8-Bashirian

JRHS 2008; 8(1): 56-63

Copyright © Journal of Research in Health Sciences

Fruit and Vegetable Intakes among Elementary Schools' Pupils: Using Five-A-Day Educational Program

Bashirian S (MSc)a, *Allahverdipour H (PhD)a, Moeini B (PhD)a

a Department of Public Health, Hamadan University of Medical Sciences, Iran

*Corresponding author: Hamid Allahverdipour , E-mail: hallahverdipour@umsha.ac.ir

Received: 18 September 2007; Accepted: 22 November 2007

Abstract

Background: Low fruit and vegetable intake is a major risk factor for cancer, coronary heart disease and stroke. The recommended intake of five portions per day would reduce death rates from these causes by 20%. In order to have reach fruit and vegetables in daily diet among students, this study examines a brief preventive intervention as for embedding schools action and students role for keeping and promoting fruit and vegetables consumption.

Methods: To promote increased fruit and vegetable consumption, this quasi-experimental study, was conducted among forth and fifth grade students (228 students: Intervention and control groups) in Hamadan, Iran from October 2007 to February 2008. The intervention consisted of behavioral curriculum in classrooms, serving fruit in the school, and parental support plus involvement. 24-hour and 1-week food recalls measured food consumption.

Results: Compared with controls, the intervention group significantly increased their knowledge of the 5-a-day optimum (P< 0.001) and also it was found visible improvement for consumption of fruit and vegetables but it was not significant based on adjusted by the Holmes- Bonfereroni procedure.

Conclusion: School-based interventions can produce important changes in knowledge of and access to fruit and vegetables among students. However, educational programs need to advocacy for providing fruit and vegetables in each community.

Keywords: Fruit, Vegetable, Nutrition, Healthy Diet, Iran

Introduction        

Diets rich in fruit and vegetables are associ­ated with a lower risk of chronic diseases (1,2) and there is substantial evidence that low fruit and vegetable intake is a major risk factor for these and other non-communicable diseases. Fruit and vegetables have a signifi­cant protective effect against cancer of the bowel, stomach and breast (3). The risk of coronary heart disease (CHD) and stroke is also sharply reduced by a higher fruit and vegetable intake (4,5).

Based on the evidences, US health authori­ties recommend a minimum of 5 servings of

fruit and vegetables a day (6,7), and the World Health Organization (WHO) recom­mends a daily intake of at least 400 g  fruit and vegetables (8,9), defined as at least five 80 g portions of a variety of fruit and vegeta­bles(9).

Methods to monitor changes in the intake of fruit and vegetables related to the US 5 a Day Campaign have been suggested and dis­cussed (10-12). The 5 a Day for Better Health Program was established in 1991 as a nutrition education campaign designed to in­crease awareness of the need to consume more vegetables and fruit, and to increase aver­age vegetable and fruit consumption in the United States to 5 or more daily servings (13).The Norwegian Nutrition Council now recommends 5 servings of potatoes, vegeta­bles, fruit, berries, and juices per day, corre­sponding to a total intake of 750 g/day, and a national campaign has been initiated to in­crease consumption(14).

During the 2004-05 school years, the Missis­sippi Department of Education Child Nutri­tion Program initiated the Mississippi Fresh Fruit and Vegetable Pilot Program. The pro­gram was designed to increase 1) knowledge of student about fresh fruit and vegetables, 2) the degree of student preference for fruit and vegetables, and 3) fruit and vegetable con­sumption. The results of this evaluation sug­gest that the distribution of fresh fruit at school free of charge to secondary school stu­dents might be an effective component of a comprehensive approach for improving stu­dents dietary behaviors; however, distribu­tion of fresh vegetables might be more effective with changes in program imple­mentation. One large study has found a 4% reduction in CHD risk and a 6% reduc­tion in stroke risk with each one portion in­crease in fruit and vegetable consumption (15). Others have demonstrated a significant fall in blood pressure with rising fruit and vegetable intake (16, 17). Besides the de­crease in mortality, increased fruit and vegeta­ble consumption has been associated with improved control in long-term condi­tions such as asthma (18), chronic obstruc­tive pulmonary disease (19), diabetes (20), re­duction in obesity (21), and cataract develop­ment (22).

Overall, it has been estimated that eating five portions per day would reduce mortality from cancer, CHD and stroke by 20% (23). In­deed, in the case of cancer, the evidence indi­cates that increasing fruit and vegetable in­take to five portions daily is the second most effective prevention strategy after smok­ing cessation (24).

A high fruit and vegetable intake will help to modify overall diet by increasing fiber and re­ducing fat and sugar intake, and will contrib­ute towards weight reduction. Fruit and vegetables also contain a plethora of essen­tial vitamins and minerals as well as non-nutritive bioactive constituents such as phyto-oestrogens and other phyto-chemicals. Many of these are also antioxidants, which may reduce the risk of cancer and other chronic diseases by destroying free radicals in the body (25).

Although diets high in fruit and vegetables are associated with decreased risk for many chronic diseases (14), consumption of fruit and vegetables among children is below rec­ommended levels (15). Despite the proven bene­fits of five a day program, UK consump­tion falls considerably short of the recommendation with only 13% of men and 15% of women achieving five a day. Aver­age intake for men is 2.7 portions, and for women 2.9 portions. The average decreases significantly with age and the number achiev­ing five a day approaches zero in adults aged 1924. Consumption is also consid­erably lower in lower socio-economic groups (2.1 and 1.9 portions, respectively, in men and women on state benefits compared with 2.8 and 3.1 portions in those not on bene­fits) (26). It is not found any study about five a day consumption pattern in Iran. 

Many factors will combine to influence an in­dividual's likelihood of achieving five a day. These include nutritional knowledge, awareness of the health impacts of different foods, attitudes to health promotion mes­sages, skills and confidence in buying, prepar­ing and serving fruit and vegetables, ac­cessibility of shops selling good quality food, the perishability of fresh fruit and vegeta­bles, and income (27).

Based on abovementioned background, a brief fruit and vegetable consumption educa­tional intervention deployed in schools and among pupils to investigate whether a school-based educational program would lead to a significant increase in the overall fruit and vegetable consumption among 5 grade children as an important factor for hav­ing healthy diet habits.

Methods

Participants and procedures    

This quasi-experimental study was per­formed on elementary school students in Hamadan, southwest Iran in 2007 with ap­proval from the relevant university research committee. For respecting ethical considera­tions, research group explained clearly proc­ess of research to director of educational area and then they permit to research group to perform project and coordinated all of proc­ess with students and their families. All participants were selected from 1st district area in the Hamadan. Eight schools were cho­sen based on randomized selection. These schools were then randomly assigned to an intervention group or a control group (four schools as intervention and four as con­trol groups). The sample consisted of 228 students who participated in this study with the average age of 11.The age range of stu­dents was between 10 and 12 yr. The interven­tion was delivered in the fifth grade classes from October 2007 to February 2008. At first, diagnostic evaluation was performed and the designed questionnaires were com­pleted by the pupils in their classrooms in the presence of a trained project worker who guided the pupils through the dietary assess­ment component (24 h recall and 1 wk) of the survey. Two months after "five a day" educational program in the intervention group, impact and outcome evaluation were done. Attrition rate for this study after out­come evaluation was calculated 15.1%.

Demographics    

Background data collected in this research in­cluded age, gender, parents' job and liter­acy, number of family members, and order of birth.

Students' knowledge of importance of fruit and vegetables      

A structured questionnaire was developed by the researchers to measure knowledge about importance of fruit and vegetables. Pupils'  knowledge was gauged about role of fruit and vegetables for prevention of disease  (“e.g. dose eating five kinds of fruit and vege­tables prevents cancer?”) and about amount of  fruit and vegetables consumption (“e.g. dose eating one apple or orange per day protect us against disease?”). In this ques­tionnaire, twenty items were designed to assess the pupils' knowledge about impor­tance of fruit and vegetables. Responses to items were yes/no and I do not know. The knowledge score was estimated by totaling the number of correct answers for all 20 items. A reliability coefficients was calcu­lated for the knowledge scale (α = 0.78) and these demonstrated high internal consis­tency.

Fruit and vegetable intake    

A written 24-hour and 1-week fruit and vegeta­ble recall were used to assess pupils' fruit and vegetable intake. The 24-hour and re­call was read aloud to the pupils by a pro­ject worker. Fruit and vegetable intake in the previous day and week was recorded for school days (i.e. the survey was conducted on weekdays Tuesday through Friday). The pu­pils recalled the types of fruit and vegeta­bles they ate at the different periods in house­hold measures (e.g. 1 apple, 12 grapes) or in portions (e.g. one portion of mixed green salad). The household measures were coded into portions per day, and one portion was set at 80 g [ranging from 65 g (one car­rot) to 105 g (one apple/one orange)].more over repetition of fruit and vegetables con­sumption was gauged by using a written 1-week fruit and vegetable recall question­naire.

Intervention   

School-based intervention research to pro­mote fruit and vegetable intake has consisted largely of multicomponent interventions in­cluded a classroom behavioral curriculum com­ponent, and a food service environ­mental component that this study focused on classroom behavioral curriculum component for promoting fruit and vegetable consump­tion related behaviors. The classroom curricu­lum component typically focused on in­creasing students' knowledge, developing be­havioral skills, and increasing motivation to choose fruit and vegetables. The curricu­lum was based on WHO recommendations, Ira­nian dietary habits, and pattern of consump­tion of fruit and vegetables. The cur­riculum was delivered in five sessions over a 2-month period. The pupils received an introduction to the health benefits of eat­ing fruit and vegetables and recommenda­tions regarding healthy levels of fruit and vegetable intake. In addition, each session started by having the pupils prepare fruit and vegetables for consumption during the ses­sions as snacks. A number of small-group ac­tivities included taste testing (preferences) and information concerning fruit and vegeta­bles about quality, taste and availability in their local areas. During the events, various fruit and vegetable dishes were served for pu­pils.

Data analysis    

All statistical analyses were performed using version 11.0 of the statistical software pack­age SPSS (SPSS Inc., Chicago, Illinois, USA) and an alpha level of .05 for knowl­edge about importance of fruit and vegeta­bles. The significance level for multiple com­parisons was adjusted by the Holmes- Bon­fereroni procedure (28).

Results

The sample was 101 students as intervention (44.6% female, and 55.4% male) and 117 students as control group (53% female and 47% male). Based rate results showed that it was not found significant difference for mean knowledge score about importance of vegetables and fruit for intervention group(X̅:12.92, SD:2.48) in comparing con­trol (X̅:12.72, SD:2.79) before implementing  interventional program (t:0.507, P=0.612). Whereas, after intervention there was significant difference for knowledge score about importance of vegetables, (X̅:19.95, SD:3.07) for intervention group ver­sus (X̅:12.89, SD:2.91) for control (t:9.969, P<0.001).

As shown in the Table 1, there were no base rate differences for consumption of citrus, ba­nana, vegetables, cucumber, tomato, car­rot, cabbage, and lettuce for 1-week fruit and vegetable recall based on routine dietary in­take of people who are living in the Hama­dans urban population before interventional program.

Table 1: Consumption of fruit and vegetables before intervention

consumption

Intervention group (n=101) n (%)

Control group (n=117) n(%)

X2

d.f

Sig

Citrus

Never

1-2 times

3-4 times

Every day


9(8.9)

26(25.7)

34(33/7)

32(31/7)


11(9.4)

35(29.9)

35(29.9)

36(30.8)

0.607

3

0.645

Banana

Never     

1-2 times

3-4 times

Every day


21(20.8)

47(46.5)

25(24.8)

8(7.9)


25(21.4)

52(44.4)

33(28.2)

7(6)

2.010

3

0.931

Vegetables

Never

1-2 times

3-4 times

Every day


19(18.8)

45(44.6)

25(24.8)

12(11.9)


10(8.5)

53(45.3)

34(29.1)

20(17.1)

3.675

3

0.081

Cucumber

Never

1-2 times

3-4 times

Every day


15(14.9)

39(38.6)

30(29.7)

17(16.8)


15(12.8)

41(35)

37(31.6)

24(20.5)

0.806

3

0.381

Tomato

Never   

1-2 times

3-4 times

Every day


35(34.7)

42(41.6)

15(14.9)

9(8.9)


33(28.2)

49(41.9)

25(21.4)

10(8.5)

1.986

3

0.327

Carrot

Never

1-2 times

3-4 times

Every day


36(35.5)

41(40.6)

15(14.9)

9(8.9)


41(35.6)

51(43.6)

15(12.8)

10(8.5)

0.292

3

0.863

Lettuce

Never

1-2 times

3-4 times

Every day


33(32.7)

38(37.6)

19(18.8)

11(10.9)


28(23.9)

54(46.2)

19(16.2)

16(13.7)

2.96

3

0.371

Cabbage

Never 

1-2 times

3-4 times

Every day


55(54.5)

36(35.4)

7(6.9)

3(3)


59(54.5)

40(34.2)

9(7.7)

9(7.7)

2.440

3

0.212

Changes in the consumption of fruit and vege­tables from baseline to end-point and fol­low-up are shown in Table.2. However, it was found noticeable improvement for con­sumption of fruit vegetables but based on Holmes-Bonfereroni procedure it was not found significant difference in 1-week fruit and vegetable recall consumption for large part of fruit and vegetables. In general, there were large variations in baseline level of con­sumption of citrus, banana, natural fruit juice, vegetables, cucumber, tomato, carrot, cabbage, and lettuce after preventative five a day educational programs.

Table 2: Consumption of fruit and vegetables after intervention

consumption

Intervention group (n=84) n (%)

Control group (n=101) n (%)

X2

d.f

Sig

Citrus

Never

1-2 times

3-4 times

Every day


2(2.4)

38(45.2)

12(14.3)

32(38.1)


16(16)

30(30)

28(28)

26(26)

8.796

3

0.032

Banana

Never     

1-2 times

3-4 times

Every day


6(7.1)

36(42.9)

24(28.4)

18(21.4)


24(24)

32(32)

34(34)

10(10)

3.021

3

0.082

Vegetables

Never

1-2 times

3-4 times

Every day


10(11.9)

32(38.1)

22(26.2)

20(23.8)


10(10)

22(22)

30(30)

16(16)

1.098

3

0.023

Cucumber

Never

1-2 times

3-4 times

Every day


6(7.1)

28(33.3)

34(40.5)

16(19)


22(22)

46(46)

28(28)

4(4)

10.031

3

0.002

Tomato

Never   

1-2 times

3-4 times

Every day


10(11.9)

38(45.2)

20(23.8)

16(19)


26(26)

50(50)

16(16)

8(8)

5.247

3

0.023

Carrot

Never 

1-2 times

3-4 times

Every day


20(23.8)

28(33.3)

14(16.7)

22(26.2)


46(46)

34(34)

10(10)

10(10)

7.234

3

0.061


Lettuce

Never

1-2 times

3-4 times

Every day


6(7.1)

30(35.7)

22(26.2)

26(31)


26(26)

44(44)

20(20)

10(10)

7.355

3

0.007


Cabbage

Never

1-2 times

3-4 times

Every


26(31)

24(28.6)

14(16.7)

20(23.8)


44(44)

26(26)

24(24)

6(6)

6.795

3

0.066

Discussion

The results presented in this paper show that a school-based five a day interventional programs, was effective in increasing schoolchildrens knowledge and intake of fruit and vegetables. The re­sults of this evaluation suggest that the fruit and vegetable educational program might have helped to increase the variety of fruit and vegetables ever eaten by students. The program also has increased the awareness of students about eating fruit and vegetables. Kearney et al. (29) state that the prescription for fruit and vegetables linked explicitly to key five a day messages could serve as a model for embedding public health action in primary care. In addition, they reported that a significant improvement in awareness about vegetables and fruit importance, which indicates five a day educational program, was implemented well. Indeed, the adjusted data show a significant association between message awareness and increased daily vegetable and fruit consumption (29). Other research has shown that awareness and knowledge of dietary recommendations are significant predictors of change (30,31) and that parental knowledge as well as awareness of the need to consume more vegetable and fruit are independent predictors of children's fruit intake (32). Moreover the results for comparing children pre-post 1-week food recalls showed that the number of serving fruit and vegetables used per day increased specially for consumption of citrus, banana, natural fruit juice, vegetables, cucumber, tomato, carrot, cabbage, and lettuce after the intervention.

In conclusion, educational programs help to insight the importance of the fruit and vegetables consumption but there are environmental and economical factors can threat five a day programs. Based on this fact, it might be suggested that the distribution of fresh fruit at school free of charge to elementary school students by governments might be an effective component of a comprehensive approach for improving student dietary behaviors especially among poor population with low intake of fruit and vegetables.

Study Limitations

One limitation of this study was that the findings were based on self-reported in­for­mation obtained from a short vegetable and fruit screener questionnaire. Second, although the 24 h measure is the most appropriate method to collect information, the 1-week measure was used that could increase the probability of recall bias in this study.

Acknowledgments

This research was supported by a grant from Deputy of Research of Hamadan University of Medical Sciences, Iran.

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