Systematic review of school and community-based fruit and vegetable interventions for minority children

Figures & data

Figure 1 Flow chart depicting the three phase data extraction process.

Abbreviations: CINAHL, Cumulative Index to Nursing and Allied Health Literature; ERIC, Education Resources Information Center.

Table 1 Summary of school and community-based interventions targeting fruit and vegetable intake in minority children (n=12)

# Program/target population/age of children	Design	Theoretical framework	Intervention groups
1. “Smart Bodies”^Citation44 Tuuri et al Native American children (low-income, urban, public elementary schools in East Baton Rouge Parish, LA, USA) Majority were African American (82%) 68.2%–98.5% of students enrolled in National School Lunch Program Fourth and fifth grade	• RCT	• Social cognitive theory^Citation45	groups pair-matched then randomly assigned to treatment or control Treated: children (n=269) from 7 schools, 44.6% fourth graders, 51.4% fifth graders Control: children (n=291) from 7 schools, 55.4% fourth graders, 48.6% fifth graders
2. “Squire’s Quest!”^Citation46 Cullen et al Native American children (from Houston, TX, USA, area elementary schools) Majority African-American (41.6%) or Hispanic (29.8%) and low-income 65.7% of students in school district eligible for free or reduced price lunches Fourth grade	• Cluster RCT	• Social cognitive theory^Citation45	schools randomly assigned to treatment or control Treatment: children (n=671) from l3 schools Control: children (n=907) from 13 schools
3. “LA Sprouts”^Citation48 Gatto et al Predominantly Latino children (from Los Angeles, CA, USA, area elementary schools) 59.8% were overweight or obese (BMI ≥85th percentile) 94% of student body eligible for free or reduced-price school meals Fourth and fifth grade (age 9-11 years)	• Quasi-experimental pilot study	• Social cognitive theory^Citation45	Treatment: children (n=34) within Los Angeles school district enrolled in after school program (school was in close geographic distance to community garden), 61.4% female Control: students (n=70) were not enrolled in after school program and were invited to participate, abbreviated intervention offered to control participants at completion of program, 41.4% female
4. “Sprouting Healthy Kids”^Citation49 Evans et al Native American children (from five ethnically diverse middle schools in Austin, TX, USA) Majority Hispanic (59%) and low- income (70%) 70% or more of students at school eligible for free or reduced price lunches Sixth and seventh grade	Posttest only control group design Evaluation of baseline data from treatment 1–4 and control groups confirmed groups did not differ significantly on main outcomes at early stage of intervention	• Social cognitive theory^Citation45	Treatment 1–4: children (n=176) received at least 2 components of intervention Control: children (n=70) not exposed to any components
5. Memphis GEMS^Citation50 Klesges et al African-American pre-adolescent females (recruited from community in Memphis, TN, USA) 8-10 years old BMI z-score between 25-35	• RCT	• Social cognitive theory^Citation45	Treatment l and 2: both groups had same number and frequency of sessions (n=303) Treatment l: girls (n=l53) received intervention focused on obesity prevention Treatment 2: girls (n=l50) received intervention focused on building social awareness and community responsibility
Duration/intervention activities	Evaluation measures	Intervention effects
week program measured at baseline and post-intervention Interactive school assemblies Daily classroom activity using teacher- directed materials Classroom curriculum (videos, books, games, and lessons) emphasized Fv consumption	• Fv survey: Fv preferences Social cognitive theory measures related to Fv consumption (selfefficacy, outcome expectations, and social norms) Knowledge of nutrition-related information	increased nutrition knowledge for children in treatment I (P<0.001) Increased self-efficacy to consume fruit, drink juice, eat fruit instead of a favorite dessert/cookies/candy and consume recommended number of FV each day (P<0.001) Decreased preferences in fourth grade students for certain healthy foods (Ρ<0.001), while fifth graders preferences for the same items did not change
session (10-week) program measured baseline and post-intervention Interactive multimedia game days of dietary assessment during two- week baseline prior to program and 4 days of post dietary assessment two weeks after program Each child completed 2 sessions of “Squires Quest!” per week for 5 weeks	FIRSSt^Citation47 FV, and fruit juice preferences Self-efficacy Fruit-juice and vegetable recipe preparation goals	increase in fruit, fruit juice, and vegetable servings was achieved at post assessment (P<0.001) Girls achieved more recipe preparation than boys Hispanic children achieved higher levels of fruit-juice and vegetable recipe preparation Sex (female) (P<0.05), higher baseline vegetable preference (P<0.001), and having a mother with a college education or more (P<0.05) were significant predictors of post-vegetable consumption
12-week program measured baseline and post-intervention (1 week before and 1 week after) 90-minute weekly sessions included: 45-minute cooking and nutritional education lesson, focused on culturally relevant FV 45-minute interactive gardening component taught by master gardener Local farmers market visits 4 times in 12 weeks	BMI z-score Body fat percentage Attitudes, preferences, perceptions and self-efficacy to eat and cook FV Acculturation, Habits, and interests Multicultural Scale for Adolescents Adaption of the Motivation for Healthy Behaving Measure from the Treatment and Self-Regulation Questionnaire School Engagement Questionnaire	improvements preferences for vegetables overall (P=0.06), but not fruits 2.1-point (16%) increase in preference for vegetables overall among overweight and obese subgroups (P=0.009) 3.9-point increase in preference for vegetables overall among female participants (P<0.05) Treatment 1 was 54% more likely to report that “vegetables from the garden taste better than vegetables from the store” (P<0.05) Treatment 1 showed a greater change in perceptions that cooking is easy (P<0.001) and gardening is easy (P<0.05) Treatment 1 participants showed increase in self-efficacy from preintervention to post-intervention Reductions in weight among treatment 1 participants were associated with increased preference for vegetables (P=0.09) and fiber from fruit (P=0.08)
month program measured postintervention In-class lessons Cafeteria component (farm-to-school) Farmer visits component Taste-testing component After-school component Field trip to farms	Student SHK Questionnaire: Motivation for eating Fv, preferences for Fv and unhealthy foods, self-efficacy for eating FV, and cognitive knowledge F&v Food Frequency Questionnaire	Higher scores on knowledge measure at posttest (P=0.02) and marginally lower on preference for unhealthy foods (P=0.07) Students exposed to more than 2 components of program scored significantly higher on FVI, self-efficacy and knowledge (P<0.05) and significantly lower on preference for unhealthy foods scale (P<0.01) Farmers visit intervention had largest treatment effect on participants Fvi (0.52 servings/day increase) Fvi increased by 0.352 servings for every additional component of intervention exposure (P<0.01)
year program with baseline, 1 year follow-up and 2 year follow-up visits weekly meetings for 14 weeks followed by monthly meetings for 20 months (34 sessions in 2 years) Each session lasted 90-minutes 2nd year interventions transitioned into monthly field trips within community	BMi z-score at 2-years post intervention waist circumference Accelerometer Triceps skinfold thickness Bioelectrical impedance Sexual maturation 24-hour dietary recall on 3 nonconsecutive days	increase in mean daily vegetable intake among girls in treatment 1 compared with treatment 2 (P=0.03) No differences in BMi z-score or any other anthropometric measures between treatments 1 and 2 at 1-year and 2-year follow up All girls reported increases in mean intake of sweetened beverages, but treatment 1 group had 0.19 fewer servings per day than treatment 2 at 2-year visit (P=0.08) Treatment 1 group reported increased water consumption from baseline and at 2 years had 0.21 more servings per day than treatment 2 (P=0.02) PA did not differ significantly between the 2 groups at either 1-year or 2-year follow-up visit
6. Somerville et al study^Citation51 Native American children (active participants in Boys and Girls Club gardening program in Pomona, CA, USA) Majority were Hispanic (83%) 6-12 years old	• One group pretest - posttest design	• Social cognitive theory^Citation45	• Treatment: children (n=40) received intervention
7. “Every Day, Lots of Ways”^Citation52 Blom-Hoffman et al African-American students attending an under-resourced urban school (in northeastern USA) 95% of students at school received free breakfast and lunch Kindergarten and first grade	• RCT	• Social learning theory^Citation45	Treatment 1: students (n=91), from three randomly assigned classrooms WLC: students from three randomly assigned kindergarten and first grade classrooms received entire program after posttest was completed with treatment 1
8. Students and Parents Actively Involved in Being Fit^Citation53 Engels et al African-American students and their parents/guardians at an urban middle school in after-school intervention, USA Children ages 11.1±1.3 years; adults ages 40.6±7.7 years	• One group pretest - posttest design	• No reported theoretical framework	• Treatment: children (n=56) and parents/guardians (n=25) received entire intervention
9. Go Girls^Citation54 Resnicow et al African-American adolescent females predominantly middle socioeconomic status churches in USA 12-15 years old (mean age 14 years) BMI z-score above 90th percentile for age and sex Parents invited to attend every other session	• RCT	• Social cognitive theory^Citation45	Treatment 1: High intensity culturally tailored behavioral group intervention (n=5 churches) Treatment 2: Moderate intensity culturally tailored behavioral group intervention (n=5 churches), served as comparison group girls completed baseline, 123 completed 6-month follow-up, 107 completed 1-year follow-up
10. One Body, One Life^Citation55 Towey et al Children and adults from local schools and community groups (in Coventry, UK) Ethnically diverse families from deprived areas in Coventry (77% from two most deprived quintiles) One or more member of the family is underweight, overweight, or obese Children 7-16 years, must be accompanied by adult	• One group pretest - posttest design	• No reported theoretical framework	• Treatment 1: children (n=221) and adults/caregivers (n=137) received entire intervention
month program measured at baseline and post-intervention Weekly one-hour session for 13 weeks Snack preparation activities Blind taste testing Apple stamping Produce Pictionary Fruit and Veggie Bingo Snack preparation for staff and family members	BMI z-score Daily Fv intake Snack preferences	Increased fruit and vegetable servings consumed daily (P<0.05) Self-reported scores for daily fruit servings increased from 2.23±4.18 to 4.13±2.16 Self-reported scores for daily vegetable servings increased from 2.17± 1.82 to 3.07±1.87 Upward trends shown in Fv snack preference Average number of Fv servings increased, average number of chip servings decreased
5-week program measured at baseline, post-intervention, and l-month follow-up lessons (2 per week) addressing 5-A-Day goal Classroom-based knowledge change component Lunchtime-based behavioral change component Home component 12-week program measured at baseline and post-intervention days each week, 60-75 minutes per session Supervised dance Sport games Fitness activities Step pedometers Nutrition learning activities	Knowledge vegetable Eating Behaviors based on visual estimates of plate waste, rated according to Comstock Scale^Citation2 Treatment Integrity Checks Treatment Acceptability Measures CIRP^Citation3 BMI z-score Daily FVI with brief food frequency research questions Step counts Body fat Resting heart rate and blood pressure Fitness run/walk test	Increased nutrition knowledge for treatment l at posttest compared with WLC (P<0.00l) No differences between knowledge scores for treatment l at posttest and l-month follow-up Significant increase in knowledge scores for WLC at posttest relative to pretest scores (P<0.00l) No significant change in treatment 1 vegetable consumption from pre- to post-intervention and post-intervention rates were similar to those of WLC Significant decreases in BMI z scores (P=0.002), body fat percentage (P=0.004), resting diastolic blood pressure (P=0.03l), and walk/run time (P=0.007) in parents/guardians Significant decreases in resting systolic blood pressure (P<0.00l) and resting diastolic blood pressure (P<0.00l) in children Increase in fruit consumption in parents/guardians and children Improvements in fruit juice, salad, and nonfried potato consumption in children Children gained more diet-related benefits while parents/ guardians gained more fitness-related benefits
month program measured at baseline, 6-month post-intervention, and l-year post-intervention (only anthropometric measures, BP, and shuttle test) 20-26 sessions for treatment 1, 6 sessions for treatment 2 Experiential behavioral activity Approximately 30 minutes of PA Preparation and tasting of healthy foods Treatment l received 4-6 telephone counseling calls	BMI z-score Waist and hip circumference Body fat percentage Serum insulin Glucose Lipids Cardiovascular fitness Overall perception of program and intervention elements	No significant difference in BMI z-score at 6-month follow-up between treatments l and 2 No significant group differences in secondary outcomes Girls in treatment l who attended more than three-quarters of the sessions had significantly lower BMI z-score (2.2 units difference, P=0.01), weight (10.1 pounds difference, P=0.07) and body fat percentage (2.5% difference, P=0.01) compared with girls in same group who attended fewer sessions waist and hip circumferences of girls in treatment l who attended more than three quarters of the sessions were also significantly lower than those who attended less frequently (P<0.05)
10-12 week program measured at baseline and post-intervention weekly 90-minute sessions Healthy eating workshop (45 minutes) PA workshop (45 minutes)	BMI z-score Body fat percentage Total body water Visceral fat Healthy eating knowledge quiz Eating behaviors - 24 hour recall PA – previous week recall	Number of participants consuming 5 or more Fv a day increased from 21% to 33%, with an increase of 0.57 portions (P<0.001) for children and 0.76 portions (P<0.001) for adults Significant reduction in amount of chips, crisps, sweets, and fizzy drinks consumed per day for children of 0.32 portions (P=0.002) and 0.34 portions for adults (P=0.01) Decrease in fast food consumption, although not significant for children (P=0.08), but was significant for parents (P<0.001) Significant changes in knowledge, activity, and FV portions per day were found in both children and adults (P<0.001)
11. Aventuras Para Ninos^Citation56 Crespo et al Latino parents and their children (in San Diego, CA, USA) Families had no major health problems and lived within school attendance boundaries Kindergarten through second grade	• Cluster RCT (13 schools randomized to 1 of 4 conditions, n=808)	• Health belief model,^Citation57 social cognitive theory^Citation45	Treatment 1: 3 schools (n=198) received individual/family level (family-only) Treatment 2: 3 schools (n=218) received school/community level (community-only) Treatment 3: 3 schools (n=165) received combined (family and community) Control: 4 schools (n=227) received no intervention
Duration/intervention activities	Evaluation measures	Intervention effects
3-year program measured during 2003-2004 school year, at baseline 1-year follow-up, and 2-year follow-up Treatment 1: home visits, newsletters, recipe cards, goal setting, booster phone calls, goal setting Treatment 2: school playgrounds, salad bars, community parks, teachers’ discipline and classroom practices, physical education equipment, menus at restaurants, posters, newsletters, frequent produce buyer cards in grocery stores Treatment 3: combination of treatments 1 and 2 Delivered by lay health educators (Promotoras)	BMI z-score Height weight Parental proxy-report assessed parent and child PA, screen time and nutrition behaviors	No significant intervention effects on children’s BMI z-score Proportion of children classified as obese (≥95th percentile weight for age) increased in all except treatment 1 at final measurement No significant intervention effects on parent BMI or BMI category Significant increase in parent-reported child physical activity, reduced child frequency of watching television when getting ready for school, increased child’s daily consumption of Fv, and increased behavioral strategies for fat Parental monitoring of children’s eating and activity and parent support for PA significantly mediated consumption of FV, family viewing of television during dinner, child PA, and less child viewing television while getting ready for school

Abbreviations: WLC, waitlist control; RCT, randomized controlled trial; BMI, body mass index; BP, blood pressure; n, sample size after attrition; FV, fruit and vegetables; FVI, fruit and vegetable intake; PA, physical activity; FIRSSt, Food Intake Recording Software System; CIRP, Children’s Intervention Rating Profile; GEMS, Girls’ health Enrichment Multi-site Study.

Tuuri G, Zanovec M, Silverman L, et al. “Smart Bodies” school wellness program increased children’s knowledge of healthy nutrition practices and self-efficacy to consume fruit and vegetables. Appetite. 2009;52:445–451.

 Web of Science ®Google Scholar

Bandura A. Health promotion by social cognitive means. Health Educ Behav. 2004;31:143–164.

 PubMed Web of Science ®Google Scholar

Cullen KW, Watson KB, Zakeri I, Baranowski T, Baranowski JH. Achieving fruit, juice, and vegetable recipe preparation goals influences consumption by 4th grade students. Int J Behav Nutr Phys Activ. 2007;4:28.

 Web of Science ®Google Scholar

Gatto NM, Ventura EE, Cook LT, Gyllenhammer LE, Davis JN. LA Sprouts: a garden-based nutrition intervention pilot program influences motivation and preference for fruits and vegetables in Latino youth. J Acad Nutr Diet. 2012;112:913–920.

 PubMed Web of Science ®Google Scholar

Evans A, Ranjit N, Rutledge R, et al. Multiple components of a garden-based intervention for middle school students increases fruit and vegetable consumption. Health Promot Pract. 2012;13:608–616.

 PubMedGoogle Scholar

Klesges RC, Obarzanek E, Kumanyika S, et al. The Memphis Girls’ health Enrichment Multi-site Studies (GEMS): an evaluation of the efficacy of a 2-year obesity prevention program in African-American girls. Arch Pediatr Adolesc Med. 2010;164:1007–1014.

 PubMedGoogle Scholar

Baranowski T, Baranowski J, Cullen KW. The Food Intake Recording Software System (FIRSSt): validation against 24-hour dietary recalls. J Am Diet Assoc. 2002;102:380–385.

 PubMed Web of Science ®Google Scholar

Somerville M, Kessler LA, Wallace SP, Burns-Whitmore B. The effect of a garden-based nutrition education program on the consumption of fruits and vegetables by Hispanic children. Calif J Health Promot. 2012;10:20–25.

 Google Scholar

Blom-Hoffman J, Kelleher C, Power TJ, Leff SS. Promoting healthy food consumption among young children: evaluation of a multi-component nutrition education program. J School Psychol. 2004;42:45–60.

 Web of Science ®Google Scholar

Engels HJ, Gretebeck RJ, Gretebeck KA, Jimenez L. Promoting healthful diets and exercise: efficacy of a 12-week after-school program in urban African Americans. J Am Diet Assoc. 2005;105:455–459.

 PubMed Web of Science ®Google Scholar

Resnicow K, Taylor R, Baskin M, McCarty F. Results of Go Girls: A weight control program for overweight African-American adolescent females. Obes Res. 2005;13:1739–1748.

 PubMedGoogle Scholar

Towey M, Harrell R, Lee B. Evaluation of “One Body, One Life”: A community-based family intervention for the prevention of obesity in children. Available from: http://www.hindawi.com/journals/jobe/2011/619643/. Accessed June 6, 2014.

 Google Scholar

Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999–2004. JAMA. 2006;295:1549–1555.

 PubMed Web of Science ®Google Scholar

Troiano RP, Flegal KM, Kuczmarski RJ, Campbell SM, Johnson CL. Overweight prevalence and trends for children and adolescents: the National Health and Nutrition Examination Surveys, 1963 to 1991. Arch Pediatr Adolesc Med. 1995;149:1085–1091.

 PubMed Web of Science ®Google Scholar

Crespo N, Elder JP, Ayala CX, et al. Results of a multi-level intervention to prevent and control childhood obesity among Latino children: the Aventuras Para Niños Study. Ann Behav Med. 2012;43:84–100.

 PubMed Web of Science ®Google Scholar

Rosenstock I. Historical origins of the health belief model. Health Educ Behav. 1974;2:328–335.

 Web of Science ®Google Scholar