Research BriefChildren’s Daily Fruit and Vegetable Intake: Associationswith Maternal Intake and Child Weight StatusPaige Miller, MPH, PhD1; Rene�e H. Moore, PhD2; Tanja V. E. Kral, PhD2

1Cancer Pr2DepartmeAddress foDisorders,3rd Floor,tkral@mai�2011 SOdoi:10.1016

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ABSTRACT

Objective: To evaluate associations between children’s and their mothers’ fruit and vegetable (FV) intakeand children’s FV intake and weight status.Methods: Mothers (n ¼ 39) residing in Philadelphia, PA completed a subsection of the Diet HistoryQuestionnaire assessing their FV intake. Mothers also completed this questionnaire to estimate FV intakeamong their 5- or 6-year-old children (n ¼ 39). Children’s height and weight were measured. Pearsoncorrelation, Student t tests, and binary logistic regression analyses were performed.Results: A significant positive mother-child association was found for FV intake (P< .001). Overweight/obese children consumed fewer FVs than normal-weight children (P ¼ .02).Conclusions and Implications: Efforts to promote FV consumption in mothers may help childrenachieve the recommended intake of FVs. Higher intakes of FVs in turn may help with child weightmanagement.Key Words: fruits, vegetables, mothers, children, obesity (J Nutr Educ Behav. 2011;43:396-400.)

INTRODUCTION

Given the high prevalence of child-hood obesity, it is crucial to identifydietary strategies to moderate energyintake in children at risk for develop-ing obesity. Fruits and vegetables(FVs) are an important part ofchildren’s diets, since they provide es-sential nutrients, including folate,vitamin A, vitamin C, calcium, iron,magnesium, potassium, and fiber1;they alsomay play a role in the regula-tion of energy intake.2 Fruits and veg-etables are high in water and fiber, butlow in energy density (kcal/g), foodproperties that have been shown toenhance satiety in adults.2

Increased consumption of FVs hasbeen shown to decrease short-termenergy intake in children3 and helpreduce body weight in overweightand obese children and their parentsin family-based behavioral weight-control programs.4,5 However, itremains unclear whether FVconsumption alone may have an

evention Fellowship Program, Nationt of Psychiatry, University of Pennr correspondence: Tanja V. E. KrPerelman School of Medicine, UnPhiladelphia, PA 19104; Phone: (21l.med.upenn.eduCIETY FOR NUTRITION EDUC/j.jneb.2010.10.003

impact on adiposity or whetherother behaviors (eg, lower intake ofenergy-dense food, changes in physi-cal activity) may partially mediatethe relationship observed betweenFV intake and weight status.6

Despite the high nutritional valueof FVs, data from a nationally repre-sentative, cross-sectional study indi-cate that fewer than 10% of children4-8 years of age consume the numberof servings of FVs recommended bythe Dietary Guidelines for Ameri-cans.7 Children from low-income,food-insufficient households and mi-nority children are at increased riskfor inadequate FV consumption,8,9

which may be attributable to limitedaccess to FVs.

Aspects in the early home food envi-ronment, including increased FVacces-sibility and availability,10 have beenshown to positively influence intakeof FVs in children.11 In addition, thereis evidence for maternal influences onchild eating behavior via modelingand child feeding practices,12-14 but

nal Cancer Institute, Bethesda, MDsylvania, Philadelphia, PAal, PhD, Center for Weight and Eatingiversity of Pennsylvania, 3535 Market St,5) 746-4237; Fax: (215) 898-2878; E-mail:

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the extent to which children resembletheir mothers in intakes of FVsremains to be determined. Theprimary aim of this research was toexamine whether the dailyconsumption of FVs among boys andgirls aged 5 and 6 years was associatedwith their mothers’ FV intake. Asecondary aim was to determinewhether children’s daily FV intake wasrelated to their weight status.

METHODSResearch Design andParticipants

Children in this study were partici-pants in a study that examined the ef-fects of doubling the portion size of 3FV side dishes at a meal on children’senergy intake.15 The sample for thissubstudy consisted of 19 boys and20 girls and their mothers living inPhiladelphia. Children were requiredto be 5 or 6 years of age, have a bodymass index (BMI)-for-age > 5th per-centile, and like most food items thatwere served in the experimental study(ie, pasta and tomato sauce, broccoli,carrots, applesauce, milk). Childrenwere excluded from the study if theyhad serious medical conditionsknown to affect food intake andbody weight; developmental, medi-cal, or psychiatric conditions thatmight influence study compliance;

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food allergies; and/or were takingmedications known to affect food in-take or body weight. Details aboutsubject recruitment, remuneration,taste preference assessment, and thenumber of subjects excluded fromthe study based on low preference rat-ings for the experimental food itemswere provided previously.15 The studywas approved by the InstitutionalReview Board of the University ofPennsylvania.

Assessment of Daily FV Intake

A 34-item subsection of the DietHistory Questionnaire, a validatedfood frequency questionnaire devel-oped by the National Cancer Insti-tute,16 was administered to themother of each child participant.Mothers were queried about theirusual intake and portion size of fruits(13 questions) and vegetables (21questions) over the previous 12months. The questionnaire assessedmothers’ and children’s intake of thefollowing fruit items: applesauce; ap-ples; pears; bananas; dried fruit;peaches, nectarines, or plums; grapes;cantaloupe; other melon; straw-berries; oranges, tangerines, or tange-los; grapefruit; and other kinds offruit. The remaining 21 questionswere related to intake of the followingvegetables: cooked greens; raw greens;coleslaw; sauerkraut or cabbage; car-rots; string beans or green beans;peas; corn; broccoli; cauliflower orBrussels sprouts; mixed vegetables;sweet peppers; fresh tomatoes; lettucesalads; sweet potatoes or yams; frenchfries, homes fries, hash browned pota-toes, or tater tots; baked, boiled, ormashed potatoes; cooked dried beans;and other kinds of vegetables.Mothers selected from 10 frequencycategories that ranged from never to$ 2 times per day for each fruit or veg-etable and from 9 frequency cate-gories that ranged from never to $ 6times per day for 100% juice. Follow-ing completion of the questionnaireassessing their own consumptionhabits, mothers completed the samequestionnaire estimating their child’sFV intake.

Data from the completed question-naires were analyzed with the nutri-ent and food group analysis softwareDiet*Calc (version 1.4.3, National

Cancer Institute, Applied ResearchProgram, Bethesda, MD, 2005). In-takes of total FVs in servings per daywere generated based on the Pyramidservings.17 One serving equals ½ cupof cooked vegetables, 1 cup of leafygreen vegetables, 1 small piece offruit, or ½ cup of sliced fruit. Adher-ence to the recommendations for FVintake was considered achieved ifmothers consumed a minimum of 4servings of fruit (ages 19-30 years) or3 servings of fruit (ages 31-50 years)and 5 servings of vegetables (ages19-50 years) per day and childrenconsumed a minimum of 2 servingsof fruit (age 5) or 3 servings of fruit(age 6) and 3 servings of vegetables(age 5) or 5 servings of vegetables(age 6) per day, respectively.17

Anthropometric Assessment

Children’s and mothers’ height andweight were measured by a trainedstaff member. Weight was measuredon a digital scale (Tanita, BWB-800,Arlington Heights, IL, 2001), accurateto 0.1 kg, and standing height wasmeasured on a Harpenden Stadiome-ter (Holtain Ltd, Crosswell, UK,2001), accurate to 0.1 cm. All mea-surements were taken with subjectswearing light clothing and no shoes.Body mass index (weight [kg] / height[m2]) percentiles and z scores for chil-dren were calculated withage- and sex-specific reference data.18

Children were classified as normal-weight (BMI-for-age 5th-84thpercentile), overweight (BMI-for-age85th-94th percentile), or obese (BMI-for-age $ 95th percentile) accordingto the Centers for Disease Controland Prevention growth referencestandards.18 Mothers were classifiedas normal-weight (BMI 18.5-24.9kg/m2), overweight (BMI 25.0-29.9kg/m2), or obese (BMI $ 30 kg/m2).19

Statistical Analysis

To examine mother-child relation-ships in FV intake (Aim 1), continuousdata were analyzed using Pearsoncorrelation analysis. The authorsidentified 2 mother-child pairs whoqualified as statistical outliers or ex-treme values ($ 1.5 � interquartilerange) with respect to FV intake; out-comes did not change when outliers

were removed from the correlationanalysis. Children’s and mothers’ FVconsumption was converted intoa binomial variable, which dichoto-mized participants into those whomet and did notmeet the Pyramid rec-ommendations for FVs. To examinechild weight status in relation tochildren’s FV intake (Aim 2), Studentt tests were used to compare FV intakebetween normal-weight (BMI-for-age5th-84th percentile) and overweight/obese (BMI-for-age $ 85th percentile)children. Data are presented as means� SEM unless otherwise indicated.Odds ratios (ORs) and 95% confidenceintervals (CIs) were estimated by bi-nary logistic regression to determinewhether children’s FV intake pre-dicted their weight status (0 ¼ normalweight, 1 ¼ overweight/obese).Reported P values are 2-sided, andP < .05 was considered significantfor all tests. All statistical analyseswere performed with SAS, version 9.2(SAS Institute, Inc., Cary, NC, 2008).

RESULTS

Maternal and child sociodemographicand anthropometric characteristicsare depicted in the Table. The major-ity of the children (74%) were AfricanAmerican. Nearly one-half (46%) ofthe mothers were single mothers,and close to 40% of all mothers re-ported a household income of lessthan $25,000. Eighty-three percentof mothers and 36% of children wereconsidered overweight or obese.

Mean intakes of fruits and vegeta-bles for children were 2.7 � 0.4 serv-ings/d and 3.4 � 0.5 servings/d;mean intakes of fruits and vegetablesfor mothers were 2.7 � 0.4 servings/d and 5.2 � 0.7 servings/d. Only41% of children and 26% of mothersmet the recommendations for fruit;similarly, only 39% of children and41% of mothers met the recommen-dations for vegetables. There was nosignificant difference between boysand girls in the number of servingsconsumed of fruit (2.7 � 0.6 vs 2.7 �0.5 servings/d; P¼ .97) and vegetables(3.2 � 0.8 vs 3.5 � 0.5 servings/d;P ¼ .77), respectively.

There was a significant positive asso-ciationbetweenmothers’ FV intake andtheir children’s FV intake (r¼ 0.85, P<.001). This association remained

Table. Demographic and Weight Characteristics of Mothers and Children

Mothers (n ¼ 39) Children (n ¼ 39)Age, y, mean (� SD) 35.2 � 6.7 5.8 � 0.6Race, n (%)a

African American 31 (80) 29 (74)Caucasian 5 (13) 5 (13)Multiracial 2 (5) 5 (13)

Marital status, n (%)b

Single 18 (46) —Married 13 (33) —Divorced, separated, or widowed 7 (18) —

College degree or above, % yes, n (%) 20 (51)Household income, n (%)< $25,000 15 (39) —$25,000-$50,000 13 (33) —> $50,000 11 (28) —

BMI, kg/m2, mean (� SD) 32.6 � 8.4 16.9 � 2.5BMI z score, mean (� SD) — 0.69 � 1.1Weight status, n (%)Normal-weight 7 (18) 25 (64)Overweight 8 (21) 8 (21)Obese 24 (62) 6 (15)

BMI indicates body mass index; —, not applicable.aMissing race for 1 mother; bMissing marital status data for 1 mother.

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significant (r¼ 0.67, P< .001) when re-moving 2 mother-child pairs from theanalysis whose FV intakes were identi-fied as outliers or extreme values.

Overweight/obese children con-sumed significantly fewer servings ofFVs compared to normal-weight chil-dren (4.0 � 0.5 vs 7.2 � 1.1 servings/d; P ¼ .02; Figure), and only 1 (7%)of the overweight/obese children,compared to 9 (36%) of the normal-weight children, met the recommen-dations for FVs. Results from thelogistic regression analysis showedthat the OR of being overweight/

0

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4

6

8

10

No rm al -w ei ght

FV

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ta

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Figure. Mean (� SEM) daily intake (servingweight (n ¼ 25) and overweight/obese (n ¼

obese was 7.3 times higher forchildren who did not meet the recom-mendations for FVs as compared tochildren who met the recommenda-tions (P ¼ .08). This finding, however,was not statistically significant. Theresults were similarly not significantwhen adjusting the model for house-hold income (OR: 7.6; P ¼ .07).

DISCUSSION

The main finding from this study wasthat children’s daily consumption of

Fruits

Vegetables

O ver we i ght /O be se

*

s/d) of fruits and vegetables for normal-14) children.

FVs was closely related to theirmothers’ consumption patterns ofFVs. Overweight and obese children,on average, consumed 3 fewer serv-ings of FVs per day. This study extendsprevious studies in 2 important ways.First, it provides estimates of habitualconsumption of FVs in an urban sam-ple of mothers and their childrenfrom a low-income, minority popula-tion. Second, these data provide an es-timate of the strength of theassociation between young children’shabitual FV intake and their weightstatus.

The present findings are in agree-ment with data from previous studiesthat report similarities between mater-nal and child diets.13,20 Mothers caninfluence their children’s eatingbehavior in several ways. First, theyserve as important role models fortheir children,12,13 and they cansignificantly influence food acceptancepatterns.21 Watching a model (eg,mother) eat an initiallydislikedornovelfood itemcanenhance foodpreferencesin children.22,23 Second, mothers oftendecide which food items are madeavailable to their children in theirhome; easy access to FVs may providechildren with more opportunities totry new food items on repeatoccasions. Multiple exposures to thetaste of novel food items cansignificantly reduce neophobia inchildren and thereby increase foodacceptance.21 Finally, the use of certainfeeding practices can help shape chil-dren’s eating behavior. For example,Fisher and colleagues demonstratedthat 5-year-old girls who received moreparental pressure to eat had lower FVintakes.13

The majority of children and theirmothers in this study did not meetcurrent recommendations for FVs,which is consistent with findingsfrom a nationally representativestudy.7 Evidence suggests that indi-viduals of higher socioeconomicstatus tend to consume diets of higherquality, whereas those of lower socio-economic status tend to consumelower-quality diets that are higher inenergy density and lower in nutrientdensity.24,25 The disparity in energycost ($/kcal) between energy-denseand nutrient-dense food (ie,nutrient-dense food such as leanmeats, fish, and fresh FVs cost morethan energy-dense food) in

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conjunction with limited access tohealthful food may help explain theseassociations.26 In the present study,nearly 50% of mothers were singleparents and close to 40% indicatedhousehold incomes of less than$25,000. Limited financial meansand limited access to fresh FVs mayhave prevented many families in thecurrent study from acquiring moreFVs for their households.

Another important finding wasthat children who ate fewer daily serv-ings of FVs had a significantly higherBMI than those who ate more FVs.Increased FV intake may moderatechildren’s energy intake by displacingintake of more energy-dense food.Findings from the main experimentwith this cohort of children indicatedthat doubling the amount of 3 FV sidedishes at a meal significantlyincreased children’s intake of the fruitside dish by 43%, whereas decreasingtheir intake from the entr�ee (pastadish) for which the portion size re-mained constant.15 Similarly, a studyin 3- to 5-year-old children showedthat lowering the energy density ofa mixed pasta dish by 25% by addingmore vegetables and reducing the fatcontent significantly decreasedenergy intake from the lunch entr�eeby 25% (63 kcal) and total energyintake at lunch by 17% (61 kcal) andincreased vegetable intake by a halfserving.27 Hence, increased consump-tion of FVs can lower children’s short-term energy intake, which in turnmay moderate weight gain inchildren. By targeting increases inFVs, children may learn to substitutemore-healthful food for less-healthful alternatives, and thesemore-healthful, less energy-densefood items may positively affectsatiety.28

Given the increased risk for obesityand inadequate FV consumptionamong minority populations,7 it is ofgreat importance to examine dietaryintake patterns in minority children.Therefore, the large percentage ofAfrican American children (74%) isa strength of this study. The studyalso had several limitations. Sincethe children were not randomlyselected and included children wholiked study-related FVs (broccoli, car-rots, and applesauce), the results maynot be generalizeable to otherchildren and it is possible that daily

FV intake may be even lower amongamore random sample of children, in-cluding those who are picky eaters.The use of self-reported intake of FVsis an additional limitation of the pres-ent study. Also, no food models wereincluded to help mothers estimateportion sizes of FVs. Abbreviated fre-quency questionnaires targeting onlyFVsmayoverestimate intake as a resultof the social desirability of increasedFV intake.29 Finally, because of thecross-sectional nature of the study,directionality of the findings betweenFV intake and child weight status or inrelation to children’s weight trajecto-ries cannot be concluded.

IMPLICATIONS FORRESEARCH ANDPRACTICE

The results from this study providefurther evidence for an importantmother-child relationship in dietaryintake with a focus on FV consump-tion. These results suggest that effortsto increase child FV consumptionshould be extended beyond the levelof the individual child to parentsand families; interventions targetingincreased FV intake in children mayhave a greater impact if FVs are avail-able in the home and are consumedby mothers or other family membersin the household. Moreover, interven-tions targeting FV consumption mayhelp children learn to substitute FVsfor more energy-dense food, whichin turn may have a protective effectagainst excessive child weight gain.

ACKNOWLEDGMENTS

This study was conducted at the Uni-versity of Pennsylvania. This researchwas supported by a grant from TheObesity Society, which the seniorinvestigator (TVEK) received as partof a New Investigator Research Award.

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