How effective educational and fruit/vegetable consumption programs are leading to better health among younger children
Being overweight is a common problem among children and adolescents in the Western world, and worldwide obesity has nearly tripled since 1975. The World Health Organization underlines the importance of tackling the problem, since in 2020 more than 39 million children under the age of 5 were overweight and/or obese. For children and adolescents aged 5-19 this number is 340 million [2]. Being overweight or obese can be defined as the result of an energy imbalance between energy intake and insufficient energy output, with abnormal or excessive fat accumulations as a consequence [2,3]. This in turn may impair health, through both physical and psychosocial consequences; physical diseases that can arise from obesity are diabetes, dyslipidemia and hypertension, which all affect one’s life-expectancy. The psychosocial comorbidities include depression, low self-esteem and school bullying, which frequently impact children’s development [3].
Childhood is a critical period when it comes to the establishment of diets and eating habits that can both increase the risk of obesity and being overweight among children. The most influential figures in a child’s lives are usually their parents and family, but teachers and school environments also play a key role. In schools they consume between one- third to one- half of their meals, and this makes it important for them to have nutrition programs. Even though there are several schools in Europe that are aware of the benefits of an increase in the consumption of fruits and vegetables among children, they are not always using nutrition education programs to tackle weight problems among the student body [1, 3, 4, 5].
Based on the aforementioned literature, I want to state that promising school environments should not only provide healthy foods such as fruits and vegetables, but should also develop nutrition education programs in order to tackle weight issues among children. To support this statement, I will first answer the question ; ‘What is the state of art regarding nutrition programs at school?’ Secondly I am going to answer the question; ‘What do we know about their effectiveness and will they be the right choice in tackling our children’s obesity issues?’
Nutrition programs to combat obesity
Nutritional programs are getting more and more popular at several schools in Europe. These programs are for example the ‘Schoolgruiten Project’, which was established in the Netherlands to improve accessibility to fruits and vegetables at schools by providing all primary school children free fruit or vegetables twice a week [1, 6]. There are programs that are mainly focused on the fruit and vegetable (FV) consumption of children, to provide a short term positive dietary impact.
Secondly, there are also programs that are focused on the longer term effectiveness of healthy diets, most of them education based. An example of one of these programs was the ‘5 a day’ program, based on a curriculum that included classes and educational videogames. The program aimed to provide nutritional knowledge, a prominent factor in improving dietary quality and FV intake. IT devices such as computers and game consoles can be used as tools to improve children’s nutritional knowledge. These modern teaching methods encourage learning processes and attract children’s attention [7].
The effectiveness of nutrition programs on schools
Several factors influence a program’s effectiveness, such as the content of the program, aims, methods, activities and type of approach. Highly successful programs consist of three categories: educational components, behavioral change approaches and parental/family components [8, 9, 10].
The ‘Schoolgruiten’ project for example focuses on behavioral change approaches (the availability of fruits and vegetables), primarily provided by teachers. The program is not focused on long term education. The ‘5 a day’ program in Italy on the other hand focuses on educational components, such as classroom based- and experiential learning from games.
To analyze the effectiveness of both programs, one needs to look at their results, for example at the ‘Schoolgruiten program’. Both children and parents report that the program significantly increased children’s fruit intake long term, but did not significantly increase their vegetable consumption. The knowledge of fruit recommendations among boys also increased, while this was not the case for girls. Therefore, the ‘Schoolgruiten’ scheme was effective in its aims [6].
The ‘5 a day’ nutrition education program led to a significant increase in nutrition knowledge and consumption among children. This increase remains significant for six months post intervention. While the consumption of vegetables significantly increased, the fruit consumption of the children did not increase significantly [7].
An alternative: the multi component approach programs
Based on its results, one could state that the ‘Schoolgruiten’ program is effective in its aim to increase the fruit intake of children, if not their vegetable intake. It also doesn’t provide educational methods about consuming fruits and vegetables, which has the consequence of not increasing the nutrition knowledge of girls long term [6].
The ‘5 a day’ nutrition educational program, on the other hand, showed significant increases in children’s consumption of vegetables and their nutrition knowledge. Though, it did not significantly increase the children’s consumption of fruits[7].
Even though both programs are successful, current evidence states that programs with the implementation of a multi-component approach seem to be more effective compared to programs with a single component approach [1,9,10]. A promising example of a multi- component approach is the Canadian ‘action schools’ program [11]. This program had the purpose of changing the fruit and vegetable (FV) intake of its students by providing free pieces of FV every day. The intake of fruits and vegetables per child was measured by hand-counting, and a food frequency questionnaire. Secondly, it had the purpose of increasing students’ knowledge and attitudes perceptions towards FV, which was assessed using a knowledge, attitudes and perceptions survey. The result of this Canadian action school program seems promising, since significant results were found in the serving of fruits in the action schools.
Secondly, the teachers put their FV knowledge into practice: teachers in these ‘action schools‘ implemented nutritional education activities across 80% of the whole school, while teachers from ‘non action schools’ implemented a mean of 64% [11].
A conclusion: Quality over quantity
So, promising school environments should not only provide healthy foods but also nutrition education programs in order to tackle weight issues among children. When comparing the three nutrition programs: FV consumption only, nutrition education only and the multi-component approach, it may seem that the effectiveness of the multicomponent program is the highest. This is based on targeting both aspects of FV consumption, and increasing knowledge among students. However, certain limitations make it less promising. In the case of the ‘action schools’ program they used self-reported data, which has been shown to be problematic. Furthermore, they did not involve family and community members, and non-classroom activities did not focus on FV-consumption specifically. Moreover, although these programs may feature a higher quantity of methods, their value decreases when the methods do not increase the FV intake among children.
Multi-component programs are not always ‘the’ solution. In addition to educational nutrition programs and FV-consumption, good programs should also include parents/family, as well as precise and consistent measurements. Moreover, one should consider other interventions, such as teaching FV-knowledge. A healthy eating habit is one of the best lessons we can impart to our children, a gift which potentially lasts for their lifetime. Let’s give them this simple gift.
Referenties
[1] Verdonschot, A., De Vet, E., Van Rossum, J., Mesch, A., Collins, C. E., Bucher, T., & Haveman-Nies, A. (2020). Education or provision? A comparison of two school-based fruit and vegetable nutrition education programs in the netherlands. Nutrients, 12(11), 3280. Requested on 30 September 2021 from: Nutrients | Free Full-Text | Education or Provision? A Comparison of Two School-Based Fruit and Vegetable Nutrition Education Programs in the Netherlands (mdpi.com)
[2] World Health Organization (2021) Obesity and overweight. Requested on 30 september 2021 from: Obesity and overweight (who.int)
[3] Verjans-Janssen, S., Van Kann, D., Kremers, S., Vos, S., Jansen, M., & Gerards, S. (2019). A cross-sectional study on the relationship between the Family Nutrition Climate and children’s nutrition behavior. Nutrients, 11(10), 2344. Requested on 30 September 2021 from: Nutrients | Free Full-Text | A Cross-Sectional Study on the Relationship between the Family Nutrition Climate and Children’s Nutrition Behavior (mdpi.com)
[4] Quelly, S. B. (2019). Helping with meal preparation and children’s dietary intake: A literature review. The Journal of School Nursing, 35(1), 51-60. Requested on 1 October 2021 from: Helping With Meal Preparation and Children’s Dietary Intake: A Literature Review (sagepub.com)
[5] Vereecken, C., De Pauw, A., Van Cauwenbergh, S., & Maes, L. (2012). Development and test–retest reliability of a nutrition knowledge questionnaire for primary-school children. Public health nutrition, 15(9), 1630-1638. Requested on 1 October 2021 from:
untitled (cambridge.org)
[6] Tak, N.I.; te Velde, S.J.; Brug, J. Long-term effects of the Dutch Schoolgruiten Project–promoting fruit andvegetable consumption among primary-school children.Public Health Nutr.2009,12, 1213–1223.
[7] Rosi, A.; Scazzina, F.; Ingrosso, L.; Morandi, A.; Del Rio, D.; Sanna, A. The “5 a day” game: A nutritionalintervention utilising innovative methodologies with primary school children.Int. J. Food Sci. Nutr.2015,66, 713–717. Requested on 3 October 2021 from: The “5 a day” game: a nutritional intervention utilising innovative methodologies with primary schoo (tandfonline.com)
[8] Craigie, A.M.; Lake, A.A.; Kelly, S.A.; Adamson, A.J.; Mathers, J.C. Tracking of obesity-related behavioursfrom childhood to adulthood: A systematic review.Maturitas2011,70, 266–284. Requested on 3 October 2021 from: Tracking of obesity-related behaviours from childhood to adulthood: A systematic review – PubMed (nih.gov)
[9]. Mak, T.; Bonsmann, S.; Genannt, S.; Caldeira, S.; Wollgast, J. How to Promote Fruit and Vegetable Consumptionin Schools: A Toolkit. InACTA Paediatrica; Wiley-Blackwell: Hoboken, NJ, USA, 2016. Requested on 30 September 2021 from: How to promote fruit and vegetable consumption in schools – Publications Office of the EU (europa.eu)
[10]. Micha, R.; Karageorgou, D.; Bakogianni, I.; Trichia, E.; Whitsel, L.P.; Story, M.; Penalvo, J.L.; Mozaffarian, D.Effectiveness of school food environment policies on children’s dietary behaviors: A systematic review andmeta-analysis.PLoS ONE2018,13, e0194555. Requested on 3 October 2021 from: Effectiveness of school food environment policies on children’s dietary behaviors: A systematic review and meta-analysis (plos.org)
[11] Day, M. E., Strange, K. S., McKay, H. A., & Naylor, P. J. (2008). Action schools! BC—healthy eating. Canadian Journal of Public Health, 99(4), 328-331. Requested on 3 October 2021 from: BF03403766.pdf (springer.com)
