PEDIATRICOBESITY
ORIGINALRESEARCH
ORIGINALRESEARCH
doi:10.1111/ijpo.243
Home environmental determinants of children’s fruit and vegetable consumption across different SES backgrounds E. de Jong1,2, T. L. S. Visscher1,2, R. A. HiraSing3, J. C. Seidell1,2 and C. M. Renders1,2 1
Research Centre for the Prevention of Overweight, VU University Amsterdam/Windesheim University of Applied Sciences, Zwolle, The Netherlands; 2Department of Health Sciences, Faculty of Earth and Life Sciences, EMGO Institute for Health and Care Research, VU University Amsterdam, Amsterdam, The Netherlands; 3Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, The Netherlands Received 1 May 2013; revised 4 October 2013; accepted 17 March 2014
Summary Objective: To investigate the association between home environmental determinants of fruit and vegetable consumption with childhood overweight separately for low, medium and high social economic status (SES) families. Method: A cross-sectional study was carried out in 2006 among 4072 children aged 4–13 years in the city of Zwolle, the Netherlands. Of these children, data were available on measured height and weight, and from a parental questionnaire, on sociodemographic characteristics and children’s fruit and vegetables intake. Associations were studied using logistic regression analyses. Results: Not eating the recommended amounts of vegetables daily was associated with overweight for children with a low SES background (odds ratio [OR]: 1.17; 95% confidence interval [CI]: 0.66–2.07) and medium SES background (OR: 1.73; 95% CI: 1.20–2.49). Eating < 2 pieces of fruit daily was associated with a lower OR for overweight among children with a high SES background (OR: 0.66; 95% CI: 0.50–0.88). Determinants of eating vegetables < 7 d were: permission to take candy without asking, eating at the table < 7 d per week, eating a takeaway meal ≥ 1 d per week, eating a home cooked meal < 6 d per week and cooking together with caregiver less than 5 d per week. Conclusion: Interventions regarding vegetable consumption should be tailored to families with low and medium SES background. The most promising avenues for intervention seem to be (i) to prevent eating takeaway meals on a weekly basis and, (ii) to promote eating a home cooked meal at the table and (iii) to involve children in the cooking process. Interventions should support parents in making these home environmental changes. Keywords: Childhood overweight, fruit and vegetable consumption, home environment, socioeconomic status.
Introduction Healthy eating is important for the prevention of overweight (1). Eating sufficient fruit and vegetables are important targets in childhood overweight prevention as their health benefits are considered to be sustainable and significant over the long term (2,3). Most Dutch children do not meet the recommendations for fruit and vegetable intake (4). Children living in families with a low socioeconomic status (SES) have a lower fruit and vegetable consumption than children living in families with high SES (5,6). These
differences may be (partly) explained by differences in home environments (5,7–11). The home environment, in which parents play a central role, is an important influence on children’s eating behaviour. Different components in the home environment are associated with fruit and vegetable intake of children and adolescents, such as home availability/accessibility of foods, setting rules and regulations, parental modelling and parental support (5,7,11–14). However, information is missing on how fruit and vegetables intake is related to the home environment within different SES groups.
Address for correspondence: Ms E de Jong, Research Centre for the Prevention of Overweight, VU-Windesheim, PO box 10090, Zwolle 8000 GB, The Netherlands. E-mail: [email protected] © 2014 The Authors Pediatric Obesity © 2014 World Obesity. Pediatric Obesity 10, 134–140
To improve programmes aimed at increasing children’s fruit and vegetable consumption, more insight is needed within families with a relatively low SES. Therefore, the main aim of this study is to find clues in the home environment for tailored childhood overweight prevention by stimulating fruit and vegetable consumption across different SES groups. The studied determinants in this paper include setting rules, family routines, availability and parental support. First step is to investigate the association between fruit and vegetable consumption and childhood overweight separately for low, medium and high SES families. Subsequently, to explore determinants in the home environment of these behaviours associated with overweight, separately for children from different SES families.
Methods Study population Data collected in the ChecKid study have been used for this study. ChecKid is a cross-sectional study carried out among primary school children (4–13 years) in 2006 in the city of Zwolle. This study aimed at identifying neighbourhoods and other groups at high risk for overweight and behaviours related to overweight. Details on the study population and data collection are described elsewhere (15). Of all 51 primary schools in the city, 80% (n = 41) agreed to participate. Of the invited parent(s), 65% (n = 5219) gave written informed consent for their children to participate. The Medical Ethics Committee of the VU University Medical Centre approved the ChecKid study.
Measures The measurements were performed during three weeks in October and November 2006. Trained students from the University of Applied Sciences Windesheim measured body height, weight and waist circumference according to the protocol for the national Dutch Growth study in 5035 children (16). Four percent of children were not measured, mostly because of school absence. The children’s body mass index (BMI) cut-off points of Cole et al. (17,18) were used to define overweight and obesity. Due to relatively low prevalence of obesity (1.6%), overweight and obesity were combined in the analyses. The questionnaire for parents included sociodemographic issues and questions about their children’s sleeping habits, diet, physical (in) activity, the home environment and rules. A total of 4257 parents (81%) returned the questionnaire.
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Parental characteristics SES was classified as low (lower general secondary education, lower vocational training and primary school or less), medium (intermediate vocational training, higher general secondary training and preuniversity education) or high (completed higher vocational training and University) based on the highest completed educational level of parents, according to the Statistics Netherlands definition (19). In the questionnaire, parental country of birth was indicated as: ‘the Netherlands’, ‘Turkey’, ‘Morocco’, ‘Surinam’, ‘Netherlands Antilles’ or ‘other country’. A total of 5.4% of the parent(s) were born in an ‘other country’ not further specified. According to the city council, 8.6% are non-western and 6.5% are western immigrants (20). Because in our data, 7.3% of the immigrants were from non-western countries, we have assumed that the 5.4% of parent(s) born in an ‘other country’ were mainly from western origin. Therefore, we dichotomized ethnicity as nonwestern background (one or both parents born in Turkey, Morocco, Surinam, Netherlands Antilles) vs. the rest (15). Parents’ self-reported body weight and height data were used to calculate their BMI. Because most of the mothers filled out the questionnaire for their child, we included maternal overweight in this study and defined it as BMI ≥ 25.0 kg m−2.
Lifestyle nutrition behaviours Parents indicated the frequency (number of week and weekend days) and amount (none, 1, 2 or >2 pieces) of children’s fruit consumption, the frequency of eating vegetables for dinner and the frequency and portions (between 1 and ≥5 portions) of eating sweet candy bars, savoury snacks and crisps of their children. The average pieces/portions of fruit and snacks per day were calculated by multiplying the number of days per week or per weekend the child ate fruit/snacks by the number of portions per day. Weekdays and weekend were combined and divided by the total number days per week. Consumption of fruit was dichotomized according to the recommendations for healthy eating behaviours from the Netherlands nutrition centre as ≥2 (0) and 1 portion per day Home environment (%) Permission to have candy without asking Permission to have crisps and nuts without asking Eating at the table < 7 d per week Eating a takeaway meal ≥ 1 d per week Eating a home cooked meal < 6 d per week Cooking together 0–1 d per week 2–4 d per week 5–7 d per week Doing groceries together 0–1 d per week 2–4 d per week 5–7 d per week
Whole group
Low SES (n = 335)
Medium SES (n = 1330)
High SES (n = 2194)
8.1 (2.3) 11.7 49.2
8.5 (2.4) 20.3 40.0
8.1 (2.3) 12.6 51.4
7.9 (2.3) 9.5 49.1
6.6 29.5
13.5 45.7
8.3 34.0
4.4 24.2
63.4 53.1
63.2 65.0
64.0 62.8
63.0 45.3
84.7 15.3
66.8 33.1
82.1 18.0
89.2 10.8
18.8 11.0 18.1 38.4 11.8
36.9 30.0 28.7 49.2 18.8
22.5 13.3 21.7 44.8 14.2
13.8 6.6 14.2 32.8 9.3
63.9 32.9 3.3
58.6 34.6 6.8
64.6 31.6 3.8
64.2 33.4 2.4
38.8 55.6 5.6
28.0 61.4 10.6
37.7 55.5 6.7
41.2 54.7 4.0
*Including obesity. SD, standard deviation; SES, socioeconomic status.
Table 2 Association between fruit and vegetable consumption and overweight
Fruit < 2 portions per day Vegetables < 7 d per week
Whole group OR (95% CI)†
Low SES (n = 335) OR (95% CI)†
Medium SES (n = 1330) OR (95% CI)†
High SES (n = 2194) OR (95% CI)†
0.82 (0.67–1.00) 1.27 (1.04–1.55)*
1.15 (0.66–2.02) 1.17 (0.66–2.07)
0.93 (0.66–1.31) 1.73 (1.20–2.49)*
0.66 (0.50–0.88)* 0.95 (0.71–1.26)
*P ≤ 0.05; † Adjusted for ethnicity, maternal overweight, gender and age. CI, confidence interval; OR, odds ratio; SES, socioeconomic status.
medium SES group, determinants of not eating vegetables daily are eating at the table less than 7 d per week, eating a takeaway meal one or more days per week, eating a home cooked meal less than 6 d per week and cooking together less than 5 d per week. Additionally, among the medium SES group, permission to take candy without asking is associated with not eating vegetables daily. The association between consuming two or more pieces of fruit and overweight among children with a high SES background might implicate that eating the
recommended two or more pieces of fruit does not automatically mean that children eat less energy dense foods (such as snacks) as suggested in other studies (23,24). Indeed, fruit is high in sugar and calories and fruit consumption could only lead to reduced energy intake if fruit intake is instead of snack intake (25). Our post hoc analyses showed that children eating two or more pieces of fruit did not have a lower snack intake than children who eat less fruit per day. Additionally, the results show that the association between fruit consumption and
© 2014 The Authors Pediatric Obesity © 2014 World Obesity. Pediatric Obesity 10, 134–140
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Table 3 Determinants of eating vegetables < 7 d per week Whole group† OR (95% CI)
Permission to take candy without asking Permission to take crisps and nuts without asking Eating at the table < 7 d per week Eating a takeaway meal ≥ 1 d per week Eating a home cooked meal < 6 d per week Cooking together 0–1 d per week 2–4 d per week 5–7 d per week Doing groceries together 0–1 d per week 2–4 d per week 5–7 d per week
Low SES† (n = 335) Medium SES† (n = 1330) High SES† (n = 2194) OR (95% CI) OR (95% CI) OR (95% CI)
1.57 (1.32–1.86)** 1.53 (0.93–2.50)
1.42 (1.06–1.90)*
1.42 (1.09–1.83)*
1.48 (1.19–1.84)** 1.38 (0.79–2.40)
1.24 (0.87–1.76)
1.37 (0.95–1.97)
2.71 (2.27–3.24)** 2.72 (1.54–4.80)*
2.80 (2.05–3.84)**
2.32 (1.79–3.01)**
3.37 (2.93–3.89)** 3.60 (2.22–5.86)**
3.32 (2.58–4.28)**
3.06 (2.55–3.68)**
4.06 (3.20–5.17)** 6.11 (2.56–14.59)** 4.24 (2.75–6.55)**
3.37 (2.44–4.64)**
1 (–) 1 (–) 0.62 (0.53–0.73)** 0.92 (0.53–1.59) 0.64 (0.41–0.99)* 0.33 (0.11–0.94)*
1 (–) 0.58 (0.44–0.76)** 0.80 (0.40–1.56)
1 (–) 0.60 (0.49–0.74)** 0.57 (0.30–1.09)
1 (–) 0.94 (0.81–1.09) 0.76 (0.56–1.04)
1 (–) 0.96 (0.75–1.24) 0.70 (0.43–1.16)
1 (–) 0.91 (0.76–1.10) 0.67 (0.41–1.08)
1 (–) 0.65 (0.34–1.25) 0.52 (0.21–1.30)
*P ≤ 0.05; **P ≤ 0.001. †Adjusted for ethnicity, maternal overweight, gender and age. CI, confidence interval; OR, odds ratio; SES, socioeconomic status.
overweight might be different for the various SES groups. Other studies showing inconsistent associations between fruit consumption and overweight in subgroups (25,26) were potentially suffering from methodological limitations (26) or a different way of operationalizing fruit consumption. Therefore, further research is needed before practical implications can be determined. When confirmed, interventions regarding fruit consumption should take these differences into account. The association between not eating vegetables daily and overweight are in line with most other studies (27). Given the findings in present study, it seems important to stimulate vegetable consumption in all SES groups as it is not only beneficial in prevention of overweight, but also has other favourable effects such as reducing the risk of cardiovascular diseases and certain types of cancer (28,29). However, in intervention programmes, special attention should be given to reach, additionally to low SES groups, medium SES groups as this is a large group and the prevalence of not consuming vegetables daily is equal to that of children with a low SES background. The focus of interventions aimed at stimulating vegetable intake should therefore be expanded from deprived neighbourhoods to middle class neighbourhoods. We identified determinants of vegetable intake in the home environment. The importance of the home environment is confirmed by multiple reviews and studies
© 2014 The Authors Pediatric Obesity © 2014 World Obesity. Pediatric Obesity 10, 134–140
in which it was concluded that the home availability, parental intake and family rules are important determinants of vegetable intake in children and adolescents (5,7,12,13,30). Supplementary to these reviews, this study adds that in families with a low or medium SES background, preventing takeaway meals on a weekly basis and promoting to eat a home cooked meal at the table every day might increase vegetable consumption. In addition, to increase vegetable consumption, it seems important to involve children with the cooking process. To our knowledge, these home environmental determinants were not yet studied within different SES categories.
Strengths and limitations Strength of the present study is the large sample size and the availability of data regarding physical and social home environment and nutritional behaviours. A limitation of this study includes the cross-sectional design, which precludes causal interpretation of the observations. Despite high participation rates, children from low and middle SES families were underrepresented (31). This selective participation could have made observed associations possibly weaker. The use of questionnaires, as in other monitoring studies could have possibly led to issues of social desirability and to difficulties with recalling the actual behaviour of the child in the past month. In addition, vegetable intake was measured only at dinner with
no information on number of portions, as in the Netherlands, vegetables are most commonly eaten at the main evening meal (32). Unfortunately, no data were available on parental modelling and home availability of vegetables, which are important determinants of children’s vegetable consumption. In addition, the age range of children was wide (4–13 years), and although age was controlled for, variables are likely to vary between a 4- and a 13-year-old. However, differences were small between 4–8 and 9–13 year-old children for the behaviours and home environmental variables. In addition, the association between fruit and vegetable consumption did not differ for age. The data used for this study were from 2006. We do not think data regarding fruit and vegetables consumption and the association of the home environmental determinants with these behaviours have changed considerably (33). SES was defined using parental educational level only. Data on other indicators for SES (job position and income) were not available. However, education level of parent(s) correlates with SES overall (based on the three indicators) and is associated with parental knowledge, lifestyle and habits (34). Moreover, in the Netherlands in large population-based studies, educational level is often used as indicator for SES (35).
Conclusion and implications The results show an association between not eating vegetables daily and overweight, especially in children with a medium SES background. The association between fruit consumption and overweight differs in different SES groups and is therefore inconclusive. Further research is needed before practical implications can be determined. Determinants in the home environment are identified that could be targeted to increase the percentage of children that consume vegetables daily. Low or medium SES families should be particularly targeted in interventions as they have a disadvantaged position regarding vegetable intake and determinants that are associated with vegetable consumption. The most promising avenues for intervention seem to be (i) to prevent eating takeaway meals on a weekly basis, (ii) to promote eating a home cooked meal at the table, and (iii) to involve children in the cooking process.
Conflict of Interest Statement No conflict of interest was declared.
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Acknowledgements We would like to thank our partners in this monitoring study: the Zwolle city council, the local health services and several welfare organizations in the city. We are greatly thankful to all the students who helped with the measurements, the participating schools and sponsorships. Also, we want to thank all the children and parents participating in this study.
Authors’ contribution JCS, CMR, RAH and TLSV were responsible for the study design. JCS and CMR supervised the data collection. EdJ was responsible for the statistical analyses and interpretation of the data in agreement with JCS, CMR and TLSV. EdJ wrote the first version of the manuscript and all authors participated in the revisions of the manuscript. All authors hereby confirm that the manuscript is an original piece of research and that they have seen and approved the final version for publication.
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ORIGINALRESEARCH
ORIGINALRESEARCH
doi:10.1111/ijpo.243
Home environmental determinants of children’s fruit and vegetable consumption across different SES backgrounds E. de Jong1,2, T. L. S. Visscher1,2, R. A. HiraSing3, J. C. Seidell1,2 and C. M. Renders1,2 1
Research Centre for the Prevention of Overweight, VU University Amsterdam/Windesheim University of Applied Sciences, Zwolle, The Netherlands; 2Department of Health Sciences, Faculty of Earth and Life Sciences, EMGO Institute for Health and Care Research, VU University Amsterdam, Amsterdam, The Netherlands; 3Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, The Netherlands Received 1 May 2013; revised 4 October 2013; accepted 17 March 2014
Summary Objective: To investigate the association between home environmental determinants of fruit and vegetable consumption with childhood overweight separately for low, medium and high social economic status (SES) families. Method: A cross-sectional study was carried out in 2006 among 4072 children aged 4–13 years in the city of Zwolle, the Netherlands. Of these children, data were available on measured height and weight, and from a parental questionnaire, on sociodemographic characteristics and children’s fruit and vegetables intake. Associations were studied using logistic regression analyses. Results: Not eating the recommended amounts of vegetables daily was associated with overweight for children with a low SES background (odds ratio [OR]: 1.17; 95% confidence interval [CI]: 0.66–2.07) and medium SES background (OR: 1.73; 95% CI: 1.20–2.49). Eating < 2 pieces of fruit daily was associated with a lower OR for overweight among children with a high SES background (OR: 0.66; 95% CI: 0.50–0.88). Determinants of eating vegetables < 7 d were: permission to take candy without asking, eating at the table < 7 d per week, eating a takeaway meal ≥ 1 d per week, eating a home cooked meal < 6 d per week and cooking together with caregiver less than 5 d per week. Conclusion: Interventions regarding vegetable consumption should be tailored to families with low and medium SES background. The most promising avenues for intervention seem to be (i) to prevent eating takeaway meals on a weekly basis and, (ii) to promote eating a home cooked meal at the table and (iii) to involve children in the cooking process. Interventions should support parents in making these home environmental changes. Keywords: Childhood overweight, fruit and vegetable consumption, home environment, socioeconomic status.
Introduction Healthy eating is important for the prevention of overweight (1). Eating sufficient fruit and vegetables are important targets in childhood overweight prevention as their health benefits are considered to be sustainable and significant over the long term (2,3). Most Dutch children do not meet the recommendations for fruit and vegetable intake (4). Children living in families with a low socioeconomic status (SES) have a lower fruit and vegetable consumption than children living in families with high SES (5,6). These
differences may be (partly) explained by differences in home environments (5,7–11). The home environment, in which parents play a central role, is an important influence on children’s eating behaviour. Different components in the home environment are associated with fruit and vegetable intake of children and adolescents, such as home availability/accessibility of foods, setting rules and regulations, parental modelling and parental support (5,7,11–14). However, information is missing on how fruit and vegetables intake is related to the home environment within different SES groups.
Address for correspondence: Ms E de Jong, Research Centre for the Prevention of Overweight, VU-Windesheim, PO box 10090, Zwolle 8000 GB, The Netherlands. E-mail: [email protected] © 2014 The Authors Pediatric Obesity © 2014 World Obesity. Pediatric Obesity 10, 134–140
To improve programmes aimed at increasing children’s fruit and vegetable consumption, more insight is needed within families with a relatively low SES. Therefore, the main aim of this study is to find clues in the home environment for tailored childhood overweight prevention by stimulating fruit and vegetable consumption across different SES groups. The studied determinants in this paper include setting rules, family routines, availability and parental support. First step is to investigate the association between fruit and vegetable consumption and childhood overweight separately for low, medium and high SES families. Subsequently, to explore determinants in the home environment of these behaviours associated with overweight, separately for children from different SES families.
Methods Study population Data collected in the ChecKid study have been used for this study. ChecKid is a cross-sectional study carried out among primary school children (4–13 years) in 2006 in the city of Zwolle. This study aimed at identifying neighbourhoods and other groups at high risk for overweight and behaviours related to overweight. Details on the study population and data collection are described elsewhere (15). Of all 51 primary schools in the city, 80% (n = 41) agreed to participate. Of the invited parent(s), 65% (n = 5219) gave written informed consent for their children to participate. The Medical Ethics Committee of the VU University Medical Centre approved the ChecKid study.
Measures The measurements were performed during three weeks in October and November 2006. Trained students from the University of Applied Sciences Windesheim measured body height, weight and waist circumference according to the protocol for the national Dutch Growth study in 5035 children (16). Four percent of children were not measured, mostly because of school absence. The children’s body mass index (BMI) cut-off points of Cole et al. (17,18) were used to define overweight and obesity. Due to relatively low prevalence of obesity (1.6%), overweight and obesity were combined in the analyses. The questionnaire for parents included sociodemographic issues and questions about their children’s sleeping habits, diet, physical (in) activity, the home environment and rules. A total of 4257 parents (81%) returned the questionnaire.
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Parental characteristics SES was classified as low (lower general secondary education, lower vocational training and primary school or less), medium (intermediate vocational training, higher general secondary training and preuniversity education) or high (completed higher vocational training and University) based on the highest completed educational level of parents, according to the Statistics Netherlands definition (19). In the questionnaire, parental country of birth was indicated as: ‘the Netherlands’, ‘Turkey’, ‘Morocco’, ‘Surinam’, ‘Netherlands Antilles’ or ‘other country’. A total of 5.4% of the parent(s) were born in an ‘other country’ not further specified. According to the city council, 8.6% are non-western and 6.5% are western immigrants (20). Because in our data, 7.3% of the immigrants were from non-western countries, we have assumed that the 5.4% of parent(s) born in an ‘other country’ were mainly from western origin. Therefore, we dichotomized ethnicity as nonwestern background (one or both parents born in Turkey, Morocco, Surinam, Netherlands Antilles) vs. the rest (15). Parents’ self-reported body weight and height data were used to calculate their BMI. Because most of the mothers filled out the questionnaire for their child, we included maternal overweight in this study and defined it as BMI ≥ 25.0 kg m−2.
Lifestyle nutrition behaviours Parents indicated the frequency (number of week and weekend days) and amount (none, 1, 2 or >2 pieces) of children’s fruit consumption, the frequency of eating vegetables for dinner and the frequency and portions (between 1 and ≥5 portions) of eating sweet candy bars, savoury snacks and crisps of their children. The average pieces/portions of fruit and snacks per day were calculated by multiplying the number of days per week or per weekend the child ate fruit/snacks by the number of portions per day. Weekdays and weekend were combined and divided by the total number days per week. Consumption of fruit was dichotomized according to the recommendations for healthy eating behaviours from the Netherlands nutrition centre as ≥2 (0) and 1 portion per day Home environment (%) Permission to have candy without asking Permission to have crisps and nuts without asking Eating at the table < 7 d per week Eating a takeaway meal ≥ 1 d per week Eating a home cooked meal < 6 d per week Cooking together 0–1 d per week 2–4 d per week 5–7 d per week Doing groceries together 0–1 d per week 2–4 d per week 5–7 d per week
Whole group
Low SES (n = 335)
Medium SES (n = 1330)
High SES (n = 2194)
8.1 (2.3) 11.7 49.2
8.5 (2.4) 20.3 40.0
8.1 (2.3) 12.6 51.4
7.9 (2.3) 9.5 49.1
6.6 29.5
13.5 45.7
8.3 34.0
4.4 24.2
63.4 53.1
63.2 65.0
64.0 62.8
63.0 45.3
84.7 15.3
66.8 33.1
82.1 18.0
89.2 10.8
18.8 11.0 18.1 38.4 11.8
36.9 30.0 28.7 49.2 18.8
22.5 13.3 21.7 44.8 14.2
13.8 6.6 14.2 32.8 9.3
63.9 32.9 3.3
58.6 34.6 6.8
64.6 31.6 3.8
64.2 33.4 2.4
38.8 55.6 5.6
28.0 61.4 10.6
37.7 55.5 6.7
41.2 54.7 4.0
*Including obesity. SD, standard deviation; SES, socioeconomic status.
Table 2 Association between fruit and vegetable consumption and overweight
Fruit < 2 portions per day Vegetables < 7 d per week
Whole group OR (95% CI)†
Low SES (n = 335) OR (95% CI)†
Medium SES (n = 1330) OR (95% CI)†
High SES (n = 2194) OR (95% CI)†
0.82 (0.67–1.00) 1.27 (1.04–1.55)*
1.15 (0.66–2.02) 1.17 (0.66–2.07)
0.93 (0.66–1.31) 1.73 (1.20–2.49)*
0.66 (0.50–0.88)* 0.95 (0.71–1.26)
*P ≤ 0.05; † Adjusted for ethnicity, maternal overweight, gender and age. CI, confidence interval; OR, odds ratio; SES, socioeconomic status.
medium SES group, determinants of not eating vegetables daily are eating at the table less than 7 d per week, eating a takeaway meal one or more days per week, eating a home cooked meal less than 6 d per week and cooking together less than 5 d per week. Additionally, among the medium SES group, permission to take candy without asking is associated with not eating vegetables daily. The association between consuming two or more pieces of fruit and overweight among children with a high SES background might implicate that eating the
recommended two or more pieces of fruit does not automatically mean that children eat less energy dense foods (such as snacks) as suggested in other studies (23,24). Indeed, fruit is high in sugar and calories and fruit consumption could only lead to reduced energy intake if fruit intake is instead of snack intake (25). Our post hoc analyses showed that children eating two or more pieces of fruit did not have a lower snack intake than children who eat less fruit per day. Additionally, the results show that the association between fruit consumption and
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Table 3 Determinants of eating vegetables < 7 d per week Whole group† OR (95% CI)
Permission to take candy without asking Permission to take crisps and nuts without asking Eating at the table < 7 d per week Eating a takeaway meal ≥ 1 d per week Eating a home cooked meal < 6 d per week Cooking together 0–1 d per week 2–4 d per week 5–7 d per week Doing groceries together 0–1 d per week 2–4 d per week 5–7 d per week
Low SES† (n = 335) Medium SES† (n = 1330) High SES† (n = 2194) OR (95% CI) OR (95% CI) OR (95% CI)
1.57 (1.32–1.86)** 1.53 (0.93–2.50)
1.42 (1.06–1.90)*
1.42 (1.09–1.83)*
1.48 (1.19–1.84)** 1.38 (0.79–2.40)
1.24 (0.87–1.76)
1.37 (0.95–1.97)
2.71 (2.27–3.24)** 2.72 (1.54–4.80)*
2.80 (2.05–3.84)**
2.32 (1.79–3.01)**
3.37 (2.93–3.89)** 3.60 (2.22–5.86)**
3.32 (2.58–4.28)**
3.06 (2.55–3.68)**
4.06 (3.20–5.17)** 6.11 (2.56–14.59)** 4.24 (2.75–6.55)**
3.37 (2.44–4.64)**
1 (–) 1 (–) 0.62 (0.53–0.73)** 0.92 (0.53–1.59) 0.64 (0.41–0.99)* 0.33 (0.11–0.94)*
1 (–) 0.58 (0.44–0.76)** 0.80 (0.40–1.56)
1 (–) 0.60 (0.49–0.74)** 0.57 (0.30–1.09)
1 (–) 0.94 (0.81–1.09) 0.76 (0.56–1.04)
1 (–) 0.96 (0.75–1.24) 0.70 (0.43–1.16)
1 (–) 0.91 (0.76–1.10) 0.67 (0.41–1.08)
1 (–) 0.65 (0.34–1.25) 0.52 (0.21–1.30)
*P ≤ 0.05; **P ≤ 0.001. †Adjusted for ethnicity, maternal overweight, gender and age. CI, confidence interval; OR, odds ratio; SES, socioeconomic status.
overweight might be different for the various SES groups. Other studies showing inconsistent associations between fruit consumption and overweight in subgroups (25,26) were potentially suffering from methodological limitations (26) or a different way of operationalizing fruit consumption. Therefore, further research is needed before practical implications can be determined. When confirmed, interventions regarding fruit consumption should take these differences into account. The association between not eating vegetables daily and overweight are in line with most other studies (27). Given the findings in present study, it seems important to stimulate vegetable consumption in all SES groups as it is not only beneficial in prevention of overweight, but also has other favourable effects such as reducing the risk of cardiovascular diseases and certain types of cancer (28,29). However, in intervention programmes, special attention should be given to reach, additionally to low SES groups, medium SES groups as this is a large group and the prevalence of not consuming vegetables daily is equal to that of children with a low SES background. The focus of interventions aimed at stimulating vegetable intake should therefore be expanded from deprived neighbourhoods to middle class neighbourhoods. We identified determinants of vegetable intake in the home environment. The importance of the home environment is confirmed by multiple reviews and studies
© 2014 The Authors Pediatric Obesity © 2014 World Obesity. Pediatric Obesity 10, 134–140
in which it was concluded that the home availability, parental intake and family rules are important determinants of vegetable intake in children and adolescents (5,7,12,13,30). Supplementary to these reviews, this study adds that in families with a low or medium SES background, preventing takeaway meals on a weekly basis and promoting to eat a home cooked meal at the table every day might increase vegetable consumption. In addition, to increase vegetable consumption, it seems important to involve children with the cooking process. To our knowledge, these home environmental determinants were not yet studied within different SES categories.
Strengths and limitations Strength of the present study is the large sample size and the availability of data regarding physical and social home environment and nutritional behaviours. A limitation of this study includes the cross-sectional design, which precludes causal interpretation of the observations. Despite high participation rates, children from low and middle SES families were underrepresented (31). This selective participation could have made observed associations possibly weaker. The use of questionnaires, as in other monitoring studies could have possibly led to issues of social desirability and to difficulties with recalling the actual behaviour of the child in the past month. In addition, vegetable intake was measured only at dinner with
no information on number of portions, as in the Netherlands, vegetables are most commonly eaten at the main evening meal (32). Unfortunately, no data were available on parental modelling and home availability of vegetables, which are important determinants of children’s vegetable consumption. In addition, the age range of children was wide (4–13 years), and although age was controlled for, variables are likely to vary between a 4- and a 13-year-old. However, differences were small between 4–8 and 9–13 year-old children for the behaviours and home environmental variables. In addition, the association between fruit and vegetable consumption did not differ for age. The data used for this study were from 2006. We do not think data regarding fruit and vegetables consumption and the association of the home environmental determinants with these behaviours have changed considerably (33). SES was defined using parental educational level only. Data on other indicators for SES (job position and income) were not available. However, education level of parent(s) correlates with SES overall (based on the three indicators) and is associated with parental knowledge, lifestyle and habits (34). Moreover, in the Netherlands in large population-based studies, educational level is often used as indicator for SES (35).
Conclusion and implications The results show an association between not eating vegetables daily and overweight, especially in children with a medium SES background. The association between fruit consumption and overweight differs in different SES groups and is therefore inconclusive. Further research is needed before practical implications can be determined. Determinants in the home environment are identified that could be targeted to increase the percentage of children that consume vegetables daily. Low or medium SES families should be particularly targeted in interventions as they have a disadvantaged position regarding vegetable intake and determinants that are associated with vegetable consumption. The most promising avenues for intervention seem to be (i) to prevent eating takeaway meals on a weekly basis, (ii) to promote eating a home cooked meal at the table, and (iii) to involve children in the cooking process.
Conflict of Interest Statement No conflict of interest was declared.
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Acknowledgements We would like to thank our partners in this monitoring study: the Zwolle city council, the local health services and several welfare organizations in the city. We are greatly thankful to all the students who helped with the measurements, the participating schools and sponsorships. Also, we want to thank all the children and parents participating in this study.
Authors’ contribution JCS, CMR, RAH and TLSV were responsible for the study design. JCS and CMR supervised the data collection. EdJ was responsible for the statistical analyses and interpretation of the data in agreement with JCS, CMR and TLSV. EdJ wrote the first version of the manuscript and all authors participated in the revisions of the manuscript. All authors hereby confirm that the manuscript is an original piece of research and that they have seen and approved the final version for publication.
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