Effectiveness of a kindergarten-based intervention to increase vegetable intake and reduce food neophobia amongst 1-year-old children: a cluster randomised controlled trial
Background: Children’s first years of life are crucial to their future health. Studies show that a varied diet with a high intake of vegetables is positive in several domains of health. The present low vegetable intake amongst children is, therefore, a concern. Food neophobia is a common barrier to vegetable intake in children. As most Norwegian children attend kindergarten from an early age, kindergartens could contribute to the prevention of food neophobia and the promotion of vegetable intake.
Objective: The aim of this study was to assess the effect of a cluster randomised trial amongst 1-year-old children in kindergarten to reduce food neophobia and promote healthy eating.
Methods: Kindergartens were randomly allocated to either a control group or one of two intervention groups. Both intervention groups (diet and diet + Sapere-method) were served a warm lunch meal including three alternating intervention vegetables, whilst the intervention group 2 (diet + Sapere) in addition received tools for weekly sensory lessons. The intervention was digitally administered via information and recipes on a study website. The control group did not receive any information. Parents completed digitally distributed questionnaires addressing food neophobia and food habits at baseline and post-intervention.
Results: The parents of 144 1-year-old children in 46 kindergartens completed the questionnaires, which were included in the main analysis. The results suggested a higher intake of the intervention vegetables in group 2 (diet + Sapere) compared to the control group. The effect on total vegetable intake was inconclusive. No effect was observed on the level of food neophobia in either of the intervention group.
Conclusion: This digitally delivered dietary and sensory intervention promoted the intake of intervention-targeted vegetables with inconclusive effect on total vegetable intake due to large loss to follow-up. No effect on the level of food neophobia was detected.
- Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380(9859): 2224–60. doi: 10.1016/S0140-6736(12)61766-8
- Why Thousand Days. 2010. Available from: https://thousanddays.org/ [cited 01 February 2021].
- Nguyen B, Bauman A, Gale J, Banks E, Kritharides L, Ding D. Fruit and vegetable consumption and all-cause mortality: evidence from a large Australian cohort study. Int J Behav Nutr Phys Act 2016; 13: 9. doi: 10.1186/s12966-016-0334-5
- Aune D, Giovannucci E, Boffetta P, Fadnes LT, Keum N, Norat T, et al. Fruit and vegetable intake and the risk of cardiovascular disease, total cancer and all-cause mortality-a systematic review and dose-response meta-analysis of prospective studies. Int J Epidemiol 2017; 46(3): 1029–56. doi: 10.1093/ije/dyw319
- Miller V, Mente A, Dehghan M, Rangarajan S, Zhang X, Swaminathan S, et al. Fruit, vegetable, and legume intake, and cardiovascular disease and deaths in 18 countries (PURE): a prospective cohort study. Lancet 2017; 390(10107): 2037–49. doi: 10.1016/S0140-6736(17)32253-5
- Schwingshackl L, Schwedhelm C, Hoffmann G, Lampousi AM, Knuppel S, Iqbal K, et al. Food groups and risk of all-cause mortality: a systematic review and meta-analysis of prospective studies. Am J Clin Nutr 2017; 105(6): 1462–73. doi: 10.3945/ajcn.117.153148
- Wang X, Ouyang Y, Liu J, Zhu M, Zhao G, Bao W, et al. Fruit and vegetable consumption and mortality from all causes, cardiovascular disease, and cancer: systematic review and dose-response meta-analysis of prospective cohort studies. BMJ 2014; 349: g4490. doi: 10.1136/bmj.g4490
- Micha R, Khatibzadeh S, Shi P, Andrews KG, Engell RE, Mozaffarian D. Global, regional and national consumption of major food groups in 1990 and 2010: a systematic analysis including 266 country-specific nutrition surveys worldwide. BMJ Open 2015; 5(9): e008705. doi: 10.1136/bmjopen-2015-008705
- Øverby NC, Kristiansen AL, Andersen LF. Spedkost 12 måneder. Landsomfattende kostholdsundersøkelse blant 12 måneder gamle barn. Oslo: The Norwegian Directorate of Health; 2009. Report No.: IS-1635.
- Paulsen M, Myhre J, Andersen LF, Kristiansen AL. Spedkost 3. Landsomfattende undersøkelse av kostholdet blant spedbarn, 12 måneder Report. Oslo: Folkehelseinstituttet og Universitetet i Oslo; 2020.
- Birch LL. Development of food preferences. Annu Rev Nutr 1999; 19: 41–62. doi: 10.1146/annurev.nutr.19.1.41
- Dovey TM, Staples PA, Gibson EL, Halford JC. Food neophobia and ‘picky/fussy’ eating in children: a review. Appetite 2008; 50(2): 181–193. doi: 10.1016/j.appet.2007.09.009
- Perry RA, Mallan KM, Koo J, Mauch CE, Daniels LA, Magarey AM. Food neophobia and its association with diet quality and weight in children aged 24 months: a cross sectional study. Int J Behav Nutr Phys Act 2015; 12(1): 13. doi: 10.1186/s12966-015-0184-6
- Russell CG, Worsley A. A population-based study of preschoolers’ food neophobia and its associations with food preferences. J Nutr Educ Behav 2008; 40(1): 11–19. doi: 10.1016/j.jneb.2007.03.007
- Johnson SL, Davies PL, Boles RE, Gavin WJ, Bellows LL. Young children’s food neophobia characteristics and sensory behaviors are related to their food intake. J Nutr 2015; 145(11): 2610–6. doi: 10.3945/jn.115.217299
- Helland SH, Bere E, Bjørnarå HB, Øverby NC. Food neophobia and its association with intake of fish and other selected foods in a Norwegian sample of toddlers: a cross-sectional study. Appetite 2017; 114: 110–7. doi: 10.1016/j.appet.2017.03.025
- Bell LK, Jansen E, Mallan K, Magarey AM, Daniels L. Poor dietary patterns at 1–5 years of age are related to food neophobia and breastfeeding duration but not age of introduction to solids in a relatively advantaged sample. Eat Behav 2018; 31: 28–34. doi: 10.1016/j.eatbeh.2018.06.005
- Nekitsing C, Blundell-Birtill P, Cockroft JE, Hetherington MM. Systematic review and meta-analysis of strategies to increase vegetable consumption in preschool children aged 2–5 years. Appetite 2018; 127:138–54. doi: 10.1016/j.appet.2018.04.019
- Caton SJ, Ahern SM, Remy E, Nicklaus S, Blundell P, Hetherington MM. Repetition counts: repeated exposure increases intake of a novel vegetable in UK pre-school children compared to flavour–flavour and flavour–nutrient learning. Br J Nutr 2012; 109(11): 2089–97. doi: 10.1017/S0007114512004126
- Hausner H, Olsen A, Møller P. Mere exposure and flavour–flavour learning increase 2–3 year-old children’s acceptance of a novel vegetable. Appetite 2012; 58(3): 1152–9. doi: 10.1016/j.appet.2012.03.009
- Ahern SM, Caton SJ, Blundell P, Hetherington MM. The root of the problem: increasing root vegetable intake in preschool children by repeated exposure and flavour flavour learning. Appetite 2014; 80: 154–60. doi: 10.1016/j.appet.2014.04.016
- Blissett J, Fogel A. Intrinsic and extrinsic influences on children’s acceptance of new foods. Physiol Behav 2013; 121: 89–95. doi: 10.1016/j.physbeh.2013.02.013
- Bandura A. Self-efficacy: the excercise of control. New York: W H Freeman/Times Books/Henry Holt & Co.; 1997.
- Holley CE, Haycraft E, Farrow C. ‘Why don’t you try it again?’ A comparison of parent led, home based interventions aimed at increasing children’s consumption of a disliked vegetable. Appetite 2015; 87: 215–22. doi: 10.1016/j.appet.2014.12.216
- Hoppu U, Prinz M, Ojansivu P, Laaksonen O, Sandell MA. Impact of sensory-based food education in kindergarten on willingness to eat vegetables and berries. Food Nutr Res 2015; 59: 28795. doi: 10.3402/fnr.v59.28795
- Coulthard H, Sealy A. Play with your food! Sensory play is associated with tasting of fruits and vegetables in preschool children. Appetite 2017; 113: 84–90. doi: 10.1016/j.appet.2017.02.003
- Association Sapere. Éducation alimentaire sensorielle. Association Sapere – The Sapere Association. Available from: https://www.sapere-association.com/fr [cited 15 February 2021].
- Hagman U, Algotson S. Mat för alla sinnen – sensorisk träning enligt Sapere-metoden [Food for the senses: sensory training according to the Sapere method]. 1st ed. Uppsala: Livsmedelsverket & Grythättan Stiftelsen för måltidsforskning; 1999.
- Taste education in Sweden.The Sapere Association. Available from: http://sapere-asso.fr/en/suede/ [cited 15 February 2021].
- Taste education in Finland. Association Sapere. Available from: http://sapere-asso.fr/en/finlande/ [cited 15 February 2021].
- Helland SH, Bere E, Overby NC. Study protocol for a multi-component kindergarten-based intervention to promote healthy diets in toddlers: a cluster randomized trial. BMC Public Health 2016; 16: 273. doi: 10.1186/s12889-016-2952-x
- Johannessen B, Helland SH, Bere E, Øverby NC, Fegran L. ‘A bumpy road’: kindergarten staff’s experiences with an intervention to promote healthy diets in toddlers. Appetite 2018; 127: 37–43. doi: 10.1016/j.appet.2018.04.008
- SSB. Kindergartens. Statistisk sentralbyrå (Statistics Norway); 2020 [updated 13. March 2020. Number of children in kindergarten]. Available from: https://www.ssb.no/utdanning/statistikker/barnehager [cited 20 February 2021].
- Barnehagemat. Næring til liv, lek og læring. Appetitt på livet. Kids edition. Report. Oslo: The Norwegian Consumer Council; 2018.
- Paulsen MM, Høvding BO, Kristiansen AL, Andersen LF. Måltider, fysisk aktivitet og miljørettet helsevern i barnehagen. Report. Oslo: The Norwegian Directorate of Health; 2012. Report No.: IS-0345.
- Bjelland M, Brantsaeter AL, Haugen M, Meltzer HM, Nystad W, Andersen LF. Changes and tracking of fruit, vegetables and sugar-sweetened beverages intake from 18 months to 7 years in the Norwegian Mother and Child Cohort Study. BMC Public Health 2013; 13: 793. doi: 10.1186/1471-2458-13-793
- Lioret S, Betoko A, Forhan A, Charles MA, Heude B, de Lauzon-Guillain B. Dietary patterns track from infancy to preschool age: cross-sectional and longitudinal perspectives. J Nutr 2015; 145(4): 775–82. doi: 10.3945/jn.114.201988
- Ventura AK, Worobey J. Early influences on the development of food preferences. Curr Biol 2013; 23(9): R401–8. doi: 10.1016/j.cub.2013.02.037
- Johnson SL, Bellows L, Beckstrom L, Anderson J. Evaluation of a social marketing campaign targeting preschool children. Am J Health Behav 2007; 31(1): 44–55. doi: 10.5993/AJHB.31.1.5
- Birch LL. Psychological influences on the childhood diet. J Nutr 1998; 128(2 SUPPL.): 407S–10S. doi: 10.1093/jn/128.2.407S
- Birch LL, Doub AE. Learning to eat: birth to age 2 y. Am J Clin Nutr 2014; 99(3): 723S–8S. doi: 10.3945/ajcn.113.069047
- Hamel LM, Robbins LB. Computer- and web-based interventions to promote healthy eating among children and adolescents: a systematic review. Oxford, England: 2013, pp. 16–30.
- Koneska E, Appelbe D, Williamson PR, Dodd S. Usage metrics of web-based interventions evaluated in randomized controlled trials: systematic review. J Med Internet Res 2020; 22(4): e15474.doi: 10.2196/15474
- Yoong SL, Williams CM, Finch M, Wyse R, Jones J, Freund M, et al. Childcare service centers’ preferences and intentions to use a web-based program to implement healthy eating and physical activity policies and practices: a cross-sectional study. J Med Internet Res 2015; 17(5): e108. doi: 10.2196/jmir.3639
- Blomkvist EAM, Helland SH, Hillesund ER, Overby NC. A cluster randomized web-based intervention trial to reduce food neophobia and promote healthy diets among one-year-old children in kindergarten: study protocol. BMC Pediatr 2018; 18(1): 232. doi: 10.1186/s12887-018-1206-8
- Pliner P. Development of measures of food neophobia in children. Appetite 1994; 23(2): 147–63. doi: 10.1006/appe.1994.1043
- Ukoumunne OC, Gulliford MC, Chinn S, Sterne JAC, Burney PGJ, Donner A. Methods in health service research: evaluation of health interventions at area and organisation level. BMJ 1999; 319(7206): 376–9. doi: 10.1136/bmj.319.7206.376
- Barratt H, Kirwan M. Clustered data – effects on sample size and approaches to analysis. healthknowledge.org.uk; 2009 [Public Health Textbook]. Available from: https://www.healthknowledge.org.uk/public-health-textbook/research-methods/1a-epidemiology/clustered-data [cited 01 February 2021].
- Gulliford MC, Ukoumunne OC, Chinn S. Components of variance and intraclass correlations for the design of community-based surveys and intervention studies: data from the Health Survey for England 1994. Am J Epidemiol 1999; 149(9): 876–83. doi: 10.1093/oxfordjournals.aje.a009904
- Rebnes G, Angelsen T. Totaloversikten 2017. Aktuell statistikk og innsikt om frukt, bær, grønnsaker og poteter i Norge. Langhus: Opplysningskontoret for frukt og grønt; 2018.
- Andersen LF, Lande B, Trygg K, Hay G. Validation of a semi-quantitative food-frequency questionnaire used among 2-year-old Norwegian children. Public Health Nutr 2004; 7(6): 757–64. doi: 10.1079/PHN2004613
- Andersen LF, Lande B, Arsky GH, Trygg K. Validation of a semi-quantitative food-frequency questionnaire used among 12-month-old Norwegian infants. Eur J Clin Nutr 2003; 57(8): 881. doi: 10.1038/sj.ejcn.1601621
- Kristiansen AL, Andersen LF. Småbarnskost 2 år. Landsomfattende kostholdsundersøkelse blant 2 år gamle barn. Oslo: The Norwegian Directorate of Health; 2009. Report No.: IS-1731.
- Recommendations on diet, nutrition and physical Activity. Oslo: The Norwegian Directorate of Health; 2014. Report No.: IS-2170.
- Kostråd for å fremme folkehelsen og forebygge kroniske sykdommer. Helsedirektoratet [The Norwegian Directorate of Health]; 2011. Report No.: IS-1881.
- Cooke L, Wardle J, Gibson EL. Relationship between parental report of food neophobia and everyday food consumption in 2–6-year-old children. Appetite 2003; 41(2): 205–206. doi: 10.1016/S0195-6663(03)00048-5
- Cassells EL, Magarey AM, Daniels LA, Mallan KM. The influence of maternal infant feeding practices and beliefs on the expression of food neophobia in toddlers. Appetite 2014; 82: 36–42. doi: 10.1016/j.appet.2014.07.001
- Heritier SR, Gebski VJ, Keech AC. Inclusion of patients in clinical trial analysis: the intention-to-treat principle. Med J Aust 2003; 179(8): 438–40. doi: 10.5694/j.1326-5377.2003.tb05627.x
- Jakobsen JC, Gluud C, Wetterslev J, Winkel P. When and how should multiple imputation be used for handling missing data in randomised clinical trials – a practical guide with flowcharts. BMC Med Res Methodol 2017; 17(1): 162. doi: 10.1186/s12874-017-0442-1
- Dumville JC, Torgerson DJ, Hewitt CE. Reporting attrition in randomised controlled trials. BMJ 2006; 332(7547): 969–71. doi: 10.1136/bmj.332.7547.969
- de Wild VWT, de Graaf C, Jager G. Use of different vegetable products to increase preschool-aged children’s preference for and intake of a target vegetable: a randomized controlled trial. J Acad Nutr Diet 2017; 117(6): 859–66. doi: 10.1016/j.jand.2016.11.006
- Appleton KM, Hemingway A, Rajska J, Hartwell H. Repeated exposure and conditioning strategies for increasing vegetable liking and intake: systematic review and meta-analyses of the published literature. Am J Clin Nutr 2018; 108(4): 842. doi: 10.1093/ajcn/nqy143
- Spill MK, Johns K, Callahan EH, Shapiro MJ, Wong YP, Benjamin-Neelon SE, et al. Repeated exposure to food and food acceptability in infants and toddlers: a systematic review. Am J Clin Nutr 2019; 109: 978S–89S. doi: 10.1093/ajcn/nqy308
- Holley C, Farrow C, Haycraft E. A systematic review of methods for increasing vegetable consumption in early childhood. Curr Nutr Rep 2017; 6(2): 157–70. doi: 10.1007/s13668-017-0202-1
- Hodder RK, O’Brien KM, Stacey FG, Wyse RJ, Clinton-McHarg T, Tzelepis F, et al. Interventions for increasing fruit and vegetable consumption in children aged five years and under. Cochrane Database Syst Rev 2018; 5: Cd008552. doi: 10.1002/14651858.CD008552.pub4
- Dazeley P, Houston-Price C. Exposure to foods’ non-taste sensory properties. A nursery intervention to increase children’s willingness to try fruit and vegetables. Appetite 2015; 84: 1–6. doi: 10.1016/j.appet.2014.08.040
- Coulthard H, Williamson I, Palfreyman Z, Lyttle S. Evaluation of a pilot sensory play intervention to increase fruit acceptance in preschool children. Appetite 2018; 120: 609–15. doi: 10.1016/j.appet.2017.10.011
- Sedgwick P, Greenwood N. Understanding the Hawthorne effect. BMJ 2015; 351: h4672. doi: 10.1136/bmj.h4672
- McCambridge J, Witton J, Elbourne DR. Systematic review of the Hawthorne effect: new concepts are needed to study research participation effects. J Clin Epidemiol 2014; 67(3): 267–77. doi: 10.1016/j.jclinepi.2013.08.015
- DeCosta P, Møller P, Frøst MB, Olsen A. Changing children’s eating behaviour – a review of experimental research. Appetite 2017; 113: 327–57. doi: 10.1016/j.appet.2017.03.004
- Cashdan E. A sensitive period for learning about food. Hum Nat 1994; 5(3): 279–91. doi: 10.1007/BF02692155
- Brueton VC, Tierney JF, Stenning S, Meredith S, Harding S, Nazareth I, et al. Strategies to improve retention in randomised trials: a Cochrane systematic review and meta-analysis. BMJ Open 2014; 4(2): e003821. doi: 10.1136/bmjopen-2013-003821
- Educational attainment of the population. Oslo: Statistics Norway; 2019 [updated 19 June 2020]. Available from: https://www.ssb.no/en/utdanning/statistikker/utniv [cited 20 February 2021].
- Golley RK, Bell LK, Hendrie GA, Rangan AM, Spence A, McNaughton SA, et al. Validity of short food questionnaire items to measure intake in children and adolescents: a systematic review. J Hum Nutr Diet 2017; 30(1): 36–50. doi: 10.1111/jhn.12399
- Mikkelsen MV, Husby S, Skov LR, Perez-Cueto FJ. A systematic review of types of healthy eating interventions in preschools. Nutr J 2014; 13: 56. doi: 10.1186/1475-2891-13-56
This work is licensed under a Creative Commons Attribution 4.0 International License.
Authors retain copyright of their work, with first publication rights granted to SNF Swedish Nutrition Foundation. Read the full Copyright- and Licensing Statement.