REPEATED EXPOSURE ON VEGETABLE INTAKE IN EARLY CHILDHOOD 1

The Efficacy of Repeated Exposure on Vegetable Intake in Early Childhood: A Systematic

Review

April 29, 2018

Alana Sherman

NTD 630 Capstone Course for Master of Science in Community Nutrition

REPEATED EXPOSURE ON VEGETABLE INTAKE IN EARLY CHILDHOOD 2

Table of Contents

Page

Abstract 26

List of Tables and Figures

Introduction

Methods

Results

Discussion

Conclusion

References

19

22

25
 List of Tables

Table Page
 1. Data Extraction 11

2. Quality Criteria Checklist 18

List of Figures

Figure Page

1. Flow Diagram of Selection Process 9

Abstract

Objective: To evaluate existing literature to ascertain whether repeated exposure can facilitate

increased consumption of a target vegetable in early childhood.

Methods: A systematic review of literature was conducted of both randomized and non-

randomized controlled trials using CINAHL, PubMed, Medline, and references extracted from

eligible literature. Selected literature was published between January 2010 and January 2018.

Participants were young children between the ages of 9 months to 6 years with no preexisting

health conditions or allergies compromising appetite or dietary intake. Articles were critically

appraised for overall validity using the Quality Criteria Checklist.

Results: A total of ten full-text articles were selected for review after meeting the identified

inclusion and exclusion criteria. The majority of evidence was consistent in reporting outcomes

in favor of repeated exposure on children’s vegetable intake. Of the ten articles reviewed, 8

observed statistically significant increases in young children’s vegetable consumption following

repeated exposure to the selected target vegetable. However, these results should be interpreted

in light of several limitations including small sample sizes, short study durations, and highly

educated sample populations.

Conclusion: The present literature provides reasonable evidence to support that repeated

exposure can effectively promote increased intake of non-bitter tasting vegetables among young

children between the ages of 1-6 years. Additional research is needed to determine whether this

approach would be equally effective on different types of vegetables presented in settings outside

of the school environment.

Introduction

Approximately 16.9% of children between the ages of 2-19 years in the United States are

classified as overweight or obese (Centers for Disease Control and Prevention [CDC], 2014).

Rising childhood obesity rates have largely been attributed to limited intake of fruits and
vegetables and excessive intake of processed foods high in fat, sugar, and salt during the first few

years of life. The Dietary Guidelines for Americans recommends that young children between

the ages of 1-5 consume between 1-1.5 cups per day of raw or cooked vegetables or vegetable

juice (U.S. Department of Health and Human Services, 2015). According to the Centers for

Disease Control and Prevention (CDC), it is estimated that 9 out of 10 children in the United

States fall below these recommendations (Kim, Moore, Latetia, Galuska, Ashton, Harris,

Grummer-Stawn, Laurence, and Rhodes 2014). In addition, 63% of the vegetables consumed by

young children are white potatoes in the form of either French fries, fried potatoes, or as chips

(Kim et al., 2010).

The etiology of obesity is far too complex to be pinpointed to a singular cause, however,

a Westernized diet characterized by high intakes of calorically-dense nutrient empty processed

foods, sugar sweetened beverages, and low intakes of fruit and vegetables (FV) have been shown

to largely contribute to this epidemic (Emmett & Jones, 2015; Okubo, Crozier, Harvey, Godfrey,

Inskip, Cooper, and Robinson, 2015; Sahoo, Sahoo, Choudhury, Sofi, Kumar, and Bhadoria,

2015). Despite this, 34.3% of children between the ages of 2-19 consume junk food or fast-food

daily (CDC, 2015). In fact, 40% of the average children’s diet in America comes from empty

calories, most commonly from: soda, fruit drinks, dairy desserts, grain desserts, and pizza (CDC,

2015).

The health benefits of consuming fruit and vegetables are well documented. Current

literature supports adequate intake of fruits and vegetables for chronic disease prevention,

obesity prevention, proper growth and development, immune support, and digestive health

(Aune, Giovanucci, Boffetta, Fadnes, Keum, Norat, and Tonstad, 2017; Boeing, Bechtold, Bub,

Ellinger, Haller, Kroke, and Watzl, 2012; Nguyen, Bauman, Gale, Banks, Kritharides, and Ding,
2016; Oyebode, Gordon-Dseagu, Walker, and Mindell, 2014). The aforementioned health

benefits have been attributed to the nutritional properties of fruit and vegetables, which are

naturally high in vitamins and minerals, phytonutrients, and fiber. A higher intake of fruit and

vegetables has been associated with lower risk for developing Type 2 Diabetes, asthma, cancer,

and osteoporosis (Boeing et al., 2012; Lanham-New, 2006; Paliyath, Bakovic & Shetty, 2011;

Razzis & Noor, 2013;).

The early childhood years, specifically between the ages of 1-6 years, mark a critical time

of growth and development where children begin to establish lasting eating behaviors. Food

neophobia, or the unwillingness to try new or unfamiliar food, arises in early childhood, leading

to problematic eating behaviors and limited dietary variety. Research has demonstrated the

efficacy of frequent exposures to unfamiliar foods as a mechanism to combat food neophobia in

children and increase intake and consumption of a target food (Maratos & Staples, 2015; Rioux,

Picard, & Lafrairea, 2016; Cole et al., 2017; Dovey et al., 2008).

Recent evidence demonstrates that repeated exposure can effectively promote increased

intake of a target, or non-familiar, vegetable (Korinek, Batholomew, Jowers, and Latimer, 2015).

Repeated exposure, otherwise known as mere exposure, is defined as repeated presentations of a

target stimulus to increase familiarization and preference for the identified food. Repeated

exposure centers around the hypothesis that as exposure increases, preference for that food will

increase respectively, thereby promoting increased liking and ultimate intake of the target food.

Targeting increased intake of fruits and vegetables at an early age at a time where

children begin to form lasting dietary preferences and behaviors will increase the likelihood that

these practices will be carried on into adulthood. More research is needed targeting children

during this vulnerable time period to modify their eating habits to support healthy growth and
development. The aim of this present literature review is to therefore investigate whether

repeated exposure can promote increased intake of vegetables among children between the ages

of 1-6 years.

Methods

Search Strategy

The articles included in this review were accessed via electronic searches using the following

databases: CINAHL, PubMed, and MEDLINE. Database searches were limited to current studies

conducted between the years 2010-2018. Key terms used in various combinations were used to

identify potential studies including: “toddlers”, “children”, “early childhood”, “repeated

exposure”, “taste exposure”, “vegetable intake”, and “fruit intake”. A detailed search strategy

can be found in Figure 1. Bibliographies of related reviews and meta-analyses were searched

manually to locate potential articles.

Selection Criteria

Studies were required to meet the following inclusion criteria: 1) published in a peer-reviewed

journal, 2) conducted on children between the ages of 1-6 years, 3) assessed the effect of

repeated exposure on vegetable intake, 4) employed an experimental study design, and 5)

measured vegetable intake as a main outcome variable. No gender restrictions were placed when

conducting the electronic search. In regards to language, only studies published in English were

considered for review. No specific study length or length of follow up was stipulated due to a

limited number of existing studies on the subject. The last search date for this review was

February 5, 2018. Additionally, only clinical, controlled, or crossover trials with a minimum

sample size of 15 were considered for review. Studies were excluded if subjects were under one
 year of age or older than 6 years of age. However, exceptions were made if the majority of

subjects fell between the ages of 1-6. Studies with subjects not in good health or with any

preexisting conditions or diseases that might compromise the results of the study were excluded.

Full-text articles
excluded, with reasons
(n = 11)
Primary reasons for
exclusion include:
 Investigated
outcomes other
Figure 1 Study Selection
than FV intake
(n=5)
 Data was
Records identified through qualitative only
database searching (n = 121) (n=1)
CINAHL 33; PubMed 62;  Mean age too
MEDLINE 37 Additional records identified
through other sources young (n=3)
Identification
(n = 2)  Mean age too
old (n=2)
Screening
Eligibility
Included Studies included
Studies included in in
quantitative synthesis
Full-text articles
qualitative synthesis
Records (systematic
assessed
Records
after(n for review)
eligibility
duplicates
=screened
0)* removed Records excluded
(n==33)
(n 10)
21)
88) (n = 67)
Data Extraction and Quality Assessment

Data related to study characteristics; participant characteristics, intervention, and setting,

as well as outcome data and results were extracted from each study in the final critical review,

which can be found in Table 1.

Table 1 Data Extraction Table

Author/Year Purpose of Study Study Population Intervention Outcomes Conclusion Limitations

Study Design
Quality
Assessment
Rating
Bouhlal and To compare Toddlers aged 2-3 y 6 mo.; with a 6 wk. (2 d/wk.) Intake of target vegetable Results No randomization
colleagues, 2014 whether flavor- (n=151) pre-exposure and exposure (salsify puree) increased across demonstrate that to the treatment
flavor learning 1. Repeated Exposure period all 3 groups from pre-test to both RE & FFL groups, increasing
Non- (FFL) or repeated (RE) group (n= 47): 1. Repeated exposure post-test (p = 0.02), however effectively the risk of
randomized exposure (RE) to a 57% female, mean age intake of the control vegetable promote both allocation bias.
(RE): 8 exposures to
between- non-familiar (months) 27.3 + 0.7, (carrot puree) did not increase. short (5 wk.) & Nursery staff
subjects vegetable can BMI 15.3 + 0.6 salsify puree and Intake increased the highest long term (6 responsible for
increase carrot puree among the RE group (64 + 11 mo.) increased measuring toddler
+ acceptance and 2. Flavor-Flavor (control) served in g) compared to the FFL-Salt liking and vegetable
intake of the target Learning (FFL-Salt counterbalanced group (23 + 11g; p < 0.001) and consumption of acceptance t/o
vegetable group) (n = 54): 50% order (n = 47) the FFL-Nutmeg group (36 + a non-familiar intervention via a
female, mean age 11g; p = 0.07). Intake and target vegetable hedonic rating
(months) 27.4 + 0.6, 2. Flavor-flavor acceptance was sustained 6-mo among toddlers. scale based on
BMI 16.3 + 0.2 learning group (FFL- follow-up across all groups. child’s reaction to
Salt): 8 exposures to food served.
3. FFL-Nutmeg group a salted salsify
(n = 50): 48% female,
vegetable puree
mean age (months) 26.7
+ 0.5, BMI 16.2 + 0.2 served in
counterbalanced
order (n=54)
3. Flavor-flavor
learning group (FFL-
Nutmeg): 8
exposures to a
spiced salsify
vegetable puree
served in
counterbalanced
 order (n=50)

de Wild, Graaf To determine n=28 healthy children 8-mo duration with 14 Ad libitum intake of both soups Both FNL and Intervention
and Jager, 2013 whether flavor- between the ages of 2- exposures (2x/wk. for 7 wks.) significantly increased, RE are effective design made
nutrient learning 4y from 2 day care Children assigned to receive a irrespective of energy measures to environment
“Effectiveness (FNL) or mere centers in Wageningen, high-energy (HE) soup, either condition, following increase intake more appealing
of flavor nutrient exposure facilitates the Netherlands spinach or endive (experimental conditioning and was sustained of a non- (decorative soup
learning and increased condition), paired with a low at 6 mo. follow-up (~58g, familiar target bowls and
mere exposure preference and SPIN-HE group (n=15): energy variant (control p<0.001) vegetable placemats) and
as mechanisms intake of a target mean age (months) 33 + condition), either spinach or between conducive to
to increase vegetable among 8.1, mean weight (kg) endive. Children offered the toddlers ages positive test
toddler’s intake toddlers between 14.0 + 2.4, mean height products before lunchtime as an 2-4y results. Testing
and preference the ages of 2-4y (cm) 91.5 + 6.3 entrée. preference
for green years served a among toddlers
vegetables” high-energy ENDI-HE (n=13): mean involves more
variant of age (months) 37 + 8.7, subjective, less
Randomized vegetable soup mean weight (kg) 15.5 reliable
crossover trial (spinach or endive) + 2.9, mean height (cm) measurement
alternated with a 98.7 + 8.3 methods.
+ low energy variant
of the other
Caton and To compare the n=72 healthy children 5 wk. intervention with 10 Target vegetable intake The results from The Pureed form
colleagues, 2013 efficacy of RE, (56% female, 44% exposures. Children assigned to (artichoke) and control this study of the target
FFL and FNL on male) between the ages one of three conditions: vegetable (carrot) intake suggest that vegetable
Randomized promoting of 9-38 mos. recruited 1. Repeated exposure increased from pre to post exposure alone (artichoke) was
controlled trial vegetable intake from six day care (RE) group: 10 intervention and was sustained is sufficient to prepared in such
among pre-school nurseries in West and exposures to target after 5 wks. among all three promote a way that could
Ø aged children South Yorkshire, treatment groups (p<0.001). increased intake have altered the
vegetable puree
United Kingdom Following intervention, overall a non-familiar taste, increasing
(artichoke) and change in artichoke intake (69 + vegetable the likelihood of
control vegetable 8.7g) was higher than overall among pre- acceptability
puree (carrot) served change in carrot intake (29 + school aged among subjects.
in counterbalanced 7.2g) across all three conditions children.
order (p < 0.001).
2. Flavor-nutrient
learning (FNL) group:
10 exposures to target
high energy vegetable
puree (artichoke)
flavored with an
 unconditioned
stimulus (sunflower
oil)
3. Flavor-flavor learning
(FFL) group: 10
exposures to target
vegetable puree
(artichoke) sweetened
with unconditional
stimulus (sucrose)

Ahern and To determine n =29 healthy preschool 6-8 exposures 2-3x/wk. at snack From pre and post intervention, These findings Only ten subjects
colleagues, whether FFL is children between the time to a root vegetable puree mean intake increased across all support the completed the
2014 more effective ages of 15-56 mos. (either celeriac, swede, or three vegetable purees, hypothesis that six-month
than simple RE in recruited from 3 day turnip) with added apple puree regardless of condition (~36g), both FFL & follow-up.
Non-RCT promoting care nurseries in West (FFL) alternated with 6-8 however, the smallest increase repeated Reproducibility
increased intake Yorkshire, United exposures to another root in intake was observed among exposure are of the study is
+ of a target Kingdom vegetable with nothing added the control condition. Increased effective challenged by
vegetable puree. (RE). A third vegetable acted as intake was sustained both 1 mo. techniques to the employment
a control. The target vegetables and 6 mo. post-intervention (p increase of a within-
were served in counterbalanced <0.001). Younger children children’s subject design as
order across conditions and (<24 mos.) consumed more vegetable intake. a compared to a
participants. vegetable puree than the older However, between-subject
children group (> 24 mos.) simple repeated design. It is also
throughout the intervention (p= exposure was difficult to
0.05). found to be determine
sufficient to whether the
promote increased intake
increased of the pureed
consumption a version of the
novel vegetable. novel vegetables
included in the
study would
translate to
increased intake
of the vegetable
served in its
natural form.
Capaldi-Phillips To compare n=29 Arizona 7 conditioning trials per Children who received RE alone did Did not test long-
& Wadhera, whether preschoolers (55% vegetable (cauliflower and Brussels sprouts with cream not facilitate term effects of
2013 associative female, 45% male) Brussels sprouts) for a total of cheese (either sweetened or increased associated
conditioning (FFL between the ages of 3-5 14 trials (1 trial/d Mon-Fri) unsweetened) liked the intake of a conditioning and
Non-RCT with and FNL) is more y Children assigned to 3 groups Brussels sprouts more than bitter vegetable exposure only
within-between effective than (each with a different vegetable the children who received (Brussels measured liking
repeated mere exposure in and cream cheese condition) Brussels sprouts with no sprouts). Both and consumption
measures promoting based on survey results cream cheese (p=0.05) There RE and immediately
design increased liking indicating children’s liking and were no significant associative following the
and consumption familiarity of different differences in cauliflower conditioning intervention.
+ of bitter non- vegetables liking between the group were effective
bitter vegetables Group A (n=7): Brussels sprouts given cream cheese and those in increasing
among children (bitter) with sweetened cream who did not receive cream intake of a non-
between the ages cheese and cauliflower (non cheese with their cauliflower bitter vegetable
of 3-5y bitter) with unsweetened cream (p=0.86). Cauliflower liking (cauliflower).
cheese increased among all groups,
Group B (n=11): Cauliflower irrespective of energy
(non bitter) with sweetened condition.
cream cheese and Brussels
sprouts (bitter) with
unsweetened cream cheese
Group C (n=11): Received both
vegetables with no cream cheese
de Wild, Graaf, To evaluate the n=39 healthy children 14 exposures (2x/wk.) for 7 Mean vegetable crisp intake Results Vegetables were
and Jager, 2014 efficacy of RE and between the ages 1.5-4y wks. total with follow-up increased for both vegetables demonstrate presented in the
FNL on increasing recruited from 2 day measurements at 2 and 6 (~8g, 300% increase), that RE is more form of freeze
Randomized vegetable intake care centers in months. Children were regardless of condition. This effective than dried crisps,
crossover trial among Wageningen, the randomized to 2 condition increase was sustained at 2 FFL as a which might be
preschoolers Netherlands. groups where they received and 6 mos. follow-up. mechanism to more preferable
+ RB-TK/PN-WS group freeze-dried vegetable crisps increase long- in taste and
(n=20): mean age 32.4 served with a dip. The first term vegetable appearance than
+ 8.9 mos., mean group was assigned to receive intake in young vegetables
weight 14.4 + 3.1 kg, red beet crisps (RB) combined children. served in their
mean height 95.8 + 8.9 with tomato ketchup (TK) pure form.
cm paired with parsnip crisps (PN) Intervention
PN-TK/RB-WS (n=19): combined with white sauce environment
mean age 32.8 + 8.1 (WS), where white sauce was might have
mos., mean weight 14.0 the unconditioned stimulus stimulated
+ 2.3 kg, mean height (UC) and tomato ketchup was increased intake,
95.1 + 4.8 cm the conditioned stimulus (C). therefore, it is
The second group received the uncertain if this
 reverse. study would be
RB-TK/PN-WS (n=20): reproducible in a
received red beet crisps different setting
combined with tomato ketchup, (home).
paired with parsnip crisps
combined with white sauce
RB-WS/PN-TK (n=19: received
red beet crisps combined with
white sauce, and parsnip crisps
with tomato ketchup (C)
Hausner, Olsen To compare the n=104 healthy children 10 exposures (2-3x/wk. for 4 In the mere exposure group, Mere exposure No control group
& Moller, 2012 effectiveness of between the ages of 22- wks. total) to an unmodified unmodified artichoke puree and FFL are built into the
mere exposure, 38 mo. recruited from artichoke puree (mere exposure, increased across exposures, and effective study to receive
Non- FNL, and FFL in five nurses in n=32), a sweetened artichoke the highest increases were mechanisms to the vegetable
randomized increasing Copenhagen, Denmark puree (FFL, n=33) or an energy observed by the 5th exposure promote purees. It is
between children between dense artichoke puree with (100g, p < .001). This increase increased unclear as to
subjects the ages of 2-3 Mere exposure group added fat (FNL, n=39) with plateaued through the 5th-10th intake of a whether the
yrs. acceptance (MExp) (n=32): 63% carrot puree serving as the exposure. Increases observed novel increases in
+ and intake of a female 37% male, mean control stimulus. Intervention following intervention were vegetable intake would
novel vegetable age 27.8 + 3.15 mos. took place in children’s daycare sustained at 3 and 6 mos. follow among young translate to
setting prior to lunchtime. up in the MExp group. Increases children artichoke served
Flavor-flavor learning were not seen in the FFL group in its pure form
group (FFL) (n=33): until the 10th exposure. No or other novel
58% male 42% female, significant increases were vegetables.
mean age 27.5 + 3.79 observed in the FNL group. The
mos. highest increases in intake of the
unmodified puree were observed
Flavor-nutrient learning in the MExp as compared to the
group (FNL) (n=39): FFL (p=.046) and FNL group
46% male 54% female, (p=.002) at 3 mo. follow-up.
mean age 30.8 + 4.20
mos.
Zeinstra, To examine the n=250 healthy children 12 exposures over a 5-mo. (21 From pre-test to post-test, Results suggest Subjects from
Vrijhof, and effect of RE to between the ages of 2- wk.) exposure period (1 pumpkin intake increased by that repeated highly educated,
Kremer, 2018 unfamiliar 3y recruited from four vegetable taste/d during ~15g among the intervention exposure can wealthy parents.
vegetables on daycare centers in afternoon snack) to three group (p < 0.001) and did not support
Randomized children’s intake Utrecht, The unfamiliar vegetables: pumpkin change among the control group increased intake
controlled trial pattern and Netherlands. blanched and as a cracker (p = 0.27). Significant increases at childcare of
acceptance of the Intervention group spread; courgette blanched and in White radish intake occurred three formerly
+ exposed novel (n=125): average age 25 as soup; white radish raw and as among the intervention group unfamiliar
vegetables + 9.6 mos., 44% female a cracker spread. The control (+16g ~178% p< 0.001) as well vegetables
 56% male, parental group followed their normal as the control group (+7g ~57% among children
education level: 95% eating routine. Each vegetable p<0.001). No significant between the
high class 5% middle was presented randomly in two changes were observed in ages of 2-3y.
class different recipe variations. courgette intake in either the
Control group (n=125): intervention (p=0.85) or control
average age 25 + 10.2 group (p=0.55). Changes in
mos., 42% female 58% intake were not correlated with
male, parental education gender, parental education,
level: 90% high class neophobia, good vegetable, Z-
10% middle class BMI, or taste preferences.

Anzman-Frasca To compare the n=47 healthy children 2 experiments included (2x/wk. Following Experiment 1, pre- RE and Children self-
and colleagues, efficacy of RE and between the ages 3-6y for 4 wks.) Exposures to 2 test to post-test, vegetable and associative reported
2012 associative from a daycare in selected target vegetables (sugar liking & intake increased across conditioning vegetable liking
conditioning (AC) Central, PA snap peas, asparagus, red bell both the RE and AC groups. (AC, flavor- by pointing at a
Randomized in promoting Experiment 1 (n=41): pepper strips, yellow squash Mean average intake of the flavor learning) cartoon smiley
controlled trial increased intake of mean age: 4.7y. + 0.8, coins, or cauliflower). assigned vegetable increased by resulted in face indicating
with between- a novel vegetable Gender: 51% female Exposures took place one hour ~16g. There was a positive increased intake whether the food
subject and among 49% male, before lunch at daycare. correlation between vegetable of a novel was “yummy”
within-subject preschoolers. race/ethnicity: 83% liking and subsequent intake (p vegetable “just okay” or
design white 10% Asian 7% 1. Experiment 1: Between- < 0.001). among “yucky.”
other, mean weight subjects design where subjects Following experiment 2, preschool
+ (kg): 18.4 + 2.8kg, randomized to 2 treatment vegetables paired with dip (AC) children
~24.4% overweight groups-the repeated exposure had higher liking ratings than following six
Experiment 2 (n=42): group (RE; vegetable alone) or vegetables presented alone (RE) exposures.
mean age 4.4 + 0.8 y, associative conditioning group (p =0.05). Significant increases
gender: 39% female (AC; vegetable plus dip). in liking were found in Tastes 1
61% male, 2. Experiment 2: Within- through Tastes 4, but these
race/ethnicity: 80% subjects design comparing RE increases plateaued around the
white, 15% Asian, 5% to AC 8th taste (p= 0.05)
other, mean weight 2 treatment groups:
(kg): 17.5 + 2.7kg, 1. RE group: children In both experiments, vegetable
~13.9% overweight received vegetable liking increased by the 6th
alone exposure.
2. AC group: vegetable
plus dip (ketchup,
ranch, or cinnamon
sugar) paired with dip
during tasting trials
Connell & To determine n=96 healthy preschool 6 wk. intervention There was an increase in intake Repeated Vegetables were
colleagues, whether RE could children between the among the control school exposure in a offered with
2011 increase ages of 3-6y Preschool A (intervention first (Preschool B), while the school setting student’s lunches
community Gender: 44% female, condition): Children offered one experimental school (Preschool was not and were offered
Randomized preschooler’s 56% male; parental new vegetable every day for 30 A) showed an overall decrease effective in together with a
controlled trial consumption of education level: 96% of days in a 3 day cycle until each in intake from T1 to T2 promoting competing
three non-familiar children had at least one child received each vegetable (p<0.001). There was a positive increased second
+ target vegetables parent with a bachelor’s 10x. correlation between average consumption of vegetable.
degree, and 75% had at Preschool B (control/delayed intake of a child’s “tablemate” three novel Students were
least one parent with a intervention): continued routine and the child’s own intake vegetables not required to
graduate professional practices during the first 6 wks. where 1g of peer intake was among “taste” foods, so
degree; age: 85% then switched conditions with associated with ~1/5-g intake preschoolers some students
between 4-5 y, Preschool A increase. between the were only
race/ethnicity: white ages of 3-6 y. exposed visually
69%, Asian 8%, to the vegetable.
African American 5%, Subjects from
Hispanic 6%, other highly educated,
12%. mostly White
families.

The overall quality of the studies included in this review were critically appraised using a quality criteria checklist (See Table

2). Articles were rated as negative, neutral, or positive, based on the results of a 14-item questionnaire designed to test the study’s

overall validity and reliability. Articles were assigned a positive rating if most or all questions were positively answered “yes.”

Articles were assigned a neutral rating when there was a combination of both positive and negative question responses. A negative

rating was assigned to articles receiving mostly negative, or “no” question responses.
Table 2 Quality Criteria Checklist

Quality Criteria Checklist

Author(s) Design Q1a Q2b Q3c Q4d Q5e Q6f Q7g Q8h Q9i Q10j QAk
Wild, Graaf & Jager, 2013 Randomized Crossover Trial Y Y Y UC Y Y Y Y Y Y +
Caton et al., 2013 RCT Y N Y UC N UC UC Y Y Y Ø
Capaldi-Phillips & Wadhera, 2014 Non-RCT with within-between Y Y Y N Y Y Y Y Y N/A +
repeat measures design
 Wild, Graaf, & Jager 2014 Crossover Y Y Y Y Y Y Y Y Y Y +
 Bouhlal et al, 2014 Non-randomized between- Y Y Y N Y Y Y Y Y Y +
subject
 Ahern et al., 2014 Non-RCT Y Y Y UC Y Y Y Y Y Y +
 Connell et al., 2012 RCT Y Y Y Y Y Y Y Y Y Y +
 Anzman-Frasca et al., 2012 RCT Y Y Y Y Y Y Y Y Y Y +
 Zeinstra, Vrijhof,& Kremer, 2018 RCT Y Y Y Y Y Y Y Y Y UC +
 Hausner, Olsen, & Moller, 2012 Non-randomized between Y Y Y N/A Y Y Y Y Y UC +
subjects
q
Q1=Question 1: Has the researcher stated his/her hypothesis or goal(s)? Y=yes; N=no; UC=unclear; N/A=not applicable, etc. (answer for Q1-Q10)
b
Q2=Question 2: Is the type of research design clearly described?
c
Q3=Question 3: Are the research methods and any assumptions clearly explained?
d
Q4=Question 4: If there was a control group, were experimental and control groups chosen or assigned without bias?
e
Q5=Question 5: Are results presented in a way that is clear and understandable?
g
Q6=Question 6: Are statistical analyses presented in a straightforward manner?
h
Q7=Question 7: Are the conclusions that the researcher states justified by the results and statistical analyses presented?
i
Q8=Question 8: Are strengths and limitations of the study identified by the researcher(s)?
i
Q9=Question 9: Did the researcher(s) describe how the study results compared to other similar studies?
j
Q10=Question 10: Was funding from a source that did not bias results?
k
QA= quality assessment; +=positive; -=negative; Ø=neutral;
 Results

A total of 123 abstracts were identified in the initial database search, with 33 remaining

after the removal of duplicate results. 88 titles and abstracts were screened for inclusion, and 67

were excluded after inability to meet eligibility criteria. The remaining 21 full-text articles were

assessed for eligibility, and 11 were excluded after applying the aforementioned inclusion and

exclusion criteria. A detailed overview of the selection process of study inclusion can be found in

Figure 1.

Study Designs

The overall methodological quality of the ten included studies in this review were fairly

diverse in terms of study design, duration, sample size, and assessment methods. Two studies

were crossover trials, four were non-randomized controlled trials (non-RCTs), and four were

randomized controlled trials (RCTs). Seven out of ten studies reported randomization of

participants. All ten studies were located in a school setting; most commonly in a daycare,

nursery, or preschool. Study duration ranged from two weeks to eight months. Five studies

followed participants six months or longer to evaluate whether RE could facilitate long-term

changes in intake. Sample size varied considerably ranging from 19 subjects to 250 subjects.

Seven out of ten studies did not report the blinding status of participants, investigators, or

outcome assessors. The studies included in this review primarily investigated repeated exposure

in comparison to other learning techniques, including flavor-nutrient learning (FNL) (n=1) and

flavor-flavor learning (FFL) (n=4) or both (n=3). Nine out of ten studies met the quality

assessment standards to be rated positive and one study received a neutral rating.
Repeated Exposure Alone

Two studies in this review tested the efficacy of repeated exposure alone in promoting

increased vegetable intake among children (O’Connell, Henderson, Luedicke, and Schwartz,

2012; Zeinstra, Vrijhof, and Kremer, 2018). O’Connell, Henderson, Luedicke, and Schwartz

(2011) conducted a study where 96 healthy preschool children between the ages of 3-6 from two

preschools in the United States were exposed ten times to three different pre-sliced raw

vegetables at lunchtime. Following the intervention, there was only an observed increase in

intake among the control school (Preschool B), while the experimental school (Preschool A)

showed an overall decrease in intake following the intervention (p = .002) (O’Connell et al.,

2012).

Repeated Exposure vs. Flavor-Flavor Learning & Flavor-Nutrient Learning

While O’Connell et al. (2012) served vegetables raw and unprepared, the majority of

studies included in this review served vegetables cooked, seasoned, or paired with a dip to

increase the vegetable’s palatability. Flavor-flavor learning (FFL) and flavor-nutrient learning

(FNL) were the two most common learning methods employed in conjunction with repeated

exposure.

Three studies in this review tested repeated exposure in comparison to both FFL and FNL

(Capaldi-Philips & Wadhera, 2014; Caton et al., 2013; Hausner, Olsen, and Moller, 2012). Two

out of these three studies yielded positive results demonstrating the ability of repeated exposure

as a successful mechanism to increase both short and long-term vegetable intake in young

children.
 Caton et al. (2013) tested the efficacy of repeated exposure versus two associative

conditioning learning approaches, FFL and FNL, in promoting increased vegetable intake among

72 healthy preschool children. Vegetables were served pureed either plain (repeated exposure),

with sunflower oil (FNL), or sweetened with sucrose (FFL). Target vegetable intake increased

from pre to post-intervention, and these increases were sustained five weeks after follow up

across all three treatment groups (p < .001) (Caton et al., 2013). Capaldi-Philips & Wadhera

(2014) compared FNL, FFL, and repeated exposure in promoting increased consumption of non-

bitter and bitter vegetables among 29 3-5 year old preschoolers in Arizona. While non-bitter

vegetable (cauliflower) consumption increased across all three energy conditions, bitter

vegetable (Brussels sprouts) intake did not increase regardless of energy condition (p = 0.86)

(Capaldi-Philips & Wadhera, 2014).

Repeated Exposure vs. Flavor-Flavor Learning

Four studies included in this review evaluated both FFL and repeated exposure as

potential strategies to induce increased vegetable consumption among children (Ahern, Caton,

Blundell, and Hetherington, 2014; Anzman-Frasca, Savage, Marini, O. Fisher, and Birch, 2012;

Bouhlal, Issanchou, Chabanet, and Niklaus, 2014; de Wild, Graaf, and Jager, 2015). Number of

exposures ranged from six to 14 exposures. All four studies found that both repeated exposure

and FFL were effective in promoting increased intake of a novel vegetable. In addition, all four

concluded that repeated exposure alone was sufficient to promote increased intake.
Repeated Exposure vs. Flavor-Nutrient Learning

One study examined the possible effectiveness of FNL in comparison to repeated

exposure in increasing children’s vegetable consumption (de Wild, Graaf & Jager, 2013). The

study’s results demonstrated that both FNL and repeated exposure were effective measures to

increase toddler’s intake of a non-familiar target vegetable.

Discussion

Mere, or repeated exposure is a psychological phenomenon based on the premise that as

familiarization of a stimulus increases, preference increases proportionally. With low intakes of

fruits and vegetables and high levels of food neophobia or fussiness occurring in early childhood,

strategies to modify dietary behavior are warranted for this impressionable population. Repeated

exposure is a cost-effective and easy-to-implement strategy to combat neophobia and improve

the dietary profile of children. Therefore, the aim of this systematic review was to investigate

whether repeated exposure could facilitate increased intake of a target vegetable among young

children between the ages of 1-6 years. Ten studies were included, which were grouped

according to whether or not they tested repeated exposure alone, or compared with an associative

conditioning learning technique (n=8)(FNL or FFL or both)(Ahern et al., 2014; Anzman-Frasca

et al., 2012; Bouhlal et al., 2014; Capaldi-Philips & Wadhera, 2014; Caton et al., 2013;

O’Connell et al., 2012; de Wild, Graaf, and Jager, 2013; de Wild Graaf and Jager, 2015;

Hausner, Olsen, and Moller, 2012; Zeinstra, Vrijhof, and Kremer, 2018). Seven out of 8 studies

evaluating repeated exposure against associative conditioning concluded that repeated exposure

alone was effective in promoting increased intake, irrespective of treatment condition.

 Inconsistent with prior research, two studies did not find statistically significant evidence

supporting repeated exposure and vegetable intake. However, these results can be attributed to

several study limitations. Capaldi-Philips & Wadhera (2014) found that repeated exposure was

effective in increasing cauliflower consumption, but not Brussels sprouts. The authors postulate

that these results can be attributed to the fact that repeated exposure may not be as effective for

bitter tasting vegetables. Future research is necessitated testing a variety of bitter and non-bitter

vegetables to determine whether this is the case. This article was the only study that did not test

long-term effects associated with repeated exposure, but rather only tested consumption

immediately following the intervention (Capaldi-Philips & Wadhera, 2014). Connell et al. (2012)

observed a slight increase in intake among the control group, but not among the intervention

group (p = .002). However, the intervention took place at lunchtime where students were

presented with a competing vegetable along with the target vegetable. Additionally, students

were not required to taste the presented vegetables, thereby; some students were only exposed

visually and not orally to the target vegetable. Another point to consider is that this is the only

study included in this review that chose to serve vegetables in their natural, raw form, which may

have been unappealing to students presented with more attractive lunch offerings (Connell et al.,

2012).

The majority of studies in this review took place in a school setting. Toddlers and young

children were therefore presented to food in the presence of their peers and teachers, which may

have influenced their willingness to try and eat the foods offered. For example, de Wild, Graaf,

and Jager (2015) placed the target vegetables in decorative soup bowls on colorful placemats,

which may have inadvertently enticed children to be more excited and interested in the
vegetables presented (de Wild, Graaf, and Jager, 2015). It is therefore unclear as to whether

repeated exposure would be as successful in a home setting.

Only one study presented the target vegetable in its pure and raw form (Connell et al.,

2012). It is possible that in some studies, the method of preparation could have altered the taste,

increasing the likelihood of acceptability among children. Therefore, it is difficult to determine

whether the increased intake of these vegetables would translate to increased intake of the

vegetable served raw, cooked, or prepared differently.

Strengths and Limitations

Articles were selected for inclusion within this review after conducting a critical appraisal

of each study to ensure the overall strength and quality of evidence. Studies were evaluated for

overall relevance and validity based on study design, risk of bias, generalizability, method of

data collection, and statistical analysis. Strict inclusion and exclusion criteria were applied to

ensure the applicability and relevance of evidence. However, these restrictions may have limited

the number of studies identified.

Sample size ranged from 19 to 250 subjects. Studies with smaller sample size lack the statistical

power needed to recognize a genuine impact or association between repeated exposure and

vegetable intake. Future studies should examine different types of vegetables, especially more

non-bitter vegetables, to elucidate whether repeated exposure is equally effective across different

vegetable families, textures, and flavors.

Several disparities in the sample population should also be noted (Connell et al., 2012).

First, the intervention took place at two preschools located in a highly educated, wealthy,

predominantly Caucasian town. 96% of children participating in the study had at least one parent
with a graduate degree, 85% of children were between the ages of 4-5, and 69% of the children

were Caucasian (O’Connell et al., 2012). While the study’s results contrast with previous

literature, they cannot be generalized to the population at large due to inconsistencies in the

sample demographics.

Implications for Future Research and Practice

The early childhood years are marked by intakes far below recommendations of fruits

and vegetables (Cole et al., 2017). Strategies to combat food pickiness, reluctance to try new

foods, and neophobia are needed to improve the dietary habits of young children to ensure

healthy growth and development. The present findings were consistent with previous literature

proposing that repeated exposure alone, with or without associative conditioning, can promote

increased consumption of a novel vegetable in early childhood.

While previous research evaluating repeated exposure and vegetable intake are limited to

school settings, further randomized controlled trials are needed in the home setting to determine

whether repeated exposure would yield equally positive results in settings outside of the school.

Future studies that follow subjects over longer periods of time are needed to specify the number

of exposures needed to improve intake, as well as to specify whether these observed increases

can be sustained over time.

Conclusion

Repeated exposure, ranging from 6-15 exposures, has been shown an effective approach to

increase non-bitter vegetable consumption among healthy young children between the ages of 1-

6 years, Grade II (Fair Evidence). Future research with longer study durations and follow-up
assessments should focus on presenting vegetables in their raw and natural form in a variety of

settings to provide further insight unto this approach.

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