European Health Forum GasteinGastein, October 2, 2009

Dr. Carmen Pérez RodrigoCommunity Nutrition Unit of Bilbao (Spain)

bisaludpublica@wanadoo.es

EC project Pro Children - identification of fruit and vegetables intake determinants and the

development of appropriate strategies to promote such intake among school children

and parents across Europe.

F&V consumption in Europe F&V consumption in Europe (g/pc/day)(g/pc/day)

Source: DAFNE Data Food Networking 2006- DG SANCO

Fruit, Vegetables andFruit, Vegetables andDisease PreventionDisease Prevention

Low fruit and vegetable intake is among the top 10 selected risk factors for global mortalityLow intake of fruits and vegetables is estimated to cause about 19% of gastrointestinal cancer, about 31% of ischaemic heart disease and 11% of stroke worldwide2.7 million deaths are attributable to low fruit and vegetable intake: more than four fifths from heart diseases.Childhood obesity: 22 million children in the EU estimated to be overweight (IOTF).

Promotion of healthy eating: children and adolescents

Increasingly important in public health as the Increasingly important in public health as the prevalence of overweight in children riseprevalence of overweight in children riseUnderstanding determinant factorsUnderstanding determinant factors

Individual level factorsIndividual level factorsEnvironmental factorsEnvironmental factors

Expected importance of environment for obesity Expected importance of environment for obesity related behaviours in children and adolescentsrelated behaviours in children and adolescentsThe school settingThe school setting:

Population groups: children, parents, teachersMost children attend to schoolSpend 6-7 hours 5 days/week; 9 months/year

Pro ChildrenPro Children

University of Oslo (Coordinador)University of Oslo (Coordinador)Unidad de NutriciUnidad de Nutricióón Comunitarian ComunitariaAyuntamiento de BilbaoAyuntamiento de BilbaoUniversity Hospital ReykjavUniversity Hospital ReykjavííkkUniversity of CopenhagenUniversity of CopenhagenUniversidade do PortoUniversidade do PortoUniversitUniversitäät Wient WienRoyal Veterinary and AgriculturalRoyal Veterinary and AgriculturalUniversity DenmarkUniversity DenmarkUniversiteit RotterdamUniversiteit RotterdamKarolinska Institutet StockholmKarolinska Institutet StockholmUniversiteit GentUniversiteit Gent

EU RTF Project QLK1-2001-547

Klepp KI, Pérez-Rodrigo C, De Bourdeaudhuij I, Due P, Elmadfa I, Haraldsdóttir J, Thórsdóttir I, Vaz de Almeida MD, Yngve A, Brug J.

Pro Children: AimsPro Children: Aims

To assess fruit and vegetableassess fruit and vegetableconsumptionconsumption in European schoolchildren and their parents, as well as determinants determinants of the children’s consumption patterns. To develop and test strategiesTo develop and test strategies, applicable across Europe, for promoting consumption of fruits and vegetables among schoolchildren and their parents

Percentage of individuals consuming fruit ≥ 1 portion/day. Pro Children, school children 11-12 yr

0

10

20

30

40

50

60

70

Portugal Spain TheNetherlands

Sweden Norway

%

Everyday, 3 portions/dayEveryday, 2 portions/day

Everyday, 1 portion/day

Austria DK Belgium Island

N=13924Yngve A, Wolf A, Eric Poortvliet et al. Ann Nutr Metab 2005;49:236–245

N=13924Yngve A, Wolf A, Eric Poortvliet et al. Ann Nutr Metab 2005;49:236–245

Percentage of individuals consuming vegetables ≥ 1 portion/day. Pro Children, school children 11-12 yr

0

10

20

30

40

50

60

70

TheNetherlands

Portugal Sweden Norway Spain

%

Everyday, 3 portions/day

Everyday, 2 portions/day

Everyday, 1 portion/day

Belgium DK Austria Island

Frequency of consumption of fruit. MothersPro Children

Wolf A, Yngve A, Elmadfa I et al. Ann Nutr Metab 2005;49:246–254

01020304050607080

Portug

alDenm

arkSwed

en

Spain

The N

etherlan

dsBelg

iumAus

triaNorw

ayIsl

and

Total

>2 portions/day2 portions/day1 portion/day

N=9167

01020304050607080

Sweden

Belgium

Portug

alDenm

arkThe

Netherl

ands

Islan

dNorw

ayAus

tria

Spain

Total

>2 portions/day2 portions/day1 portion/day

N=9167

Wolf A, Yngve A, Elmadfa I et al. Ann Nutr Metab 2005;49:246–254

Frequency of consumption of vegetables. Mothers Pro Children

Qualitative Exploration of determinants of Fruit and Vegetable Intake among 10-11 yr-Old children

Personal FactorsPersonal FactorsHealth BeliefsTaste PreferencesKnowledgeAwarenessPersonal Barriers

Factors Related to the Home EnvironmentFactors Related to the Home EnvironmentFamily InfluencesAvailability and AccessibilityFood RulesEncouragement

FactorsFactors related to the school environmentrelated to the school environmentAvailabilityPeer InfluencesSocial Norms

Wind M, Bobelijn K, De Bourdeaudhuij I, Klepp KI, Brug J. Ann Nutr Metab 2005;49:228–235

Pro Children: literature review. Potential determinants of fruit and vegetable intake in children and adolescents

SociodemographicGenderAgeSESUrbanizationEthnicity

Personal factors:Personal factors:PreferencesPreferencesKnowledgeKnowledgeAttitudesAttitudesIntentionsIntentionsSelf efficacySelf efficacySubjective normsSubjective normsOutcome expectanciesOutcome expectanciesFamily related factors

Parental intakeHome availabilityAccessFamily structureFamily sizeFamiliy mealsParenting stylesParental support

Friends related factorsFriends related factorsSchool related factorsSchool related factorsTV watchingTV watchingEating fast foodEating fast food

Rasmussen M, Kroelner R, Klepp KI, Lytle L, Brug J, Bere E, Due P. IJBNPA 2006, 3:22. doi:10.1186/1479-5868-3-22

Theoretical Model applied to children consumption Theoretical Model applied to children consumption of fruit and vegetables: Pro Children Projectof fruit and vegetables: Pro Children Project

Klepp K-I, Pérez Rodrigo C, De Bourdeaudhuij I et al.Ann Nutr Metab 2005; 49, 212-220.Klepp K-I, Pérez Rodrigo C, De Bourdeaudhuij I et al.Ann Nutr Metab 2005; 49, 212-220.

Cultural Environment

Physical environmentPhysical environmentPolicies

Dietary guidelinesAvailability Accessbility

Fruit & VegetableFruit & Vegetableconsumptionconsumption

EthnicityCountry

Socio economical level

National levelCommunity level

School level:School level:School mealsSchool meals

Perceived environment:At homeAt schoolOther environments

Mass mediaSchool:

teachers, peersFriends

Family

Physical activityTV viewing

BiologicalPsychological

Specific F&V factors: preferences, attitudes, knowledge

Personal factors

Social environment

Pro Children intervention:Pro Children intervention:Is it required?Is it required?

Fruit and vegetable intake is too low among European childrenPro Children consortium: aimed to initiate, develop, implement and evaluate school-based fruit and vegetable promotion actions among primary school children aged 10-13 in different European countries: To develop an evidence-based and theory-driven intervention package that is applicable in different European countries.

Identified changeable important determinants of fruit and vegetaIdentified changeable important determinants of fruit and vegetable ble consumption in Pro Children interventionconsumption in Pro Children intervention

Determinants

Personal Social EnvironmentalAwareness of importance of fruit and vegetable intake for health and well-being

Parental facilitation and direct encouragement

Availability and accessibility of fruit and vegetable at home

Positive taste preferences for different fruits and vegetables Parental modelling behaviour Availability and accessibility of fruit

and vegetable in the schoolAwareness of own fruit and vegetableintake Peer modelling behaviour A fruit and vegetable promotion

school environmentAwareness of recommended intake levels Teacher support Neighbourhood support

Self-efficacy and skills for asking for fruit and vegetableSelf-efficacy and skills for preparing fruit and vegetableSelf-efficacy and skills for obtaining fruit and vegetableSelf-efficacy and skills for keeping fruit and vegetable freshFamiliarity with different fruits and vegetables

Pérez Rodrigo C, Wind M, Hildonen C, Bjelland M, Aranceta J, Klepp KI, Brug J. Ann Nutr Metab 2005;49:267–277

Matrix of learning objectives for school children in Pro ChildreMatrix of learning objectives for school children in Pro Children intervention n intervention arranged by determinants: personal determinants. arranged by determinants: personal determinants.

Performance objectives

Personal determinants

Awareness Skills Self-efficacy Self-evaluation Preferences/ Taste

To assess adequacy of one’s own current fruit and vegetable intake

Children are aware of importance of fruit and vegetable intake for health and well-being

Children can complete a computer based fruit and vegetable test

Children complete a computer based fruit and vegetable test

Children are aware of recommended intake levels

Children can read and understand a feedback report

Children read and understand a tailored feedback report

Children know what is a portion of fruit and a portion of vegetables

Children develop skills to identify what is a portion of fruit and a portion of vegetables

Children set goals for increased consumption

Children taste a variety of fruits and vegetables at home

Children know what a fruit juice is and what is not

Children taste a variety of fruits and vegetables at school

Children are aware of own intake

Children taste a variety of fruit juices at school

Pérez Rodrigo C, Wind M, Hildonen C, Bjelland M, Aranceta J, Klepp KI, Brug J. Ann Nutr Metab 2005;49:267–277

Learning objective Availability Awareness Preferences Peer

influencesParental

influences

Skills:Prepare

Ask/ObtainChildren are aware of importance of fruit and vegetable intake for health and well-being

Education-worksheet guided activity

Children know recommendation

CT*-feedback

Children know what a fruit juice is and what is not

Education-worksheet guided activity

Taste-testing activity at school

Fruit and vegetable is an issue for children

Education-worksheet on label reading

Web-based international discussion forum

Children find fruit and vegetable at school

School fruit (fruit break)

Eat fruit and vegetable together in class

Parents give fruit and vegetable to children to bring to school

Selected educational strategies related to learning objectives aSelected educational strategies related to learning objectives and nd modifiable determinants in Pro Children interventionmodifiable determinants in Pro Children intervention

CT: Computer tailoringCT: Computer tailoring

Pro Children: InterventionPro Children: Intervention

School

School-basedIntervention program

Family

Community

ClassroomOut-of-classroom

School meals

Whole SchoolWhole SchoolWorksheetsWorksheetsEducationalEducationalActivitiesActivitiesComputerComputerTailoringTailoringWeb siteWeb site

Fruit breakFruit breakSpecial schoolSpecial school

eventseventsSchool ProjectSchool Project

committeescommittees

WorksheetsWorksheetsNewslettersNewsletters

School EventsSchool EventsComputerComputertailoringtailoring

School HealthSchool HealthMass MediaMass Media

Grocery storesGrocery stores

Guidance for parents: worksheet 8Guidance for parents: worksheet 8Estimados padres/madres,Nuevamente nos ponemos en contacto con Uds. en relación con el proyecto Pro Children en el que participa su hijo/a. Esta vez la actividad que proponemos a su hijo/a requiere que le anime y le recuerde algunas cosas. En clase, junto con su profesor/a y sus compañeros/as ha decidido qué va a hacer a lo largo de la semana que viene para comer más frutas y verduras. Ya se ha hecho su plan. Ha pensado también algunas cosas concretas que va a hacer.Le pedimos que comente con su hijo/a en casa estos propósitos y que le ayude a conseguirlo, por ejemplo recordándole si ya ha cogido la fruta para llevar al colegio, o la estrategia que se haya trazado.Queremos plantearlo como un pequeño juego que resulte una experiencia atractiva para los chicos/as. Se trata de intentar un pequeño reto a lo largo de una semana.Muchas gracias por su ayuda.

La Comisión Escolar de Proyectos Saludables Pro Children.

Pro Children Family Newsletter

Num 3; 2004

“Volcán” from San Inazio school wins Pro Children recipe competition

30 schools from Norway, The Netherlands and Spain took part in the international recipe contest using fruits and vegetables

Last April 14th after long discussions, the international Pro Children jury decided in Rotterdam the winning recipes of the fruit and vegetable recipe competition. “Kristoffers Wok” from Oslo, “Pizza cauliflower” from Rotterdam and “Volcano” from Bilbao were the winners. 6 recipes from each country, 3 fruit recipes and 3 vegetable ones, were nominated for the final voting among more than 100 hundred submitted. Prizes will be delivered to winning schools in June .

More info on page 3.

In the picture one of the selected recipes, “Aubergine Jamaican style”from Uribarri school.

International Recipe CompetitionInternational Recipe Competition

School fruit breakSchool fruit breakBilbao Bilbao

Study design

Cluster randomised trial

Intervention group32 schools (n=1115)

Control Group30 schools (n=991)

Norway: 9 schools (n=337) Norway: 9 schools (n=390)

The Netherlands: 12 schools (n=410) The Netherlands: 12 schools (n=325)

Spain: 11 schools (n=368) Spain: 9 schools (n=276)

1st EvaluationChildren & Families

InstrumentDesign

Design of the intervention

Intervention group

2nd EvaluationChildren & Families

2nd EvaluationChildren & Families

Control group

Pro Children: changes in total fruit and vegetables intake among intervention and control schools

Total Fruit intakeTotal Fruit & Vegetables intake

Total Vegetables intake

*** Intervention effect was significant (P<0,05)

te Velde SJ, Brug J, Wind M, Hildonen C, Bjelland M, Perez-Rodrigo C and Klepp KI. Br J Nutr, 2007

Knowledge scoreKnowledge scoreProportion who knows Proportion who knows

recommendationsrecommendations

46,5 47,7 44,7

63,8

23,3 24,9 20,2

34,8

0

20

40

60

80

100

Fruit 0 Fruit 1 Vegetables 0 Vegetables 1

Control Intervention

%

Wind M, te Velde S, Hildonen C, Bjelland M, Pérez-Rodrigo C, Klepp KI, Brug J, 2006

Preferences fruit Preferences fruit and vegetablesand vegetables

1,25 1,22 1,25 1,21

0,43 0,36 0,33 0,37

0

0,5

1

1,5

2

Fruit 0 Fruit 1 Vegetables 0 Vegetables 1Control Intervention

Perceived Perceived availability at availability at

schoolschool 28,6 27,631,5

46,7

21,3 19,5 21,528,7

-55

15253545556575

Fruit 0 Fruit 1 Vegetables 0 Vegetables 1

Control Intervention

7,6

15,4

6,1

16,5

7,9

17,5

4,3

15

0

10

20

30

40

50

Fruit 0 Fruit 1 Vegetables 0 Vegetables 1Control Intervention

Bring F&V Bring F&V to schoolto school

Wind M, te Velde S, Hildonen C, Bjelland M, Pérez-Rodrigo C, Klepp KI, Brug J, 2006

Project appreciation scores by children, teacher Project appreciation scores by children, teacher referred implementation and parental involvementreferred implementation and parental involvement

Children project appreciation

Degree of implementation

Parental involvement

Country n Mean (SD) n Mean (SD) n Mean (SD)Total 842 2.3 (0.5)** 818 9.1 (3.0)** 559 3.3 (1.9)**Norway 240 2.4 (0.5) 225 10.9 (2.4) 160 3.4 (1.8)

Spain 297 2.3 (0.4) 320 9.4 (1.9) 233 3.5 (1.9)

The Netherlands 305 2.2 (0.5) 273 7.4 (3.5) 166 2.8 (1.9)GenderBoys 380 2.3 (0.5) 369 9.3 (3.0) 237 3.1 (2.0)*Girls 462 2.3(0.4) 449 9.1 (3.0) 322 3.4(1.8)

** p<0,001; *p< 0,05

Wind M, Bjelland M, Pérez-Rodrigo C, te Velde S, Hildonen C, Bere E, Klepp KI, Brug J. HER, 2007

ConclusionsConsumption of F&V in European school children is below recommended intake levels in a large proportion of this population group.

Intake below desirable levels is more frequent among boys.

The Pro Children intervention is a promising means to promote European schoolchildren’s fruit and vegetable intakes: school-based, multi-component, involving parents, increasing availability and access to F&V.

Family support and involvement is important: encourage to eat F&V.

Strategies should be implemented over time with adequate duration.

More research is needed to find the barriers for implementation and solutions to improve it, particularly family support.

This paper was produced for a meeting organized by Health & Consumers DG and represents the views of its author on thesubject. These views have not been adopted or in any way approved by the Commission and should not be relied upon as a statement of the Commission's or Health & Consumers DG's views. The European Commission does not guarantee the accuracy of the dataincluded in this paper, nor does it accept responsibility for any use made thereof.