from home, during 2 consecutive weekdays before the start of the intervention, after the intervention was complete, and again one year later. Researchers measured the number of servings of selected food groups in the food records.

Key Findings
Fruit consumption in all 3 groups of children was similar at the start of the study, about 1 serving per day. The children who took part in either of the interventions increased their fruit consumption significantly compared to the control group, eating about 2 to 2.5 servings per day. At 1-year follow up, only those children whose teacher had modeled fruit consumption continued to eat significantly more fruit, about 2 servings per day. Those who had completed the educational curriculum had decreased consumption back to 1 serving a day, the same as their pre-intervention level and the same as the control group.

Practice Implications
This study points out the remarkable influence that teachers can have on children, and in particular the persistence of that effect. This contrasts with the temporary impact that what they teach has on children.

Much has been written about how teachers should teach better lifestyle habits, but surprisingly little has been written about the health and eating habits that teachers model for their students.

This brings to mind the temporary effect seen in the PREDIMED Study, which attempted to increase adherence to a Mediterranean style diet via 5 years of quarterly training sessions with dieticians. Twelve months into the study the participants had made significant improvements to their diets,¹ but these changes faded with time. After 5 years there were only minor differences in food consumption between the participants assigned to follow a Mediterranean diet and those assigned to a low-fat diet.²

Changing eating habits through education appears to produce at best temporary improvement. Neither children nor adults change their eating habits for the long term based what they were taught. This study suggests children may change behavior based on what what their teachers do. In the case of adults, perhaps they may mimic the behaviors their doctors model for them.

Unfortunately modeling healthy lifestyle choices will be a challenge for many teachers. In Germany, a recent study of 313 kindergarten teachers reported that more than 40% were overweight and nearly 1 in 5 were obese. This is significantly higher than the national average. Only 40% of the teachers were aware that being overweight is associated with physical health risks. Even those who understood the impact underestimated the effect.³

This discussion reminds me of our colleague Reiner Kremer who confided that he serves his patients freshly made smoothies in his office waiting room. His may be a better strategy to improve a patient’s nutrition than any lectures he might give them. Perhaps keeping fresh fruit on our desks (and perhaps a bowl of nuts as well) might also trigger a shift in behavior greater than our telling our patients to eat more fruit and nuts.

Eating fruit may not be the only healthful behavior that teachers can model for their students. Pondering the implications of this study raises the question whether schools should put less effort into curriculum development and more into teacher development. Are there ways to encourage teachers to model behaviors that will increase the health and productivity of their students?

References
1. Zazpe I, Sanchez-Tainta A, Estruch R, et al. A large randomized individual and group intervention conducted by registered dietitians increased adherence to Mediterranean-type diets: the PREDIMED study. J Am Diet Assoc. 2008;108(7):1134-1144; discussion 1145.
2. Estruch R, Ros E, Salas-Salvadó J, et al. PREDIMED Study Investigators.Primary prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med. 2013;368(14):1279-1290.
3. Hoffmann SW, Tug S, Simon P. Obesity prevalence and unfavorable health risk behaviors among German kindergarten teachers: cross-sectional results of the kindergarten teacher health study. BMC Public Health. 2013;13:927.