Abstract
Objective:
To describe fruit and vegetable (FV) consumption as snacks and the association with diet quality, and to compare the snacking environment, and child and parent characteristics between children who consumed FV as snacks and those who did not.
Methods:
This secondary analysis study used baseline data from a healthy weight management study with 8- to 12-year-old children with a body mass index ≥75th percentile. Data collection included 24-hour dietary recalls, measured height/weight and child and parent surveys.
Results:
Children (n=119) consumed 0.1 cup-equivalents per 1,000 kcal of FV as snacks, the equivalent of 16.9% of their daily FV consumption. More FV consumption as snacks occurred at home when a parent was present and was associated with higher parent support for FV consumption as snacks (p = .03).
Conclusions and Implications:
Renewed attention to strategies to promote FV consumption as snacks, especially at away-from-home locations is merited.
Keywords: Fruit, Vegetables, Snacks, Child, Body Mass Index
INTRODUCTION
Consumption of fruits and vegetables (FV) is associated with many health benefits, including a reduction in long-term risk of obesity.1 However, FV consumption is low among school-aged children with approximately 0.5 cup-equivalents per 1,000 calories.2 To increase FV consumption, the 2015–2020 Dietary Guidelines for Americans recommend offering FV as snacks3 (defined as an eating occasion occurring outside regular meals).4 This dietary recommendation may be particularly beneficial for children with a body mass index (BMI) at or above the 75th percentile because they have an increased risk for excess weight gain during preadolescence.5,6
FV is not a common snack choice for children.7 In order to support behavior change that aligns with the dietary recommendations, it is critical to identify factors associated with children’s FV consumption as a snack. Previous research indicates children of parents who serve FV as snacks, or role-model consuming fruit as snacks, report higher FV consumption.7,8 These findings are consistent with the Social Support Theory9 and highlight the importance of parent support for children’s FV consumption as snacks. Better understanding of children’s snacking environment, including location and presence of parents and others while eating occurs, in addition to the level of parent support for FV consumption as snacks, may inform interventions to increase parent support for children’s FV consumption as snacks.
The aims of the current study were to (a) describe the practice of consuming FV as snacks among 8- to 12-year-old children with a BMI at or above the 75th percentile by identifying the proportion of daily FV consumed as snacks versus as part of a meal, (b) examine the associations between FV consumption as snacks and total daily FV consumption and diet quality, and (c) compare children who consumed FV as snacks and those who did not by select child and parent characteristics and time, location and others present during a snacking occasion.
METHODS
Study Design
This secondary analysis study used baseline data from the Student Nurses and Parents Seeking Healthy Options Together (SNAPSHOT) study, a community-based randomized controlled obesity prevention trial in the St. Paul/Minneapolis, Minnesota metropolitan area.10
Participants
The SNAPSHOT study recruited 132 parent-child dyads from 1 urban school district with 43 elementary schools and 1 suburban school district with 10 elementary schools and 1 parochial school. Recruitment methods included flyers, school and district website announcements, in-person presentations at school events and general mailing. Eligible children were 8 to 12 years old (3rd to 5th grades) with a BMI at or above the 75th percentile, calculated using child height and weight reported by parent, school nurse or health care provider. Other eligibility criteria included child and parent English literacy, participation of a parent/guardian with whom the child lived most of the time, no plans to move outside of the school district within the next 12 months, and no food allergies, no physical limitations, medical, and/or emotional health conditions that would limit the child’s ability to participate in physical and group activities with other children.
Data Collection Procedures
During the summers of 2014 through 2017, parents and children provided written informed consent and assent to a team of trained research staff who collected baseline data, including measured height and weight, and parent and child surveys. Trained research staff also conducted 2 24-hour dietary recall interviews by phone with children (1 on a weekday and 1 on a weekend day), with parental assistance if necessary. Data were entered into the Nutrition Data System for Research (NDSR) software versions 2014 through 2017 with final calculations completed with NDSR version 2017. Among the sample, 90% (n=119) completed dietary recall interviews (n=107 completed 2 and n=12 completed 1). Children also wore an accelerometer as part of data collection, but this was not used in the current analyses. Each parent and child received a $75 and a $50 retail gift card, respectively, for their data collection participation. Additional details about the study design and measurement protocols are published elsewhere.10 The Institutional Review Boards of the University of Minnesota and Temple University approved the study protocols.
Measures
As part of the dietary recall interview and per the NDSR protocol, children self-identified an eating occasion as either a meal or a snack. Research staff requested time of day and location of snacking episodes, defined as home, work, school, daycare, deli/take-out/store, fast food restaurants/cafeteria, friends’ home, community meal program, party/reception/sporting event, traveling, and other. If the snacking episode occurred at home, the child reported whether parents, siblings, extended family members or friends were present (yes or no) and whether the child used a media device including a television, computer, tablet or phone while snacking (yes or no). Children’s daily FV consumption for all eating occasions and snacks were estimated in cup-equivalents per 1,000 kcal by summing the cup-equivalents of FV consumed at the daily level or only as snacks, dividing each by daily caloric intake and multiplying by 1,000 to account for calories consumed.2 The estimation of FV consumption for all eating occasions and snacks included all fresh, frozen, canned and dried fruits; dark-green vegetables; red and orange vegetables; starchy vegetables; other vegetables; and cooked dried beans (legumes) and excluded fried fruits/vegetables, such as fried potatoes and 100% fruits/vegetable juices, due to high fat and sugar content.11 Child diet quality was assessed using the Healthy Eating Index (HEI)-2015 score. The HEI-2015 scores range from 0 to 100, with 100 meeting the 2015–2020 Dietary Guidelines for Americans.12 FV consumption for all eating occasions and snacks and the HEI-2015 scores were calculated by using the average values of 2 dietary recalls when available.
Parent and child demographic information obtained via parent survey included age (in years calculated using date of birth), sex (female versus male), race/ethnicity (white that included non-Hispanic white versus non-white that included Hispanic or Latino/Latina, Black/African American, Asian, American Indian/Alaskan Native, more than one race and other), and receipt of public assistance such as the Supplemental Nutrition Assistance Program or free-reduced priced lunches (no versus yes to one or both). Child height and weight were measured using a standardized protocol13 to calculate BMI percentile based on the 2000 CDC growth charts.14 Six items on the child survey that addressed children’s FV consumption as a snack, adapted from a previous study,15 were summed to create a score that represented parent support for child’s FV consumption. Survey items included: “My parents eat fruit for a snack”, “My parents eat vegetables for a snack”, “My parents try to get me to eat fruit for a snack”, “My parents try to get me to eat vegetables for a snack”, “In my home, there is fruit ready for me to have as a snack”, and “In my home, there are vegetables ready for me to have as a snack”. Response options for each item were almost never (0), sometimes (1) and almost always (2). Responses were summed (range: 0–12), with a higher score indicating higher parental support of child’s FV consumption as a snack. The Cronbach’s alpha was 0.72.
Data Analysis
Descriptive statistics were provided for study participant characteristics and children’s FV consumption. The associations between FV consumption as a snack and overall daily FV consumption as well as HEI-2015 score were examined using general linear modeling (PROC GLM) after controlling for receipt of public assistance, child race and sex. These covariates were included based on prior literature2 and an association with the outcome variable. FV consumption as snacks was dichotomized as none versus any for further analyses due to a non-normal distribution. Bivariate analyses including chi-square (χ2) tests of independence and t-tests were used to identify the differences in FV consumption as snacks by time of day (morning, afternoon, evening and night), location (home versus other), presence of parent, siblings, friends, extended families, or eating alone during a snacking occasion (yes versus no), screen use (yes versus no), and child and parent characteristics. A priori P value used for significance was 0.05. All analyses were performed using SAS software version 9.3 (SAS Institute Inc., Cary, NC, USA).
RESULTS
Average child age was 9.3 (SD = 0.9) years, 49% were girls, 60% non-white, and 50% with obesity (BMI at or above the 95th percentile). Parent mean age was 39.6 (SD = 7.1) years. Most parents (93%) were female; 56% reported receiving public assistance.
On average, children reported 1.4 snacking episodes per day (standard deviation = 0.8, median = 1.5, range = 0 – 3.5). Among children who reported a snacking episode(s), 18% consumed vegetables, 45% fruits, and 48% fruits and vegetables. The average daily consumption of FV as a snack was 0.1 cup-equivalents per 1,000 kcal with snacks making up 16.9% of total daily FV consumption (See Table 1). The mean HEI-2015 score was 49.7 (SD 13.1). Consuming fruits and vegetables as a snack was positively associated with overall daily FV consumption (β = 1.3, SE = 0.2, P < .001) and HEI-2015 score (β = 11.2, SE = 3.3, P = .001). Compared to snacking episodes that did not include FV, more snacking episodes with any FV consumption occurred at home (73% vs. 58%, P = .02) and when a parent was present (69% vs. 47%, P = .004, See Table 2). Places children consumed a snack without FV included camping, pool/park and movies (12%), friend’s home (10%), transportation vehicles such as cars, bus and train (9%), party/reception/sporting event (5%), and fast food restaurants/cafeteria (4%). Children who consumed FV as a snack reported higher parent support for child’s FV consumption than those who did not consume FV as snacks (7.7 ± 2.4 vs. 6.6 ± 2.9, P = .03; see Table 3).
Table 1.
Mean Intake and Proportion of Fruit and Vegetable Consumption as a Snack among 8- to 12-Year-Old Children with a Body Mass Index at or above the 75th Percentile (n=119)
| Mean | SD | Median | Min | Max | |
|---|---|---|---|---|---|
| Fruits | |||||
| Overall consumption (cup-equivalent serving per 1,000 kcal) | 0.3 | 0.3 | 0.2 | 0 | 1.3 |
| Snack consumption (cup-equivalent serving per 1,000 kcal) | 0.1 | 0.2 | 0 | 0 | 1.1 |
| Proportion of snack consumption to overall consumption (%) | 29.3 | 38.8 | 0 | 0 | 100 |
| Vegetables | |||||
| Overall consumption (cup-equivalent serving per 1,000 kcal) | 0.4 | 0.4 | 0.3 | 0 | 2.2 |
| Snack consumption (cup-equivalent serving per 1,000 kcal) | 0.03 | 0.1 | 0 | 0 | 0.9 |
| Proportion of snack consumption to overall consumption (%) | 5.0 | 14.6 | 0 | 0 | 89.3 |
| Fruits and Vegetables | |||||
| Overall consumption (cup-equivalent serving per 1,000 kcal) | 0.7 | 0.6 | 0.6 | 0 | 3.3 |
| Snack consumption (cup-equivalent serving per 1,000 kcal) | 0.1 | 0.3 | 0 | 0 | 2.0 |
| Proportion of snack consumption to overall consumption (%) | 16.9 | 23.3 | 0 | 0 | 95.3 |
Footnotes. SD = Standard Deviation, Min = Minimum, Max = Maximum.
Fruits and vegetables included fruits, dark-green vegetables, red and orange vegetables, starchy vegetables, other vegetables, cooked dried beans (legumes) and excluded fried fruits/vegetables, such as fried potatoes and 100% fruit/vegetable juices.
Children’s daily fruit and vegetable consumption for all eating occasions and snacks were estimated in cup-equivalents per 1,000 kcal by summing the cup-equivalents of FV consumed at the daily level or only as snacks, dividing each by daily caloric intake and multiplying by 1,000 to account for calories consumed.
Table 2.
Episodes of Consuming Fruits and Vegetables as Snacks (n=324), by Time of Day, Location, Presence of Others, and Screen Use among 8- to 12-Year-Old Children
| Characteristic | Fruit and vegetable consumption as snacks | ||
|---|---|---|---|
| None (n=236) | Any (n=88) | P-value for χ2 | |
| n (%)a | |||
| Time | .07 | ||
| Morning (6:00:00–11:59:59am) | 30 (13%) | 21 (24%) | |
| Afternoon (12:00:00–16:59:59pm) | 97 (41%) | 27 (31%) | |
| Evening (17:00:00–19:59:59pm) | 49 (21%) | 16 (18%) | |
| Night (20:00:00pm – 05:59:59am) | 60 (25%) | 24 (27%) | |
| Location | .02 | ||
| Home | 137 (58%) | 64 (73%) | |
| Otherb | 99 (42%) | 24 (27%) | |
| Presence of parent when snacking at home | .004 | ||
| No | 73 (53%) | 20 (31%) | |
| Yes | 64 (47%) | 44 (69%) | |
| Presence of siblings when snacking at home | .64 | ||
| No | 70 (51%) | 35 (55%) | |
| Yes | 67 (49%) | 29 (45%) | |
| Presence of friends when snacking at home | .06 | ||
| No | 128 (93%) | 64 (100%) | |
| Yes | 9 (7%) | 0 (0%) | |
| Presence of extended families when snacking at home | |||
| No | 121 (88%) | 55 (86%) | .63 |
| Yes | 16 (12%) | 9 (14%) | |
| Alone when snacking at home | |||
| No | 103 (75%) | 52 (81%) | .34 |
| Yes | 34 (25%) | 12 (19%) | |
| Screen use when snacking at home | |||
| No | 63 (47%) | 33 (52%) | .45 |
| Yes | 72 (53%) | 30 48%) | |
Footnotes. Chi-square (χ2) tests of independence were used.
% refers to percent of snacking episodes with or without fruit and vegetable consumption by each characteristic.
Other includes work, school, daycare, deli/take-out/store, fast food restaurants/cafeteria, friends’ home, community meal program, party/reception/sporting event, traveling, and other such as camping, pool/park and movies.
Table 3.
Child and Parent Characteristics by Fruits and Vegetable Consumption as a Snack (n=119)
| Characteristic | Fruit and vegetable consumption as snacks | ||
|---|---|---|---|
| None (n=62) | Any (n=57) | P-value | |
| n (%) | |||
| Child sex | .94 | ||
| Female (n=58) | 30 (48%) | 28 (49%) | |
| Male (n=61) | 32 (52%) | 29 (51%) | |
| Child Race/Ethnicity | .46 | ||
| Non-white (n=71) a | 35 (56%) | 36 (63%) | |
| White (n=48)b | 27 (44%) | 21 (37%) | |
| Parent Race/Ethnicity | .19 | ||
| Non-white (n=47) a | 21 (34%) | 26 (46%) | |
| White (n=72)b | 41 (66%) | 31 (54%) | |
| Receipt of Public Assistance | .69 | ||
| No (n=52) | 26 (42%) | 26 (46%) | |
| Yes (n=67) | 36 (58%) | 31 (54%) | |
| Mean (SD) | |||
| Child age | 9.3 (0.8) | 9.3 (1.0) | .99 |
| Parent age | 38.3 (7.1) | 40.9 (7.0) | .04 |
| Child BMIc z-score | 1.7 (0.6) | 1.5 (0.7) | .24 |
| Child BMIc percentile | 92.4 (9.3) | 89.6 (10.2) | .13 |
| Parent supportd | 6.6 (2.9) | 7.7 (2.4) | .03 |
Footnotes.
Non-white included Hispanic or Latino/Latina, Black/African American, Asian, American Indian/Alaskan Native, more than one race and other.
White refers to non-Hispanic white.
BMI = Body Mass Index
Parent support was measured by summing responses (0–2) to six items on the child survey that addressed children’s FV consumption as a snack. The response ranges from 0 to 12, with a higher score indicating higher parental support of their child’s FV consumption as a snack.
Chi-square (χ2) tests of independence were used for child sex, race/ethnicity, and receipt of public assistance and t-tests were used for age, BMI z-score, BMI percentile and parent support.
DISCUSSION
Initiatives to increase consumption of FV are not new but outcomes are inconsistent.3 Current findings expand the research literature by describing the consumption of FV as snacks among 8- to 12-year-old children with BMI at or above the 75th percentile, a population who may benefit from increased FV intake to prevent excess weight gain.5,6 The number of snacks reported by our sample is comparable to similar aged children (1–3 snacks per day).16 However, only 16.9% of total daily FV intake was as snacks, with more fruits than vegetables consumed. This finding reflects children’s general FV consumption patterns and preference of fruits over vegetables,2 with vegetables more likely consumed with meals than as a snack.7 Encouraging children’s FV consumption as snacks may lead to an increase in overall FV intake and a reduction in consumption of unhealthy snacks such as soda, candy and potato chips.17 Given the contribution of unhealthy snacks to excess weight gain18 and increasing rates of severe childhood obesity,19 renewed attention to promoting FV as snacks, with an emphasis on vegetables, particularly among children with BMI at or above the 75th percentile, is warranted.
Children in the current study, which included one-half with obesity reported FV consumption below the recommended amount of 2 cup-equivalents per 1,000 kcal3 as well as the mean FV intake among children aged 6 to 11 years old (about 1 cup-equivalent per 1,000 kcal).2 The HEI-2015 total score was lower than that of a national sample of children aged 2 to 18 years old (54.9).20 Research suggests that FV consumption among children with overweight/obesity is about half that of children with normal weight,21 with diet quality inversely associated with weight status.22 Promoting FV consumption at meals in addition to snacks may result in increased FV intake, particularly for children with elevated BMI.
Study strengths included an assessment of FV consumption at a variety of eating occasions, dietary data collection using high-quality recall interviews, objective height and weight measurements to calculate child BMI percentile, and the sample’s racial and socioeconomic diversity. Limitations included the small study sample recruited for a healthy-weight management intervention study. Children in the current study had a BMI at or above the 75th percentile, which limits generalizability to other child populations, including children with BMI below the 75th percentile. Data were collected only during summer months. FV intake and parent support for FV consumption as snacks were measured by parent-report and child report, respectively. However, 24-hour dietary recall is the gold standard of dietary intake assessment23 and the parent support scale showed acceptable reliability in the current study. Lastly, the findings do not indicate causal associations due to the cross-sectional study design.
IMPLICATIONS FOR RESEARCH AND PRACTICE
The current study supports the importance of renewed attention to strategies that promote parent support of children’s FV consumption, including providing fruits, and particularly vegetables, as snack options. FV consumed as snacks mostly occurred at home versus school, daycare, or a friend’s home. Although data collection during summer may have contributed to this finding, previous research also supports that children consume more FV at home than away-from-home locations.24 However, preadolescent children will spend more time away from home as their independence increases and life boundaries expand. Foods that are readily available away from home are often energy-dense and nutrient poor.25 Strategies to modify away-from-home food environments to increase access and availability to FV deserve attention. Lastly, increasing child self-efficacy to choose healthy snacks when less healthy food options are available merits reconsideration, as does re-engagement with existing nutrition education programs. For example, a school-based program that emphasizes making healthy snacks might use FV provided through the U. S. Department of Agriculture’s Fresh Fruit and Vegetable Program26 or the Smart Snacks in Schools Program.27
Acknowledgements:
Research study reported in this manuscript was supported by the National Institute of Nursing Research under Award Number R01NR013473 (M.Y. Kubik, PI, the SNAPSHOT study, National Clinical Trial number NCT02029976) of the National Institutes of Health (NIH). This research was also supported by the National Institutes of Health’s National Center for Advancing Translational Sciences, grants KL2TR002492 and UL1TR002494. The content is solely the responsibility of the authors and does not necessarily represent the views of the NIH. There are no conflicts of interest to disclose.
Footnotes
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Contributor Information
Jiwoo Lee, School of Nursing, University of Minnesota, 308 Harvard St. SE. Minneapolis, MN 55455, Telephone: 612-624-5198, Fax: 612-626-6606.
Martha Y. Kubik, School of Nursing, George Mason University, 4400 University Drive, Fairfax, Virginia 22030, Telephone: 703-993-1961.
Jayne A. Fulkerson, School of Nursing, University of Minnesota, Telephone: 612-624-4823, Fax: 612-626-6606.
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