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Meta-Analysis
. 2017 Sep 25;9(9):CD008552.
doi: 10.1002/14651858.CD008552.pub3.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

Rebecca K Hodder  1 , Fiona G Stacey, Rebecca J Wyse, Kate M O'Brien, Tara Clinton-McHarg, Flora Tzelepis, Nicole K Nathan, Erica L James, Kate M Bartlem, Rachel Sutherland, Emma Robson, Sze Lin Yoong, Luke Wolfenden
Affiliations
Meta-Analysis

Interventions for increasing fruit and vegetable consumption in children aged five years and under

Rebecca K Hodder et al. Cochrane Database Syst Rev. .

Update in

Abstract

Background: Insufficient consumption of fruits and vegetables in childhood increases the risk of future chronic diseases, including cardiovascular disease.

Objectives: To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE, Embase Classic and Embase to identify eligible trials on 30 September 2016. We searched CINAHL and PsycINFO in July 2016, Proquest Dissertations and Theses in November 2016 and three clinical trial registers in November 2016 and June 2017. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included studies to identify further potentially relevant trials.

Selection criteria: We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

Data collection and analysis: Two review authors independently extracted data and assessed the risks of bias of included studies; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures.We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures.

Main results: We included 50 trials with 137 trial arms and 10,267 participants. Thirty trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Eleven trials examined the impact of parent nutrition education in increasing child fruit and vegetable intake. Eight studies examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. One study examined the effect of a nutrition intervention delivered to children in increasing child fruit and vegetable intake.Thirteen of the 50 included trials were judged as free from high risks of bias across all domains; performance, detection and attrition bias were the most common domains judged at high risk of bias of remaining studies.Meta-analysis of trials examining child-feeding practices versus no intervention revealed a positive effect on child vegetable consumption (SMD 0.38, 95% CI 0.15 to 0.61; n = 1509; 11 studies; very low-quality evidence), equivalent to a mean difference of 4.03 grams of vegetables. There were no short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.11, 95% CI -0.05 to 0.28; n = 3023; 10 studies; very low-quality evidence) or multicomponent interventions versus no intervention (SMD 0.28, 95% CI -0.06 to 0.63; n = 1861; 4 studies; very low-quality evidence).Insufficient data were available to assess long-term effectiveness, cost effectiveness and unintended adverse consequences of interventions.Studies reported receiving governmental or charitable funds, except for two studies reporting industry funding.

Authors' conclusions: Despite identifying 50 eligible trials of various intervention approaches, the evidence for how to increase fruit and vegetable consumption of children remains sparse. There was very low-quality evidence child-feeding practice interventions are effective in increasing vegetable consumption of children aged five years and younger, however the effect size was very small and long-term follow-up is required. There was very low-quality evidence that parent nutrition education and multicomponent interventions are not effective in increasing fruit and vegetable consumption of children aged five years and younger. All findings should be considered with caution, given most included trials could not be combined in meta-analyses. Given the very low-quality evidence, future research will very likely change estimates and conclusions. Such research should adopt more rigorous methods to advance the field.This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

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Conflict of interest statement

Rebecca K Hodder: none known.

Fiona G Stacey: none known.

Kate M O'Brien: none known.

Tara Clinton‐McHarg: none known.

Flora Tzelepis: none known.

Nicole K Nathan: none known.

Erica L James: none known.

Kate M Bartlem: none known.

Rachel Sutherland: none known.

Emma Robson: none known.

Sze Lin Yoong: none known.

Rebecca J Wyse and Luke Wolfenden: are authors on an included randomised trial of an intervention to increase fruit and vegetable consumption (Wyse 2014); neither were involved in the determination of study eligibility, data extraction or risk of bias assessment for this study. The authors have not received any benefit, in cash or kind, any hospitality, or any subsidy derived from the food industry or any other source perceived to have an interest in the outcome of the review.

Figures

Figure 1
Figure 1
Study flow diagram.
Figure 2
Figure 2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figure 3
Figure 3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Figure 4
Figure 4
Funnel plot of comparison: 1 Short‐term impact (< 12 months) of child feeding intervention versus no intervention on child consumption of target fruit or vegetable, outcome: 1.1 Fruit and/or vegetable intake.
Figure 5
Figure 5
Funnel plot of comparison: 3 Short‐term impact (< 12 months) of parent nutrition education intervention versus usual care., outcome: 3.1 Fruit and/or vegetable intake.
Figure 6
Figure 6
Funnel plot of comparison: 4 Short‐term impact (< 12 months) of multicomponent intervention versus usual care, outcome: 4.1 Fruit and/or vegetable intake.
Analysis 1.1
Analysis 1.1
Comparison 1 Short‐term impact (< 12 months) of child feeding intervention versus no intervention, Outcome 1 Vegetable intake.
Analysis 1.2
Analysis 1.2
Comparison 1 Short‐term impact (< 12 months) of child feeding intervention versus no intervention, Outcome 2 Vegetable intake ‐ sensitivity analysis ‐ risk of bias.
Analysis 1.3
Analysis 1.3
Comparison 1 Short‐term impact (< 12 months) of child feeding intervention versus no intervention, Outcome 3 Vegetable intake ‐ sensitivity analysis ‐ primary outcome.
Analysis 1.4
Analysis 1.4
Comparison 1 Short‐term impact (< 12 months) of child feeding intervention versus no intervention, Outcome 4 Vegetable intake ‐ sensitivity analysis ‐ missing data.
Analysis 1.5
Analysis 1.5
Comparison 1 Short‐term impact (< 12 months) of child feeding intervention versus no intervention, Outcome 5 Vegetable intake ‐ subgroup analysis ‐ modality.
Analysis 1.6
Analysis 1.6
Comparison 1 Short‐term impact (< 12 months) of child feeding intervention versus no intervention, Outcome 6 Vegetable intake ‐ subgroup analysis ‐ setting.
Analysis 2.1
Analysis 2.1
Comparison 2 Short‐term impact (< 12 months) of parent nutrition education intervention versus no intervention, Outcome 1 Fruit and vegetable intake.
Analysis 2.2
Analysis 2.2
Comparison 2 Short‐term impact (< 12 months) of parent nutrition education intervention versus no intervention, Outcome 2 Fruit and vegetable intake ‐ sensitivity analysis ‐ primary outcome.
Analysis 2.3
Analysis 2.3
Comparison 2 Short‐term impact (< 12 months) of parent nutrition education intervention versus no intervention, Outcome 3 Fruit and vegetable intake ‐ sensitivity analysis ‐ missing data.
Analysis 2.4
Analysis 2.4
Comparison 2 Short‐term impact (< 12 months) of parent nutrition education intervention versus no intervention, Outcome 4 Fruit and vegetable intake ‐ subgroup analysis ‐ modality.
Analysis 2.5
Analysis 2.5
Comparison 2 Short‐term impact (< 12 months) of parent nutrition education intervention versus no intervention, Outcome 5 Fruit and vegetable intake ‐ subgroup analysis ‐ setting.
Analysis 3.1
Analysis 3.1
Comparison 3 Short‐term impact (< 12 months) of multicomponent intervention versus no intervention, Outcome 1 Fruit and vegetable intake.
Analysis 3.2
Analysis 3.2
Comparison 3 Short‐term impact (< 12 months) of multicomponent intervention versus no intervention, Outcome 2 Fruit and vegetable intake ‐ sensitivity analysis ‐ primary outcome.
Analysis 3.3
Analysis 3.3
Comparison 3 Short‐term impact (< 12 months) of multicomponent intervention versus no intervention, Outcome 3 Fruit and vegetable intake ‐ sensitivity analysis ‐ missing data.
Analysis 3.4
Analysis 3.4
Comparison 3 Short‐term impact (< 12 months) of multicomponent intervention versus no intervention, Outcome 4 Fruit and vegetable intake ‐ subgroup analysis ‐ setting.
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Update of

References

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References to other published versions of this review

    1. Wolfenden L, Wyse RJ, Britton BI, Campbell KJ, Hodder RK, Stacey FG, McElduff P, James EL. Interventions for increasing fruit and vegetable consumption in preschool aged children. Cochrane Database of Systematic Reviews 2010, Issue 6. [DOI: 10.1002/14651858.CD008552] - DOI - PMC - PubMed
    1. Wolfenden L, Wyse RJ, Britton BI, Campbell KJ, Hodder RK, Stacey FG, et al. Interventions for increasing fruit and vegetable consumption in children aged 5 years and under. Cochrane Database of Systematic Reviews 2012, Issue 11. [DOI: 10.1002/14651858.CD008552.pub2] - DOI - PMC - PubMed

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