Strategies to Increase Vegetable Intake in the Early Years

Vegetables consumed regularly and in variety as part of a balanced diet are known to protect against non-communicable diseases. However, children across Europe fail to meet recommended intakes. Therefore, effective interventions for encouraging vegetable intake are needed for preschool children. The present thesis adopted a mixed methods design to investigate strategies to increase vegetable intake in children aged 2-5 years, who are at the peak of food fussiness. A systematic review synthesised evidence from the existing literature using meta-analyses and found that repeated taste exposure was the most effective strategy for promoting vegetable intake compared to other interventions. Study 1 investigated effects of taste exposure and nutrition education delivered separately or in combination, which showed that taste exposure significantly increased intake of an unfamiliar vegetable. Study 2 tested the effects of reading a storybook about vegetables and sensory play on intake of a novel vegetable, finding that learning and play are essential for recognition and intake, with sensory play also promoting willingness to taste. Study 3 used semi-structured interviews to explore parental perspectives on vegetable strategies. This indicated that parents use a range of strategies with children, yet their success varies. This study raised concerns of ecological validity in methods tested by scientific studies in comparison to how they are implemented in homes. The present thesis provides evidence for implementing strategies which increase familiarity and learned safety with vegetables, in particular taste exposure. Repeated multisensory learning, including tasting should be incorporated into nutrition education programmes to enhance vegetable consumption. Encouraging preschool children to eat more vegetables in balance with other foods provides protective health benefits for a lifetime. By making a commitment to prioritise greater vegetable intakes, parents and caregivers can apply known, successful strategies, suited to their specific child, to increase familiarity and intake of vegetables in the child’s diet

Implementing a “vegetables first” approach to complementary feeding

PURPOSE OF REVIEW: To provide a rationale for promoting a vegetables first approach to complementary feeding (CF), building on prior exposure to vegetable flavours experienced in utero and via breastfeeding (chemosensory continuity). RECENT FINDINGS: Vegetables confer selective health benefits but population intakes are below recommendations globally; maternal intake of vegetables during both pregnancy and lactation promotes familiarity with some vegetable flavours. Building on this exposure, vegetables as a first food during CF further promote acceptance. However, experiments testing efficacy of a vegetables first approach to CF demonstrate increased liking and intake, some evidence of generalisability but little evidence of sustained effects beyond infancy. SUMMARY: The aim to increase the quantity and variety of vegetables eaten by children is both desirable, to improve nutrient quality of the diet, and achievable. However, longer, larger, randomised control trials are needed to evidence any longer term, sustainable benefits to liking and intake of vegetables

Increasing Intake of an Unfamiliar Vegetable in Preschool Children Through Learning Using Storybooks and Sensory Play: A Cluster Randomized Trial

Background: Most children eat fewer vegetables than recommended. Storybooks and sensory play may increase vegetable intake. Objective: This study tested the effects on intake of learning about an unfamiliar vegetable (celeriac) through storybooks and sensory play. It was predicted that an illustrated, congruent storybook would increase intake of celeriac compared to an incongruent storybook (carrot); and that adding congruent sensory play with celeriac to the storybook would produce a synergistic effect on intake of celeriac. Design: Children from 12 UK preschools were randomly assigned by clusters to four intervention conditions using a 2×2 factorial design. The factors were vegetable congruency (sensory play and/or storybook were congruent, or incongruent [carrot] with celeriac) and intervention type (storybook only or storybook combined with sensory play). Participants/setting: Three hundred and thirty-seven children aged 2 to 5 years were recruited to take part in November 2017. Intervention: Over a 2-week period, children in all four conditions were read a vegetable storybook featuring celeriac or carrot. In addition, two conditions received sensory play with either carrot or celeriac added to the storybook method. Main outcome measures: Intake of the unfamiliar vegetable (celeriac) was measured at baseline and after the 2-week intervention. Statistical analysis performed: Complex samples logistic regression and general linear modeling were performed to examine group differences at post-intervention. Results: Children receiving the congruent (celeriac) storybook had higher odds of eating celeriac compared to children who received the incongruent (carrot) storybook. Receiving congruent sensory play increased the odds of eating celeriac, whereas receiving incongruent sensory play did not. From the 267 children who completed both baseline and post-intervention assessments, 85 ate no celeriac at baseline and were classed as non-eaters. Sensory play (congruent or incongruent) increased the odds of eating some celeriac in non-eaters compared to storybook only conditions. Conclusions: Congruency between storybook and vegetable increased intake; sensory play with celeriac increased the likelihood of eating celeriac. Storybooks and sensory play are simple interventions to increase willingness to try an unfamiliar vegetable

Systematic review and meta-analysis of strategies to increase vegetable consumption in preschool children aged 2-5 years

Background Most children do not meet daily recommendations for fruit and vegetable intake, and consumption of vegetables remains especially low. Eating habits track from childhood to adulthood hence establishing liking and intake of vegetables is important. Objective To identify the most successful strategies to enhance vegetable intake in preschool children aged 2–5 years. Design The research was a systematic review and a meta-analysis of published studies. A comprehensive search strategy was performed using key databases such as Medline, Embase, PsychINFO, EBSCO and CENTRAL. Articles published between 2005–January 2016, specifically with measured vegetable consumption were included. Results 30 articles and 44 intervention arms were identified for inclusion (n = 4017). Nine dominant intervention strategies emerged to promote vegetable intake in preschool children. These included; choice, pairing (stealth), education, food service, modelling, reward, taste exposure, variety and visual presentation. The meta-analysis revealed that interventions implementing repeated taste exposure had better pooled effects than those which did not. Intake increased with number of taste exposures and intake was greater when vegetables offered were in their plain form rather than paired with a flavor, dip or added energy (e.g. oil). Moreover, intake of vegetables which were unfamiliar/disliked increased more than those which were familiar/liked. Conclusions Repeated taste exposure is a simple technique that could be implemented in childcare settings and at home by parents. Health policy could specifically target the use of novel and disliked vegetables in childcare settings with emphasis on a minimum 8–10 exposures. The systematic review protocol was registered on the PROSPERO (number: CRD42016033984)

Influence of oral processing on appetite and food intake - A systematic review and meta-analysis.

Food delivers energy, nutrients and a pleasurable experience. Slow eating and prolonged oro-sensory exposure to food during consumption can enhance the processes that promote satiation. This systematic review and meta-analysis investigated the effects of oral processing on subjective measures of appetite (hunger, desire to eat) and objectively measured food intake. The aim was to investigate the influence of oral processing characteristics, specifically "chewing" and "lubrication", on "appetite" and "food intake". A literature search of six databases (Cochrane library, PubMed, Medline, Food Science and Technology Abstracts, Web of Science, Scopus), yielded 12161 articles which were reduced to a set of 40 articles using pre-specified inclusion and exclusion criteria. A further two articles were excluded from the meta-analysis due to missing relevant data. From the remaining 38 papers, detailing 40 unique studies with 70 subgroups, raw data were extracted for meta-analysis (food intake n = 65, hunger n = 22 and desire to eat ratings n = 15) and analyzed using random effects modelling. Oral processing parameters, such as number of chews, eating rate and texture manipulation, appeared to influence food intake markedly but appetite ratings to a lesser extent. Meta-analysis confirmed a significant effect of the direct and indirect aspects of oral processing that were related to chewing on both self-reported hunger (-0.20 effect size, 95% confidence interval CI: -0.30, -0.11), and food intake (-0.28 effect size, 95% CI: -0.36, -0.19). Although lubrication is an important aspect of oral processing, few studies on its effects on appetite have been conducted. Future experiments using standardized approaches should provide a clearer understanding of the role of oral processing, including both chewing and lubrication, in promoting satiety

Varying cognitive targets and response rates to enhance the question-behaviour effect: An 8-arm Randomised Controlled Trial on influenza vaccination uptake

Rationale: The question-behaviour effect (QBE) refers to the finding that survey questions about a behaviour can change that behaviour. However, little research has tested how the QBE can be maximized in behavioural medicine settings. The present research tested manipulations of cognitive targets (questions about anticipated regret or beneficence) and survey return rates (presence vs. absence of a sticky note requesting completion of the questionnaire) on the magnitude of the QBE for influenza vaccination in older adults. Method: Participants (N = 13,803) were recruited from general practice and randomly allocated to one of eight conditions: control 1 (no questionnaire); control 2 (demographics questionnaire); intention and attitude questionnaire (with or without a sticky note); intention and attitude plus anticipated regret questionnaire (with or without a sticky note); intention and attitude plus beneficence questionnaire (with or without a sticky note). Objective records of subsequent influenza vaccination from general practice records formed the dependent variable. Results: Intention-to-treat analyses indicated that receiving an influenza vaccination questionnaire significantly increased vaccination rates compared to the no questionnaire, OR = 1.17, 95% CI = 1.01, 1.36 and combined control conditions, OR = 1.13, 95% CI = 1.01, 1.25. Including the sticky note significantly increased questionnaire return rates, OR = 1.25, 95% CI = 1.04, 1.50. However, there were no differences in vaccination rates between questionnaires containing different cognitive targets, a sticky note or not, and no interactions. There were no significant differences in the per-protocol analyses, i.e. among respondents who completed and returned the questionnaires. Conclusion: The QBE is a simple, low-cost intervention to increase influenza vaccination rates. Increasing questionnaire return rates or asking anticipated regret or beneficence questions in addition to intention and attitude questions did not enhance the QBE