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Mary Imogene Bassett Research Institute, (B.A.D., H.L.R., S.L.B.) Bassett Healthcare, Cooperstown, New York
Department of Pediatrics, (B.A.D.) College of Physicians and Surgeons Columbia University, New York, New York
Address reprint requests to: B.A. Dennison, MD, Mary Imogene Bassett Research Institute, One Atwell Road, Cooperstown, NY 13326-1394
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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Objective: To determine, in a sample of healthy children, the extent to which young children’s diets include the recommended numbers of fruit and vegetable servings per day.
Design: Cross-sectional study.
Setting: A general primary care health center in upstate New York.
Participants: One-hundred-sixteen 2-year-old children and 107 5-year-old children, who were scheduled for a non-acute visit, and their parent/primary caretaker (PPC) were recruited between 1992 and 1993.
Measurements: For 168 children (94 2-year-old children and 74 5-year-old children), mean dietary intakes were calculated from 7 days of written dietary records, entered and analyzed using the Minnesota Nutrition Data System. The numbers of fruit and vegetable servings/day were calculated according to USDA definitions of serving sizes.
Results: The 2-year-old children consumed the same amounts of fruits, 100% fruit juice, and total fruits and vegetables as the 5-year-old children (0.8 and 0.7 fruit servings/day, 1.0 and 0.8 juice servings/day, and 2.2 and 2.1 total fruit and vegetable servings/day, respectively). Fruit juice accounted for 54% of all fruit servings consumed and 42% of all fruit and vegetable servings consumed. Total fruit consumption (fruits plus juice) was correlated with carbohydrate intake (R=0.46), and inversely correlated with total fat and saturated fat intakes (R=-0.48 and R=-0.36, respectively, both p<0.0001) and with cholesterol intake (R=-0.21, p<0.01). Citrus fruit and juice consumption was strongly correlated with vitamin C intake (R=0.56, p<0.0001). Total vegetable consumption was strongly correlated with beta-carotene and vitamin A intakes (R=0.63 and R=0.32, respectively, both p<0.0001). Total fruit and vegetable consumption correlated with intakes of beta-carotene, vitamin A, vitamin C, fiber, and potassium (R=0.55, R=0.31, R=0.56, R=0.58, and R=0.66, respectively, all p<0.0001). Forty percent of 2-year-old children and 50% of 5-year-old children consumed <2 servings/day of fruits and vegetables. Ninety-five percent of children consuming 
2 servings/day of fruits and vegetables met the RDA for vitamin C vs. 50% of those consuming <2 servings/day (p<0.001).
Conclusions: In this study, preschool-aged children consumed, on average, about 80% of the recommended fruit servings/day, but only 25% of the recommended vegetable servings/day. Low intakes of fruits and vegetables were associated with inadequate intakes of vitamin A, vitamin C, and dietary fiber, in addition to high intakes of total fat and saturated fat.
Key words: child nutrition, fruits, vegetables, fruit juice, diet, vitamins, nutrition policy, fiber
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INTRODUCTION |
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The Food Guide Pyramid, developed by the US Department of Agriculture (USDA) and the US Department of Health and Human Services, depicts graphically the recommended balance among food groups in a daily eating pattern [7]. The pyramid recommends 2 to 4 servings/day of fruits and 3 to 5 servings/day of vegetables, depending on one’s total caloric intake. The smaller number of servings/day is for people who consume about 1600 kcal/day, while the larger number of servings/day is for those who consume about 2800 kcal/day. Therefore, most Americans should consume a minimum of 2 servings/day of fruits and 3 servings/day of vegetables; thus, giving rise to the slogan "5-A-DAY" (i.e., 2+3=5 servings/day of fruits and vegetables). To promote increased public awareness of the importance of fruits and vegetables to the diet and to encourage increased consumption of fruits and vegetables, in 1991 the National Cancer Institute and the Produce for Better Health Foundation developed the national "5-A-Day for Better Health" campaign [8].
The purpose of this study was to determine, in a sample of healthy children, the extent to which young children’s diets included the recommended number of servings/day of "5-A-DAY" fruits and vegetables. The relationship between fruit and vegetable consumption and overall dietary quality was also examined.
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METHODS |
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Dietary Intake Assessment
The child’s PPC was given detailed instructions by a research nutritionist in how to complete a written, consecutive, 7-day dietary record for this child. Measuring cups, measuring spoons, rulers, and a Kids Food Portion Booklet were distributed to improve estimation of portion sizes. PPC were given a postage-paid, pre-addressed envelope to return the dietary record. PPC were called twice to remind them to mail in the dietary record. Dietary data were reviewed by a registered dietitian. All dietary data were entered by an experienced research nutritionist. Nutrient calculation was performed using the Nutrition Data System (NDS) software (Nutrition Coordinating Center, University of Minnesota, MN; program version 2.3; food data base version 5A; nutrient data base version 20). Very few children were reported to be regularly taking supplemental vitamins. As the focus of this study was on nutrient intakes from fruits and vegetables, contributions from supplemental vitamins were not included in the nutrient calculations.
Calculation of Fruit and Vegetable Consumption
The child’s daily consumption of fruits, fruit juice, and vegetables were determined using the standard serving size definitions according to the USDA guidelines presented in the Food Guide Pyramid [7]. One-half cup of fresh, frozen, or canned fruit, or one-quarter cup of dried fruit was equal to one serving of fruit. Three-fourths of a cup (6 fl oz) of 100% fruit juice or vegetable juice was equal to one fruit or one vegetable serving, respectively. Fruit drinks and/or juice blends that were not 100% fruit juice were not included in calculating fruit servings. One-half cup of cooked or raw vegetables or one cup of leafy raw vegetables was equal to one serving of vegetables. In the initial analyses, serving sizes were calculated the same for all children; in the later analyses, serving sizes for the 2-year-old children were reduced by one-third.
According to the USDA guidelines, some foods fit into more than one category. These crossover foods can be counted as servings from either one or the other group, but not both [7]. Legumes (dry beans, peas, and lentils) may be placed with either the vegetable food group or included with the meat group. As most American children consume very few legumes, it usually makes little difference how they are classified. Potatoes may either be classified as a vegetable or counted as a starch and included in the grain family. Potatoes are frequently eaten, so their classification does make a difference. While, most nutrition experts agree that potato chips should not be counted as a vegetable as they contain too much fat, there is no consensus on french fries or other fried vegetables [7]. The Food Guide Pyramid considers french fries to be a "vegetable plus added fat," whereas french fries do not meet the criterion for inclusion in the National Cancer Institute "5-A-DAY for Better Health" program. In some studies, fried vegetables are counted as vegetables, while in other studies they are not included. Thus, we tallied legumes separately and potatoes separately; one-half cup was equal to one serving.
Children’s Anthropometric Measurements
The children’s height, in stocking feet, was measured to the nearest 0.05 cm using a Harpenden Stadiometer (Cambridge, MD). The child, lightly clad and in stocking feet, was weighed to the nearest 0.25 pound using a standard balance beam scale. Body mass index (BMI) was calculated as BMI=weight (kg)/height (m)2.
Questionnaire Data
Demographic data and information concerning lifestyle behaviors and dietary habits were collected from the child’s PPC by an experienced interviewer. All questionnaire data were dual-entered and verified before being entered into a Statistical Analysis System (SAS) data set (SAS Institute, Cary, NC: Version 6.08).
Statistical Analysis
After the dietary data were entered and analyzed using the NDS computer software system, the daily intakes of each nutrient were calculated and transferred as an ASCII file directly into a SAS data set. The 7-day mean nutrient intakes and 7-day mean numbers of servings/day of fruits, fruit juice, vegetables, potatoes, and legumes were determined and used in all analyses.
The Recommended Dietary Allowance (RDA) for vitamin C for children, aged 1 through 3 years is 40 mg/day, and for children, aged 4 through 6 years, is 45 mg/day [9]. The RDA for vitamin A for children, aged 1 through 3 years, is 400 mg/day, and for those, aged 4 through 6 years, is 500 mg/day. For vitamin intakes, an adequate dietary intake was defined as 100% RDA for age, a marginal intake was defined as 67% but <100% RDA for age, and an inadequate intake was defined as <67% RDA for age [10]. An adequate fiber intake was defined as 0.5 g/kg according to the recommendations of the American Academy of Pediatrics (AAP), Committee on Nutrition; an inadequate fiber intake was defined as <0.5 g/kg [11].
Chi-square tests or Fisher’s exact tests were used to compare dichotomous variables. Student’s t-tests were used to compare continuous variables. Spearman correlation analysis was used to determine the relationship between the number of servings/day of fruits and vegetables consumed and the dietary intakes of selected macronutrients, vitamins, and minerals. Unless otherwise indicated, all statistical tests were 2-sided. All statistical analyses were conducted using the SAS software package on an ALPHA computing system.
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RESULTS |
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Forty percent of the 2-year-old children and 50% of the 5-year-old children consumed less than two servings/day of fruits and vegetables (Fig. 2). Vitamin C intake was most strongly correlated with consumption of citrus fruits and citrus fruit juices (R=0.69, p<0.0001). Non-citrus fruit juice was also significantly correlated with vitamin C intake, reflecting both natural vitamin C and vitamin C-fortification (R=0.24, p<0.01). Vitamin C intake also correlated significantly with total consumption of fruits and vegetables (R=0.56, p<0.0001). Ninety-five percent of children consuming two or more servings/day of fruits and vegetables met the RDA for vitamin C compared to only 50% of children consuming less than two servings/day of fruits and vegetables (Fig. 3, p<0.001). Children eating less than 2 servings/day of fruits and vegetables were three times as likely to not meet the RDA for vitamin A compared to those consuming 2 servings/day (23% vs. 8%, p<0.05). Dietary fiber intakes also correlated significantly with total fruit and vegetable consumption (Fig. 4, p<0.005).
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DISCUSSION |
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The children in this study consumed 1.8 total fruit servings/day (0.9 servings/day of fruits and 0.9 servings/day of fruit juice), which is very similar to the 1.5 to 1.6 total fruit servings/day consumed by the preschool-aged children in the Continuing Survey of Food Intakes in Individuals (CSFII: 1989–1991) [14,15]. Munoz et al reported that 32% of children, aged 2 through 5 years, consumed two servings/day of fruits [15]. After reducing the serving sizes for the younger children by one-third (as was done in the paper by Munoz, et al), 63% of the 2-year-old children and 35% of the 5-year-old children consumed 2 servings/day of fruits. After similarly reducing the vegetable serving size for the 2-year-old children (and including potatoes and legumes), we found that only 3% of the 2-year-old children and none of the 5-year-old children consumed 3 servings/day of vegetables over a 1-week period. These percentages are significantly less than the 21% of children in the CSFII Study reported to be eating 3 or more vegetable servings/day, over a 3-day period [15]. While the children in this study consumed fewer vegetables than reported in other studies, strict comparisons are difficult. In the CSFII study, the children, aged 2 through 5 years, consumed, on average, 0.9 servings/day of vegetables plus 1.1 servings/day of starchy vegetables, which included french fries, other fried vegetables, and vegetables with added fat. Furthermore, the number of days of dietary data collected and the dietary assessment methodologies differed in the two studies.
Fruit juice plays a larger role in children’s diets than adult’s diets. Children, especially young children, consume more servings and a greater percent of total calories from fruit juice, but fewer servings and calories from vegetables than adults. In this study, as in others, fruit juice contributed about 50% of the total fruit servings consumed by the children compared to 35% in adults’ diets; fruit juice also contributed 33–42% of the total fruit and vegetable servings consumed by these children vs. 9% in adults’ diets [14,16,17]. Given children’s innate preference for sweet foods [18], it is not surprising that some children might consume relatively large amounts of fruit juice. Excess fruit juice consumption has been associated with diarrhea, growth failure, and short stature in some children, while in other children, excess juice intake has been associated with obesity [19,20,21].
The majority of adults, like most children, do not consume the recommended number of fruit and vegetable servings/day. In this study, over a 1-week period, no child ate the recommended 2 fruit servings/day plus 3 vegetable servings/day; in the CSFII Study, over a 3-day period, only 1% of children met the five food group recommendations listed in the Food Guide Pyramid. A study in 1985 reported that adult women consumed, on average 2.5 servings/day of fruits and vegetables [22], while a more recent study of adults (CSFII: 1989–1991), reported the average intake of fruits and vegetables (including fried vegetables, potatoes, and fruits and vegetables consumed as any part of a mixed dish) was 4.3 servings/day [17]. Whether this represents a real increase in fruit and vegetable consumption or is due to methodological changes in how the dietary intakes were determined is not clear. Only 12% of adults surveyed, however, consumed the recommended 2 fruit servings/day and 3 vegetable servings/day.
In some studies the variety and amount of fruits and vegetables consumed by children and adults increased with increasing income, while starchy vegetables showed the opposite trend [14,17,23]. Our only income indicator was WIC participation; we did not see a difference in fruit or vegetable intake by WIC participation. In a study of school-aged children, higher income parents were more likely to report preparing raw fruits and vegetables for children’s snacks (i.e., cutting up fruits and vegetables into small pieces), while children from lower income groups were responsible more often for preparing their own snacks and meals [24].
The most powerful negative predictor of fruit and vegetable intake by lower income individuals is the reported higher costs of foods perceived to be healthy [25]. In this study, the low-income parents often reported that the high cost, or perceived high cost, of fresh fruits and vegetables was a major barrier to their buying more fruits and vegetables. Several parents reported she/he could not afford to buy bananas (or grapes or some other fruit) because his/her children would "eat them too quickly" and they would not last. Despite the perception that fruits and vegetables are "too expensive," meats consume 30% of the US food dollar, compared to only 8% spent on fruits and 7% spent on vegetables [26]. Among adults, beliefs in the health benefits of fruits and vegetables were also related to consumption of fruits and vegetables [25].
For preschool-aged children, the AAP Committee on Nutrition recommendation for dietary fiber (0.5 g/kg/day) is very similar to the American Health Foundation recommendation (age plus 5 g/day) [27]. For the average 2-year old child, the two recommendations are 6.9 vs. 7 g/day, and for the average 5-year-old child, the two recommendations are 9.9 vs. 10 g/day, respectively. Intakes of fruits, vegetables, and total fruits and vegetables were strongly correlated with dietary fiber intake, with minimal contributions by fruit juices, which contain very little dietary fiber.
Higher intakes of fruit (including fruit juices) were associated with reduced intakes of dietary total fat, saturated fatty acids, and cholesterol. In a national study, children meeting the USDA recommended intakes for fruits had significantly lower intakes of total fat [15]. In a dietary intervention study with children, aged 4 through 10 years, those who had the greatest reductions in their total fat intakes made a number of dietary changes, including increased consumption of fruits and vegetables [28].
Eating habits begin to form early in life [29], with preference for sweetened beverages being present even in neonates [18]. Preschool-aged children’s food preferences are best explained by sweet taste and exposure [30]. Their vegetable preferences are best explained by exposure. They prefer and were best able to identify vegetables frequently served in their homes or at their day care centers [31]. Among adults, habits, such as "eating lots of fruits and vegetables" during childhood was a significant positive predictor of their current fruit and vegetable intake [32]. Parents and increasingly day care providers play an important role, both as role models and gatekeepers of the foods available, in influencing what children eat [33].
Serving vegetables several times a day (i.e., for snacks, lunch, and dinner) and serving more than one vegetable at a time are ways to increase children’s consumption of vegetables. Encouraging parents and day care providers to not only offer a variety of fruits and vegetables, but to also model eating them is probably one of the best ways to increase children’s fruit and vegetable consumption. The emphasis should be on variety, lest over-zealous parents or day care providers increase any particular fruit, fruit juice, or vegetable to the exclusion of providing a well-balanced diet. There is a place for moderation and common sense in modifying children’s current diets to achieve better dietary balance and dietary intakes more consistent with the Food Guide Pyramid [7].
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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Received July 1, 1997. Accepted February 1, 1998.
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REFERENCES |
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  T. A. Nicklas, C. E. O'Neil, and R. Kleinman Association Between 100% Juice Consumption and Nutrient Intake and Weight of Children Aged 2 to 11 Years Arch Pediatr Adolesc Med, June 1, 2008; 162(6): 557 - 565. [Abstract] [Full Text] [PDF]
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