Effective Strategies to Increase Vegetable Consumption in Children

Introduction
The amount of vegetables recommended for children by the USDA vary due to their age, but one
thing that doesnt vary is that the majority of children in the United States, over 75%, are not
meeting the recommendation for their age group (1). Poor food choices due to a preference for
high calorie foods with high sugar and fat content are observed in children (2). These poor food
choices, along with low activity levels, genetics, and behavior can lead to children being
overweight(3).Childhood obesity has been increasing; according to NHANHES, in children ages
6-11 it went from 11% of children in 1994 to almost 18% in 2008 (2). Developing healthy eating
habits, such as consuming the recommended amount of vegetables, may lower the risk of heart
disease, some cancers, obesity, and type 2 diabetes. (2,3). Due to the low consumption of
vegetables, and high obesity rates, effective methods to increase the consumption of vegetables
have been studied in the US and other countries as well. A childs vegetable preference is a
predictor of their vegetable consumption, so ways to increase a childs preference for vegetables
is also important in the battle of low vegetable consumption (4). This paper reviews successful
methods that have been studied to significantly increase the amount and the variety of vegetables
eaten by children.
Exposure Technique
Exposing children to the taste of a vegetable multiple times has been reported to yield a
preference of that vegetable by children. An increase in preference and liking of vegetables
correlate with higher consumption rates of vegetables. Children aged 2 6 years often have
neophobia, a fear of eating unfamiliar foods; which can make it difficult for to get a child to try a
new vegetable (5).
The study done in Louisiana by Lakkakula and co-workers on a cafeteria-based tasting program,
exposed children in first, third, and fifth grade to new vegetables and fruits. The study was done
by assessing childrens food preferences prior to the tasting-program, requiring the children to
taste the new vegetable 12 times over a 10 week period, and then following up after each taste to
determine their preference for the fruit or vegetable. The study found that on average it takes the
child 2 tastes of most fruit, such as apricots and cantaloupe, to increase their preference for that
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food, and at least 5 tastes to increase preference for vegetables such as bell peppers and carrots.
Each time the child tastes the fruit or vegetable, the probability that the child will like the taste
rises for each age group. For example, children who disliked carrots at their first taste, the
probability that they will like it changes from 0 from the first taste to .99 by the 12th taste. The
study was followed up by assessing the childrens preference for the same foods exposed during
the intervention 4 and 10 months after the initial food tasting. The increased preference for the
foods following the intervention was maintained. This means that exposing the children to new
fruits and vegetables is an effective way to increase the preference for that food, which is a
predictor of their consumption (5).
Exposure and Reward
The exposure technique can also be coupled with a reward, which is done in the study by CSIRO
Food and Nutritional Sciences in South Australia. The study compared the exposure technique to
exposing children to the vegetable followed by a sticker reward. It was thought that the principle
of positive reinforcement would increase consumption of vegetables more than exposure alone.
The children who had the sticker reward after tasting the vegetable refused tasting less often and
tasted the food more than the children who did not get any reward for trying the food. Both
groups of children increased their liking for the vegetables, which follows from the 5 tastes
needed to increase their preference found in the previous study. 58% of the children with the
reward, vs. 48% of the children with only exposure to vegetables, increased their preference for
the vegetables offered to them. The study also found an increase in the consumption of
vegetables from baseline in both groups during and after the intervention. Since the consumption
continued after the exposure and reward was offered, this reiterates that a higher preference for
the taste increases the consumption of vegetables (4).
Hiding Vegetables
When exposure techniques dont work because of a childs vegetable resistance or neophobia,
there are still ways to get a child to increase their consumption of a variety of vegetables without
them playing an active role in the process. Hiding vegetables into entrees by pureing them has
been found to increase vegetable consumption while also decreasing the energy density of their
meal. A study tested this way of increasing vegetables by providing 3 meals a day to children
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aged 3-5 with pureed vegetables added to the recipe while still supplying vegetable side dishes.
There were three different meal plans offered during the study, 100% energy density(ED), 85%,
ED and 75% ED of the standard energy density. Children ate a consistent amount of food
whether it had pureed vegetables in it or not, regardless of the energy density, and showed a
general liking for the entrees with the hidden vegetables, finding many yummy. This method
increased daily vegetable consumption 50% in the 85% ED group, and 73% in the 75% ED
group (6). Some name brands of processed foods already do this with their products, offering
servings of vegetables in their products while hiding the taste of them, such as Chef Boyardee
and V8 Fusion.
Garden Projects
Heim and co-workers did a pilot project which was done at a YMCA camp to get children
involved in the growing and preparation of their food at a 12-week summer camp. The children
played an active role in preparing snacks with the fruits and vegetables from the garden, as well
as getting cook books with recipes for the produce being grown. Children were exposed to new
fruits and vegetables that some may have not been before. Their liking for those new foods
increased as well. The mean preference increase for spinach for example, from baseline to follow
up increased 35%. An important outcome of this pilot was that children increased their frequency
of asking their parents for certain fruits and vegetables in their home, from a mean of 2.16 to
2.32(p <.002), taking a responsible role in their own health and food intake (7).
Garden activities combined with nutritional education also prove to be an effective method to
increase consumption of fruits and vegetables. Another study compared 3 schools; a control
school, a school implementing a nutritional education program, and another with a nutritional
education program with garden activities. The children were an average age of 11.1 years. The
activities included maintaining a garden which was 25x25 ft. The garden itself had a variety of
vegetables, such as potatoes, peppers, peas, squash, and spinach. The students that attended the
school with the garden activities and nutritional education program almost doubled their
combined fruit and vegetable intake, which was 4.5 servings after the program, making their
average consumption only .5 servings less than the recommended amount. Surprisingly, the
students attending the school with just a nutritional education program had no significant
difference in their consumption, meaning the horticulture aspect of the program proved to play
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an important role in the vegetable consumption increase(8). When participants of the garden pilot
were asked what they liked most about it, one child responded I liked that we did it ourselves
and we have the pride for it and another said being able to pick fruits and vegetables and eat
the same ones (7).
Implementation Intervention and the Theory of Planned Behavior
In the United Kingdom, vegetable intake is low, similarly to the US. A study done at
Staffordshire University in the UK compared an intervention using the Theory of Planned
Behavior (TPB) with a volitional intervention. The volitional intervention was based on
implementing intentions, while the TPB was motivational. Group A of the study was the
volitional intervention. The children, from 11-16 years old, were asked to write down exactly
how they were going to implement 5 servings of fruits and vegetables a day into their diet for the
following week. Group B, using the motivational intervention, completed a health activity
education sheet. The goal was to try to change the childrens beliefs on fruits and vegetables.
TPB is based on changing salient beliefs and creating new ones. Both methods increased fruit
and vegetable intake in children, with the implementation intervention showing more significant
results in increased intakes. The volitional intervention participants increased their consumption
by .52 servings, while the motivational group increased by .31(9).
Conclusion
Various methods have been studied and proved to increase vegetable consumption in children.
Increasing childrens preference for the taste of vegetables is the first step since its a predictor of
their consumption, and exposure coupled with rewards shows to be a good way of doing that.
Exposure alone will also increase the childs preference. Garden projects increase the education
and exposure of nutritious fruits and vegetables, which can excite the children about adding a
variety of vegetables to their diet. Theory of planned behavior increased their consumption as
well, volitional and motivation both increased their consumption a considerable amount. Hiding
vegetables by pureing them into common recipes can be another method to increase the
consumption, although this technique lacks the children being active in the process.
Studies should be conducted on what influences children to eat vegetables into adulthood.
Children arent the only life stage that doesnt get enough vegetables, adults dont either.
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According to a Behavioral Risk Factor Surveillance System (BRFSS) survey, only 27.2% of
adults eat vegetables 3 or more times a day (10). Further studies should be conducted to see if
these techniques, or other techniques, can increase vegetable consumption in childhood and last
throughout adulthood as well.

REFERENCES
1. Lorson BA, Melgar-Quinonez HR, Taylor CA. Correlates of fruit and vegetable intakes in US
children. J Am Diet Assoc. 2009;109(3):474-478.
2. Brown J, Isaacs J, Krinke U, et al. Nutrition through the life cycle. Fourth ed. Belmont, CA:
Wadsworth; 2010.
3. Insel P, Turner ER, Ross D. Nutrition. Third ed. Sudbury, MA: Jones and Bartlett; 2007.
4. Corsini N, Slater A, Harrison A, Cooke L, Cox DN. Rewards can be used effectively with
repeated exposure to increase liking of vegetables in 46-year-old children. Public Health Nutr.
2011;FirstView:1. Available from: http://dx.doi.org/10.1017/S1368980011002035.
5. Lakkakula A, Geaghan JP, Wong W, Zanovec M, Pierce SH, Tuuri G. A cafeteria-based tasting
program increased liking of fruits and vegetables by lower, middle and upper elementary schoolage children. Appetite. 2011;57(1):299-302.
6. Maureen K Spill, Leann L Birch, Liane S Roe, Barbara J Rolls. Hiding vegetables to reduce
energy density: An effective strategy to increase children's vegetable intake and reduce energy
intake. Am J Clin Nutr. 2011;94(3):735-741. Available from:
http://www.ajcn.org.silk.library.umass.edu/content/94/3/735.long.
7. Heim S, Stang J, Ireland M. A garden pilot project enhances fruit and vegetable consumption
among children. J Am Diet Assoc. 2009;109(7):1220-1226.
8. McAleese JD, Rankin LL. Garden-based nutrition education affects fruit and vegetable
consumption in sixth-grade adolescents. J Am Diet Assoc. 2007;107(4):662-665.
9. Lucy Gratton, Rachel Povey, David Clark-Carter. Promoting children's fruit and vegetable
consumption: Interventions using the theory of planned behavior as a framework. British
Journal of Health Psychology. 2007;12(4):639-650. Available from:
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%40sessionmgr11&vid=1&hid=12&bdata=JnNpdGU9ZWhvc3QtbGl2ZSZzY29wZT1zaXRl#d
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http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5610a2.htm. Published
March 16, 2007. Accessed November 3rd, 2011

Outline
1. Introduction
a. Children are not eating the recommended amount of vegetables
i. What are the risks?
ii. What can be done to increase consumption?
b. Purpose of paper
i. Studies have been done
ii. Brief overviews of affective methods that have been
studied
2. Body
a. Exposure Technique
i. Study done in Louisiana
ii. Neophobia
iii. Exposing children to vegetables (made them try 12 times)
iv. Increased liking of vegetables after 5 tastes
b. Exposure and Reward
i. Comparing exposure only to exposure plus reward
ii. CSIRO did the study in Australia
iii. Both groups increased preference
c. Hiding Vegetables
i. Puree vegetables into common recipes

ii. Different energy densities

iii. Increased vegetable consumption while lowering energy
density
d. Garden Projects
i. YMCA 12 week summer camp
ii. What children did, garden and learn about foods
iii. Increased preference for vegetables and asking behavior
iv. Garden activities at school vs. just nutrition education
v. Garden activities increased consumption to close to
recommended amounts
vi. Kids liked the garden
e. Theory of Planned Behavior
i. TPB vs. Implementation
ii. Both increased, implementation increased more
3. Conclusion
a. All methods were effective in increasing consumption
b. Studies should be done to see what influences children into
adulthood to eat vegetables, if these methods stick or not.