European Health Forum GasteinGastein, October 2, 2009
Dr. Carmen Pérez RodrigoCommunity Nutrition Unit of Bilbao (Spain)
EC project Pro Children - identification of fruit and vegetables intake determinants and the
development of appropriate strategies to promote such intake among school children
and parents across Europe.
F&V consumption in Europe F&V consumption in Europe (g/pc/day)(g/pc/day)
Source: DAFNE Data Food Networking 2006- DG SANCO
Fruit, Vegetables andFruit, Vegetables andDisease PreventionDisease Prevention
Low fruit and vegetable intake is among the top 10 selected risk factors for global mortalityLow intake of fruits and vegetables is estimated to cause about 19% of gastrointestinal cancer, about 31% of ischaemic heart disease and 11% of stroke worldwide2.7 million deaths are attributable to low fruit and vegetable intake: more than four fifths from heart diseases.Childhood obesity: 22 million children in the EU estimated to be overweight (IOTF).
Promotion of healthy eating: children and adolescents
Increasingly important in public health as the Increasingly important in public health as the prevalence of overweight in children riseprevalence of overweight in children riseUnderstanding determinant factorsUnderstanding determinant factors
Individual level factorsIndividual level factorsEnvironmental factorsEnvironmental factors
Expected importance of environment for obesity Expected importance of environment for obesity related behaviours in children and adolescentsrelated behaviours in children and adolescentsThe school settingThe school setting:
Population groups: children, parents, teachersMost children attend to schoolSpend 6-7 hours 5 days/week; 9 months/year
Pro ChildrenPro Children
University of Oslo (Coordinador)University of Oslo (Coordinador)Unidad de NutriciUnidad de Nutricióón Comunitarian ComunitariaAyuntamiento de BilbaoAyuntamiento de BilbaoUniversity Hospital ReykjavUniversity Hospital ReykjavííkkUniversity of CopenhagenUniversity of CopenhagenUniversidade do PortoUniversidade do PortoUniversitUniversitäät Wient WienRoyal Veterinary and AgriculturalRoyal Veterinary and AgriculturalUniversity DenmarkUniversity DenmarkUniversiteit RotterdamUniversiteit RotterdamKarolinska Institutet StockholmKarolinska Institutet StockholmUniversiteit GentUniversiteit Gent
EU RTF Project QLK1-2001-547
Klepp KI, Pérez-Rodrigo C, De Bourdeaudhuij I, Due P, Elmadfa I, Haraldsdóttir J, Thórsdóttir I, Vaz de Almeida MD, Yngve A, Brug J.
Pro Children: AimsPro Children: Aims
To assess fruit and vegetableassess fruit and vegetableconsumptionconsumption in European schoolchildren and their parents, as well as determinants determinants of the children’s consumption patterns. To develop and test strategiesTo develop and test strategies, applicable across Europe, for promoting consumption of fruits and vegetables among schoolchildren and their parents
Percentage of individuals consuming fruit ≥ 1 portion/day. Pro Children, school children 11-12 yr
0
10
20
30
40
50
60
70
Portugal Spain TheNetherlands
Sweden Norway
%
Everyday, 3 portions/dayEveryday, 2 portions/day
Everyday, 1 portion/day
Austria DK Belgium Island
N=13924Yngve A, Wolf A, Eric Poortvliet et al. Ann Nutr Metab 2005;49:236–245
N=13924Yngve A, Wolf A, Eric Poortvliet et al. Ann Nutr Metab 2005;49:236–245
Percentage of individuals consuming vegetables ≥ 1 portion/day. Pro Children, school children 11-12 yr
0
10
20
30
40
50
60
70
TheNetherlands
Portugal Sweden Norway Spain
%
Everyday, 3 portions/day
Everyday, 2 portions/day
Everyday, 1 portion/day
Belgium DK Austria Island
Frequency of consumption of fruit. MothersPro Children
Wolf A, Yngve A, Elmadfa I et al. Ann Nutr Metab 2005;49:246–254
01020304050607080
Portug
alDenm
arkSwed
en
Spain
The N
etherlan
dsBelg
iumAus
triaNorw
ayIsl
and
Total
>2 portions/day2 portions/day1 portion/day
N=9167
01020304050607080
Sweden
Belgium
Portug
alDenm
arkThe
Netherl
ands
Islan
dNorw
ayAus
tria
Spain
Total
>2 portions/day2 portions/day1 portion/day
N=9167
Wolf A, Yngve A, Elmadfa I et al. Ann Nutr Metab 2005;49:246–254
Frequency of consumption of vegetables. Mothers Pro Children
Qualitative Exploration of determinants of Fruit and Vegetable Intake among 10-11 yr-Old children
Personal FactorsPersonal FactorsHealth BeliefsTaste PreferencesKnowledgeAwarenessPersonal Barriers
Factors Related to the Home EnvironmentFactors Related to the Home EnvironmentFamily InfluencesAvailability and AccessibilityFood RulesEncouragement
FactorsFactors related to the school environmentrelated to the school environmentAvailabilityPeer InfluencesSocial Norms
Wind M, Bobelijn K, De Bourdeaudhuij I, Klepp KI, Brug J. Ann Nutr Metab 2005;49:228–235
Pro Children: literature review. Potential determinants of fruit and vegetable intake in children and adolescents
SociodemographicGenderAgeSESUrbanizationEthnicity
Personal factors:Personal factors:PreferencesPreferencesKnowledgeKnowledgeAttitudesAttitudesIntentionsIntentionsSelf efficacySelf efficacySubjective normsSubjective normsOutcome expectanciesOutcome expectanciesFamily related factors
Parental intakeHome availabilityAccessFamily structureFamily sizeFamiliy mealsParenting stylesParental support
Friends related factorsFriends related factorsSchool related factorsSchool related factorsTV watchingTV watchingEating fast foodEating fast food
Rasmussen M, Kroelner R, Klepp KI, Lytle L, Brug J, Bere E, Due P. IJBNPA 2006, 3:22. doi:10.1186/1479-5868-3-22
Theoretical Model applied to children consumption Theoretical Model applied to children consumption of fruit and vegetables: Pro Children Projectof fruit and vegetables: Pro Children Project
Klepp K-I, Pérez Rodrigo C, De Bourdeaudhuij I et al.Ann Nutr Metab 2005; 49, 212-220.Klepp K-I, Pérez Rodrigo C, De Bourdeaudhuij I et al.Ann Nutr Metab 2005; 49, 212-220.
Cultural Environment
Physical environmentPhysical environmentPolicies
Dietary guidelinesAvailability Accessbility
Fruit & VegetableFruit & Vegetableconsumptionconsumption
EthnicityCountry
Socio economical level
National levelCommunity level
School level:School level:School mealsSchool meals
Perceived environment:At homeAt schoolOther environments
Mass mediaSchool:
teachers, peersFriends
Family
Physical activityTV viewing
BiologicalPsychological
Specific F&V factors: preferences, attitudes, knowledge
Personal factors
Social environment
Pro Children intervention:Pro Children intervention:Is it required?Is it required?
Fruit and vegetable intake is too low among European childrenPro Children consortium: aimed to initiate, develop, implement and evaluate school-based fruit and vegetable promotion actions among primary school children aged 10-13 in different European countries: To develop an evidence-based and theory-driven intervention package that is applicable in different European countries.
Identified changeable important determinants of fruit and vegetaIdentified changeable important determinants of fruit and vegetable ble consumption in Pro Children interventionconsumption in Pro Children intervention
Determinants
Personal Social EnvironmentalAwareness of importance of fruit and vegetable intake for health and well-being
Parental facilitation and direct encouragement
Availability and accessibility of fruit and vegetable at home
Positive taste preferences for different fruits and vegetables Parental modelling behaviour Availability and accessibility of fruit
and vegetable in the schoolAwareness of own fruit and vegetableintake Peer modelling behaviour A fruit and vegetable promotion
school environmentAwareness of recommended intake levels Teacher support Neighbourhood support
Self-efficacy and skills for asking for fruit and vegetableSelf-efficacy and skills for preparing fruit and vegetableSelf-efficacy and skills for obtaining fruit and vegetableSelf-efficacy and skills for keeping fruit and vegetable freshFamiliarity with different fruits and vegetables
Pérez Rodrigo C, Wind M, Hildonen C, Bjelland M, Aranceta J, Klepp KI, Brug J. Ann Nutr Metab 2005;49:267–277
Matrix of learning objectives for school children in Pro ChildreMatrix of learning objectives for school children in Pro Children intervention n intervention arranged by determinants: personal determinants. arranged by determinants: personal determinants.
Performance objectives
Personal determinants
Awareness Skills Self-efficacy Self-evaluation Preferences/ Taste
To assess adequacy of one’s own current fruit and vegetable intake
Children are aware of importance of fruit and vegetable intake for health and well-being
Children can complete a computer based fruit and vegetable test
Children complete a computer based fruit and vegetable test
Children are aware of recommended intake levels
Children can read and understand a feedback report
Children read and understand a tailored feedback report
Children know what is a portion of fruit and a portion of vegetables
Children develop skills to identify what is a portion of fruit and a portion of vegetables
Children set goals for increased consumption
Children taste a variety of fruits and vegetables at home
Children know what a fruit juice is and what is not
Children taste a variety of fruits and vegetables at school
Children are aware of own intake
Children taste a variety of fruit juices at school
Pérez Rodrigo C, Wind M, Hildonen C, Bjelland M, Aranceta J, Klepp KI, Brug J. Ann Nutr Metab 2005;49:267–277
Learning objective Availability Awareness Preferences Peer
influencesParental
influences
Skills:Prepare
Ask/ObtainChildren are aware of importance of fruit and vegetable intake for health and well-being
Education-worksheet guided activity
Children know recommendation
CT*-feedback
Children know what a fruit juice is and what is not
Education-worksheet guided activity
Taste-testing activity at school
Fruit and vegetable is an issue for children
Education-worksheet on label reading
Web-based international discussion forum
Children find fruit and vegetable at school
School fruit (fruit break)
Eat fruit and vegetable together in class
Parents give fruit and vegetable to children to bring to school
Selected educational strategies related to learning objectives aSelected educational strategies related to learning objectives and nd modifiable determinants in Pro Children interventionmodifiable determinants in Pro Children intervention
CT: Computer tailoringCT: Computer tailoring
Pro Children: InterventionPro Children: Intervention
School
School-basedIntervention program
Family
Community
ClassroomOut-of-classroom
School meals
Whole SchoolWhole SchoolWorksheetsWorksheetsEducationalEducationalActivitiesActivitiesComputerComputerTailoringTailoringWeb siteWeb site
Fruit breakFruit breakSpecial schoolSpecial school
eventseventsSchool ProjectSchool Project
committeescommittees
WorksheetsWorksheetsNewslettersNewsletters
School EventsSchool EventsComputerComputertailoringtailoring
School HealthSchool HealthMass MediaMass Media
Grocery storesGrocery stores
Guidance for parents: worksheet 8Guidance for parents: worksheet 8Estimados padres/madres,Nuevamente nos ponemos en contacto con Uds. en relación con el proyecto Pro Children en el que participa su hijo/a. Esta vez la actividad que proponemos a su hijo/a requiere que le anime y le recuerde algunas cosas. En clase, junto con su profesor/a y sus compañeros/as ha decidido qué va a hacer a lo largo de la semana que viene para comer más frutas y verduras. Ya se ha hecho su plan. Ha pensado también algunas cosas concretas que va a hacer.Le pedimos que comente con su hijo/a en casa estos propósitos y que le ayude a conseguirlo, por ejemplo recordándole si ya ha cogido la fruta para llevar al colegio, o la estrategia que se haya trazado.Queremos plantearlo como un pequeño juego que resulte una experiencia atractiva para los chicos/as. Se trata de intentar un pequeño reto a lo largo de una semana.Muchas gracias por su ayuda.
La Comisión Escolar de Proyectos Saludables Pro Children.
Pro Children Family Newsletter
Num 3; 2004
“Volcán” from San Inazio school wins Pro Children recipe competition
30 schools from Norway, The Netherlands and Spain took part in the international recipe contest using fruits and vegetables
Last April 14th after long discussions, the international Pro Children jury decided in Rotterdam the winning recipes of the fruit and vegetable recipe competition. “Kristoffers Wok” from Oslo, “Pizza cauliflower” from Rotterdam and “Volcano” from Bilbao were the winners. 6 recipes from each country, 3 fruit recipes and 3 vegetable ones, were nominated for the final voting among more than 100 hundred submitted. Prizes will be delivered to winning schools in June .
More info on page 3.
In the picture one of the selected recipes, “Aubergine Jamaican style”from Uribarri school.
International Recipe CompetitionInternational Recipe Competition
School fruit breakSchool fruit breakBilbao Bilbao
Study design
Cluster randomised trial
Intervention group32 schools (n=1115)
Control Group30 schools (n=991)
Norway: 9 schools (n=337) Norway: 9 schools (n=390)
The Netherlands: 12 schools (n=410) The Netherlands: 12 schools (n=325)
Spain: 11 schools (n=368) Spain: 9 schools (n=276)
1st EvaluationChildren & Families
InstrumentDesign
Design of the intervention
Intervention group
2nd EvaluationChildren & Families
2nd EvaluationChildren & Families
Control group
Pro Children: changes in total fruit and vegetables intake among intervention and control schools
Total Fruit intakeTotal Fruit & Vegetables intake
Total Vegetables intake
*** Intervention effect was significant (P<0,05)
te Velde SJ, Brug J, Wind M, Hildonen C, Bjelland M, Perez-Rodrigo C and Klepp KI. Br J Nutr, 2007
Knowledge scoreKnowledge scoreProportion who knows Proportion who knows
recommendationsrecommendations
46,5 47,7 44,7
63,8
23,3 24,9 20,2
34,8
0
20
40
60
80
100
Fruit 0 Fruit 1 Vegetables 0 Vegetables 1
Control Intervention
%
Wind M, te Velde S, Hildonen C, Bjelland M, Pérez-Rodrigo C, Klepp KI, Brug J, 2006
Preferences fruit Preferences fruit and vegetablesand vegetables
1,25 1,22 1,25 1,21
0,43 0,36 0,33 0,37
0
0,5
1
1,5
2
Fruit 0 Fruit 1 Vegetables 0 Vegetables 1Control Intervention
Perceived Perceived availability at availability at
schoolschool 28,6 27,631,5
46,7
21,3 19,5 21,528,7
-55
15253545556575
Fruit 0 Fruit 1 Vegetables 0 Vegetables 1
Control Intervention
7,6
15,4
6,1
16,5
7,9
17,5
4,3
15
0
10
20
30
40
50
Fruit 0 Fruit 1 Vegetables 0 Vegetables 1Control Intervention
Bring F&V Bring F&V to schoolto school
Wind M, te Velde S, Hildonen C, Bjelland M, Pérez-Rodrigo C, Klepp KI, Brug J, 2006
Project appreciation scores by children, teacher Project appreciation scores by children, teacher referred implementation and parental involvementreferred implementation and parental involvement
Children project appreciation
Degree of implementation
Parental involvement
Country n Mean (SD) n Mean (SD) n Mean (SD)Total 842 2.3 (0.5)** 818 9.1 (3.0)** 559 3.3 (1.9)**Norway 240 2.4 (0.5) 225 10.9 (2.4) 160 3.4 (1.8)
Spain 297 2.3 (0.4) 320 9.4 (1.9) 233 3.5 (1.9)
The Netherlands 305 2.2 (0.5) 273 7.4 (3.5) 166 2.8 (1.9)GenderBoys 380 2.3 (0.5) 369 9.3 (3.0) 237 3.1 (2.0)*Girls 462 2.3(0.4) 449 9.1 (3.0) 322 3.4(1.8)
** p<0,001; *p< 0,05
Wind M, Bjelland M, Pérez-Rodrigo C, te Velde S, Hildonen C, Bere E, Klepp KI, Brug J. HER, 2007
ConclusionsConsumption of F&V in European school children is below recommended intake levels in a large proportion of this population group.
Intake below desirable levels is more frequent among boys.
The Pro Children intervention is a promising means to promote European schoolchildren’s fruit and vegetable intakes: school-based, multi-component, involving parents, increasing availability and access to F&V.
Family support and involvement is important: encourage to eat F&V.
Strategies should be implemented over time with adequate duration.
More research is needed to find the barriers for implementation and solutions to improve it, particularly family support.
This paper was produced for a meeting organized by Health & Consumers DG and represents the views of its author on thesubject. 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 & Consumers DG's views. The European Commission does not guarantee the accuracy of the dataincluded in this paper, nor does it accept responsibility for any use made thereof.