A cluster randomized controlled trial of a telephone-based parent intervention to increase preschoolers’ fruit and vegetable consumption

Background: Inadequate fruit and vegetable consumption is associated with increased chronic disease risk and represents a considerable global health burden. Despite evidence that dietary habits track from early childhood, there are few published trials of interventions attempting to increase preschoolers’ fruit and vegetable consumption.

Objective: The Healthy Habits trial aimed to assess the efficacy of a telephone-based intervention for parents to increase the fruit and vegetable consumption in their 3–5-y-old children.

Design: A cluster randomized controlled trial was conducted involving 394 parents of children aged 3–5 y recruited through local preschools. Parents allocated to the intervention received printed resources plus four 30-min telephone calls targeting aspects of the home food environment associated with children's fruit and vegetable consumption. Parents allocated to the control group received generic printed nutrition information. Children's fruit and vegetable consumption was assessed by using the Fruit and Vegetable Subscale of the Children's Dietary Questionnaire, which was administered via telephone interview at baseline and 2 and 6 mo later.

Results: Analysis of all available data showed that children's fruit and vegetable scores were significantly higher in the intervention group than in the control group at 2 mo (P < 0.001) and at 6 mo (P = 0.021). Sensitivity analysis using baseline observation carried forward showed an intervention effect at 2 mo (P = 0.008) but not at 6 mo (P = 0.069).

Conclusions: Telephone-delivered parent interventions may be an effective way of increasing children's fruit and vegetable consumption in the short term. Further investigation to determine whether the intervention effect is maintained in the longer term is recommended.

Children's consumption of energy dense nutrient poor foods, fruit and vegetables; are they related? An analysis of data from a cross sectional survey

Issue addressed: Many children consume excessive amounts of energy-dense, nutrient-poor (EDNP) or 'extra' foods and low intakes of fruit and vegetables. The aim of this study was to examine the associations between EDNP foods and ascertain whether certain EDNP foods and beverages are more likely to be eaten in association with other EDNP foods.

Methods: A cross-sectional representative population survey of children in preschool (n=764), and of school students in Years K, 2 and 4 (n=1,560) and in Years 6, 8 and 10 (n=1,685) residing in the Hunter New England region of New South Wales, Australia. Dietary data were collected using a short food frequency questionnaire. Multivariate logistic regression models examined the association between EDNP foods and fruit and vegetable intake. Data were stratified by sex and age cohort.

Results: More frequent consumption of some EDNP food types was significantly associated with more frequent consumption of other EDNP foods. Fast food and soft drinks consumption were associated with each other as well as with fried potato and salty snacks; and with lower intakes of fruit and vegetables in some but not all age groups.

Conclusion: The positive associations found between EDNP foods point towards the existence of a high-risk group of children who frequently consume a variety of EDNP foods and drinks.

Perceived quality and availability of fruit and vegetables are associated with perceptions of fruit and vegetable affordability among socio-economically disadvantaged women

Objective Perceptions that fruit and vegetables are expensive have been found to be associated with lower consumption of fruit and vegetables among disadvantaged women; however, the determinants of these perceptions are relatively unknown. The purpose of the current paper is to examine whether perceived availability and quality of fruit and vegetables, and social support for healthy eating, are associated with perceptions of fruit and vegetable affordability among women residing in disadvantaged neighbourhoods.

Design Cross-sectional self-report survey.

Setting The study was conducted in Melbourne, Australia.

Subjects An Australian sample of 4131 women, aged 18–45 years, residing in neighbourhoods ranked in the lowest Victorian tertile of relative disadvantage by the Australian Bureau of Statistics, an index that considers aspects of disadvantage such as residents’ income, education, motor vehicle access and employment.

Results Results showed that irrespective of education, income and other key covariates, women who perceived poor availability and quality of fruit and vegetables in their local neighbourhood were more likely to perceive fruit and vegetables as expensive.

Conclusions Our results suggest that perceptions of fruit and vegetable affordability are not driven exclusively by lack of financial or knowledge-related resources, but also by women's psychological response and interpretation of their local nutrition environment.

ShopSmart 4 Health - protocol of a skills-based randomised controlled trial promoting fruit and vegetable consumption among socioeconomically disadvantaged women

Background
There is a need for evidence on the most effective and cost-effective approaches for promoting healthy eating among groups that do not meet dietary recommendations for good health, such as those with low incomes or experiencing socioeconomic disadvantage. This paper describes the ShopSmart 4 Health study, a randomised controlled trial conducted by Deakin University, Coles Supermarkets and the Heart Foundation, to investigate the effectiveness and cost-effectiveness of a skill-building intervention for promoting increased purchasing and consumption of fruits and vegetables amongst women of low socioeconomic position (SEP).

Methods/design
ShopSmart 4 Health employed a randomised controlled trial design. Women aged 18–60 years, holding a Coles store loyalty card, who shopped at Coles stores within socioeconomically disadvantaged neighbourhoods and met low-income eligibility criteria were invited to participate. Consenting women completed a baseline survey assessing food shopping and eating habits and food-related behaviours and attitudes. On receipt of their completed survey, women were randomised to either a skill-building intervention or a wait-list control condition. Intervention effects will be evaluated via self-completion surveys and using supermarket transaction sales data, collected at pre- and post-intervention and 6-month follow-up. An economic evaluation from a societal perspective using a cost-consequences approach will compare the costs and outcomes between intervention and control groups. Process evaluation will be undertaken to identify perceived value and effects of intervention components.

Discussion
This study will provide data to address the currently limited evidence base regarding the effectiveness and cost-effectiveness of skill-building intervention strategies aimed at increasing fruit and vegetable consumption among socioeconomically disadvantaged women, a target group at high risk of poor diets.

When nutritional guidelines and life collide: family fruit and vegetable socialisation practices in low socioeconomic communities

Parents play a critical role in promoting fruit and vegetable consumption, for eating patterns established early in life tend to persist into adulthood. Despite this, the factors that facilitate or inhibit parents&rsquo; capacity to socialise fruit and vegetable consumption into their children&rsquo;s daily diets remain poorly defined. Thirty-eight semi-structured interviews with residents, allied healthcare professionals, community leaders, community programme leaders and a local government leader living or working in two low socioeconomic suburbs were consequently conducted to ascertain factors exogenous and endogenous to the family unit that shaped parental food socialisation practices. Budgetary and time constraints emerged as exogenous factors that constrained fruit and vegetable socialisation. Constraining effects were also found for a range of endogenous factors, including commensal experiences, children&rsquo;s food fussiness and the feeding styles employed by parents. As such, while many caregivers may wish to socialise fruit and vegetable consumption into their children&rsquo;s daily diets, their capacity to do so is often inhibited by factors beyond their volitional control. Failure to take heed of these factors could therefore result in the development of social marketing campaigns that are ineffective at best or give rise to unintentionally harmful outcomes at worst.

Factors affecting acceptability of an email-based intervention to increase fruit and vegetable consumption

 Background: Fresh Facts is a 30-day email-delivered intervention designed to increase the fruit and vegetable consumption of Australian young adults. This study investigated the extent to which the program was acceptable to members of the target audience and examined the relationships between participant and intervention characteristics, attrition, effectiveness, and acceptability ratings. Methods: Young adults were randomised to two levels of message frequency: high-frequency (n = 102), low-frequency (n = 173). Individuals in the high-frequency group received daily emails while individuals in the low-frequency group received an email every 3 days. Results: Individuals in the high-frequency group were more likely to indicate that they received too many emails than individuals in the low-frequency group. No other differences in acceptability were observed. Baseline beliefs about fruit and vegetables were an important predictor of intervention acceptability. In turn, acceptability was associated with a number of indicators of intervention success, including change in fruit and vegetable consumption. Conclusions: The findings highlight the importance of considering the relationship between these intervention and participant factors and acceptability in intervention design and evaluation. Results support the ongoing use of email-based interventions to target fruit and vegetable consumption within young adults. However, the relationships between beliefs about fruit and vegetable consumption and acceptability suggest that this intervention may be differentially effective depending on individual's existing beliefs about fruit and vegetable consumption. As such, there is a pressing need to consider these factors in future research in order to minimize attrition and maximize intervention effectiveness when interventions are implemented outside of a research context.

Does food store access modify associations between intrapersonal factors and fruit and vegetable consumption?

Background/Objectives:Existing theoretical frameworks suggest that healthy eating is facilitated by an individual's ability, motivation and environmental opportunities. It is plausible, although largely untested, that the importance of factors related to ability and motivation differ under varied environmental conditions. This study aimed to determine whether the magnitude of associations between fruit and vegetable consumption and intrapersonal factors (ability and motivation) were modified by differences in access to stores selling these items (environmental opportunities).Subjects/Methods: Cross-sectional analysis of 4335 women from socioeconomically disadvantaged neighbourhoods in the state of Victoria, Australia. Self-reported fruit and vegetable consumption was assessed against a number of ability- and motivation-related factors. To examine whether associations were modified by store access, interactions with access to supermarkets and greengrocers within 2 km of participants' households were tested.Results:Of the two factors related to ability and seven factors related to motivation, almost all were associated with fruit and vegetable consumption. In general, associations were not modified by store access suggesting that these factors were not tempered by environmental opportunities.Conclusions:This study provides little support for the hypothesis that the importance of intra-personal factors to fruit and vegetable consumption is modified by food store access. Further research on this topic is required to inform behaviour change interventions.European Journal of Clinical Nutrition advance online publication, 21 January 2015; doi:10.1038/ejcn.2014.287.

A cluster randomised controlled trial of a telephone-based intervention targeting the home food environment of preschoolers (The Healthy Habits Trial): the effect on parent fruit and vegetable consumption

Abstract
Background: The home food environment is an important setting for the development of dietary patterns in childhood. Interventions that support parents to modify the home food environment for their children, however, may also improve parent diet. The purpose of this study was to assess the impact of a telephone-based intervention targeting the home food environment of preschool children on the fruit and vegetable consumption of parents.
Methods: In 2010, 394 parents of 3 – 5 year – old children from 30 preschools in the Hunter region of Australia were recruited to this cluster randomised controlled trial and were randomly assigned to an intervention or control group. Intervention group parents received four weekly 30-minute telephone calls and written resources. The scripted calls focused on; fruit and vegetable availability and accessibility, parental role-modelling, and supportive home food routines. Two items from the Australian National Nutrition Survey were used to assess the average number of serves of fruit and vegetables consumed each day by parents at baseline, and 2-, 6-, 12-, and 18-months later, using generalised estimating equations (adjusted for baseline values and clustering by preschool) and an intention-to-treat-approach.
Results: At each follow-up, vegetable consumption among intervention parents significantly exceeded that of controls. At 2-months the difference was 0.71 serves (95% CI: 0.58-0.85, p < 0.0001), and at 18-months the difference was 0.36 serves (95% CI: 0.10-0.61, p = 0.0067). Fruit consumption among intervention parents was found to significantly exceed consumption of control parents at the 2-,12- and 18-month follow-up, with the difference at 2-months being 0.26 serves (95% CI: 0.12-0.40, p = 0.0003), and 0.26 serves maintained at 18-months, (95% CI: 0.10-0.43, p = 0.0015).
Conclusions: A four-contact telephone-based intervention that focuses on changing characteristics of preschoolers’ home food environment can increase parents’ fruit and vegetable consumption.
(ANZCTR12609000820202)

Socioeconomic inequalities in fruit and vegetable intakes

Socioeconomic position (SEP) refers to an individual’s social and economicranking within society based on access to resources (such asmaterial and social assets, including income, wealth, and educational credentials)and prestige (ie, an individual’s status in a social hierarchy, linkedfor instance to their occupation, income, or education level) (Krieger et al.,1997). Individual SEP can be measured using a variety of indicators whichcommonly include education, occupation, and income (Galobardes et al.,2006). Composite measures are frequently used when examining neighborhoodlevel measures of SEP and are commonly created by combining censusdata on a range of indicators.