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Patterns in Child and Adolescent Consumption of Fruit and Vegetables: Effects of Gender and Ethnicity across Four Sites

AMC Cancer Research Center, Lakewood, Colorado (K.D.R.)
The University of Texas—MD Anderson Cancer Center (T.B.)
Minnesota Department of Health (D.B.B.), New Orleans, Louisiana
Tulane School of Public Health and Tropical Medicine, New Orleans, Louisiana (R.P.F., T.A.N.)
University of Minnesota (P.J.E.)
University of Alabama at Birmingham (D.B.)

Address reprint requests to: Kim D. Reynolds, PhD, AMC Cancer Research Center, Center for Behavioral Research, 1600 Pierce Street, Lakewood, Colorado 80214.

	ABSTRACT

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION REFERENCES

 
Objectives: Few studies have examined the association of gender and ethnicity with fruit and vegetable consumption. We examined these associations using baseline data from four school-based sites funded under the National Cancer Institute’s 5 A Day for Better Health Program.

Methods: Diet was measured using 24-hour recalls at three sites and seven-day food records at one site. Demographics were obtained via self-report or school records. Regression analyses for clustered data were employed with fruit and vegetables combined and fruit and vegetables separately.

Results: Girls ate more fruit, more vegetables and more fruit and vegetables combined than boys at the Georgia site. Ethnicity was significant in two sites: In Georgia, African-Americans ate more fruit and more fruit and vegetables combined than European-Americans; in Minnesota, Asian-American/Pacific Islanders and African-Americans ate more fruit than European-Americans, and European-Americans and African-Americans ate more vegetables than Asian-Americans. No significant effects were found at the Alabama or Louisiana sites.

Conclusions: Ethnicity was related to fruit and vegetable consumption in Georgia and Minnesota. Consistent with prior studies, gender was related to fruit and vegetable consumption, with girls consuming more servings than boys; however, this was observed at one site only, Georgia. Consumption levels were similar to national estimates for children and varied by region. Further studies are needed using a single methodology to facilitate regional comparisons.

Key words: diet survey, child nutrition, demographics, fruit, vegetables

	INTRODUCTION

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Higher levels of fruit and vegetable consumption are protective against heart disease and several cancers [1–5]. As a result, national dietary guidelines have recommended consumption of at least five servings of fruit and vegetables every day [6]. These guidelines have been applied to youth because chronic disease has been detected at the earliest ages [7], cancers have long developmental periods, risk factors for chronic disease are elevated among some children and track from childhood into the adult years [8,9], risk related behaviors track from childhood into the adult years [10] and childhood may be the easiest time to learn healthier life style behaviors [11], thereby minimizing risk in the earliest years and providing the behaviors and skills to minimize risk in the adult years [11,12].

Several studies have examined the association of gender with the consumption of fruit and vegetables [15–20]. According to the Continuing Survey of Food Intakes by Individuals [15], among children ages 2 to 18 years, consumption of fruit and vegetables was 3.5 servings per day with consumption increasing in older males (4.3 servings per day), but remaining the same among females regardless of age. In a national sample, girls 6 to 11 years old ate more vitamin C containing fruit and vegetables than boys, but no gender differences were obtained for total fruit and vegetables or Vitamin A containing fruit and vegetables [16]. Girls 12 to 17 years old were eating more total fruit and vegetables, but boys were eating more vitamin A containing fruit and vegetables. In a study conducted in Scotland, boys ate slightly more potatoes, while girls ate more salads, raw vegetables and fruit. No differences were reported for root vegetables, cooked green vegetables, peas or beans, or fruit juice [17]. A sample of 3,285 low income children in the United Kingdom, aged 10 to 11 and 14 to 15, showed that boys ate more servings of beans and potatoes, excluding chips, in both age groups than girls, while girls consumed more servings of fruit [18]. Gender differences were more pronounced in the older children for each of these food items. A study conducted in Augusta Georgia revealed no relationship of gender with the consumption of fruit and vegetables [19,20]. In a survey administered to American-Indian and Alaska-Native youth, females were less likely to report low intakes of fruit and vegetables [21].

Fewer studies have examined the relationship between ethnicity and fruit and vegetable consumption. Data from the Continuing Survey of Food Intakes by Individuals show that children in the Other ethnicity category consumed the highest number of servings of fruit and vegetables per day with African-Americans and European-Americans eating the next highest number and Hispanics the fewest servings [15]. Data from a national sample indicated that among 6 to 11 years olds, European-American children ate more total fruit and vegetables than African-American children, but African-American children were eating more vitamin A and vitamin C containing fruit and vegetables [16]. Among 12 to 17 year olds, European-American children were still eating more total fruit and vegetables, but there were no ethnic differences in the other categories. In sum, European-Americans may consume more servings per day of fruit and vegetables, but the data are scant, and more detailed conclusions cannot be drawn from the literature.

One study identified an interaction between gender and ethnicity, as well as between gender and age, in the consumption of fruit and vegetables [13]. In this national sample, the grams of vegetable consumption increased among boys as they grew from 6 to 11 years to 12 to 19 years, but not among girls. Six to 11 year-old African-American girls ate more grams of vegetables than European-American girls, with no differences observed among boys, whereas 12 to 19 year-old African-American boys ate more grams of vegetables than European-American boys with no differences among girls. Fruit consumption declined among boys and girls as they grew from 6 to 11 years to 12 to 19 years, but more so among the girls. Girls ate more fruit than boys at 6 to 11 years of age.

In sum, the effects of gender on consumption are complex with a tendency for girls to consume more total servings of fruit and vegetables and more fruit and salads, while boys may consume more potatoes. Little data are available on ethnic differences, and the studies do not clearly indicate higher consumption within one ethnic group.

This study examines the association of fruit and vegetable consumption with gender and ethnicity and improves on prior research efforts by using: a) data from the four school sites in the National Cancer Institute funded 5 A Day Program, b) a shared definition of fruit and vegetables and c) a parallel analysis strategy to aid in the interpretation of findings across sites.

	METHODS

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The "5 A Day" Initiative
In 1991, the National Cancer Institute initiated the National 5 A Day for Better Health Program to encourage Americans to eat five or more servings of fruit and vegetables every day [22]. The initiative is being conducted in collaboration with the Produce for Better Health Foundation, a nonprofit foundation representing the fruit and vegetable industry. The initiative includes media, retailer and community-based research components. In the community-based research component, nine sites developed and evaluated interventions to increase fruit and vegetable consumption in specific channels (for example, at worksites and in schools). The four school-based sites included Alabama, Georgia, Louisiana, and Minnesota.

Participants
The number of participants used in the analysis included Alabama (n=1169), Georgia (n=1481), Louisiana (n=608), and Minnesota (n=500). Age, gender and ethnicity distributions are presented in Table 1. Elementary schools were sampled at all sites except in Louisiana when high schools were sampled. Students were assessed within each school with the samples mostly European-American and African-American. Asian-Americans, largely of Southeast Asian heritage, were included in Minnesota only.

Alabama: 24-hour Diet Recalls:
A 24-hour diet recall was collected for each participating fourth-grader. Recall data were obtained for approximately equal numbers of children on each day of the week, Monday through Sunday. The Sunday through Thursday data were collected in schools, with students being called out of class and interviewed individually. Students detailed food intake during the previous day, indicating portion sizes on two-dimensional food models. Diet information was directly entered into a lap-top computer, using the Nutrition Data System, Version 2.5 (NDS, Minneapolis, Minnesota). Friday and Saturday dietary information was collected on Saturday and Sunday by telephone using NDS and laptop data entry, with students using the two-dimensional food models at home to indicate portion sizes. These methods have demonstrated acceptable levels of agreement with observations of food eaten at lunch and with parent reports [23–25].

For quality control, all diet recall records were reviewed by the chief nutritionist or the project coordinator, and samples of diet recall interviews were tape recorded according to a predetermined random order and reviewed by the chief nutritionist or project coordinator. During these reviews, the chief nutritionist or project coordinator entered dietary data from children’s interviews into the NDS and compared records with those of the data collector. Three project nutritionists were trained and certified by the Nutrition Coordinating Center at the University of Minnesota in the use of the NDS system. These nutritionists, in turn, trained the data collectors in the use of the NDS system using a standardized 24-hour dietary recall methodology. Training took place over one week, with two additional days of practice in non-participating schools.

Georgia: 7-day Food Records:
Seven-day food records were completed by third-grade children in Georgia using a validated protocol [26–28]. On day one of data collection, a folder was distributed containing an instruction sheet, a sample completed-day’s-food-record sheet and five blank white dietary record forms. Each form included spaces for date of recording, child’s name, teacher’s name, day of the week and blank lines on which to record food and drink grouped into the following categories: breakfast, snack, lunch, snack, dinner and snack. Children were instructed to record all foods and beverages consumed for each of the next seven days. For each line of recorded food, there were boxes to check numbers of servings (1/2, 1, 2, fill in) and whether the item was eaten "at school" or "not at school." During diary completion, the leader read the printed instructions while other staff members walked through the class reviewing completed diaries for possible errors. On Friday, children were given weekend food and drink notes which were the same as weekday diaries, but yellow in color, and instructed to complete the forms after meals and snacks on Saturday and Sunday.

Registered dietitians were trained in use of the diary-coding protocol to identify fruit and vegetables items and code only those items into five mutually exclusive categories: all fruit, all 100% fruit juices, regular vegetables (non-fried), deep fat fried vegetables (e.g. french fries, onion rings, fried okra) and legumes. Vegetables high in fat (e.g. nuts), low fruit/high fat desserts and snacks (e.g. apple pie), fried vegetable snacks (e.g. potato chips), and vegetables used as grain (e.g., corn chips) were not counted. Throughout coding, double coding was conducted of 10% of the records by two dietitians with review by the supervisor for identification and resolution of inconsistencies. Intercoder reliability varied from .83 to .99 across food categories [28].

Louisiana: 24-hour Diet Recalls:
Twenty-four-hour dietary recalls were collected at baseline in the 12 participating high schools on a randomly selected 30% of the 9th grade cohort. The 24-hour diet recall method was modeled after several national programs [29–31]. Each student was interviewed, privately, at school for 25 to 30 minutes to obtain an hour-by-hour history of all foods and beverages consumed during the previous 24-hour period.

Quality controls included a standardized protocol, NASCO food models for quantification, a product identification notebook for snack probing and a school-lunch and family-recipe collection [32]. Interviewers were trained and certified to use the 2.5 software version of the Nutrition Data System, developed by the Nutrition Coordinating Center (NCC) at the University of Minnesota, in face-to-face interactive interviews using laptop computers. The senior nutritionist conducted observations of 10% of the interviews, completing a checklist for protocol adherence.

Minnesota: 24-hour Diet Recalls:
A random sample of 34 students in each school was obtained in order to insure twenty-seven 24-hour recalls and matched lunchroom observations per school. A matched set of recalls and observations were sought to assess the validity of the 24-hour recall measure. The survey team was in each school for three to four days, working in different classrooms each day. For a student absent on the day he or she would have been chosen, the next name on the list was chosen instead; when possible, students missed due to absence on one day were chosen later in the week. The chosen students were instructed on how to keep a 24-hour non-quantified food record [29]. Food records were completed as a means of increasing the accuracy of student reports of consumption when students completed the 24-hour recall. Students were also observed at lunch that same day and were eligible for the 24-hour recall the next day. Only those students who returned the food record the next day completed the 24-hour dietary recall. No data on weekend consumption was collected. Methods for the 24-hour recall were adapted from those employed in the Child and Adolescent Trial for Cardiovascular Health (CATCH) [29]. The food record and food models were used by trained interviewers as prompts during the recall. The interviewers entered the student’s information directly into a laptop computer using the University of Minnesota Nutrition Data System, Version 2.6, software and data base [33]. These methods have been shown previously to provide valid estimates of group intake [29,34]. Because of the large number of Southeast Asian immigrant children studied, interviewers were trained to recognize the characteristic foods eaten by people from these cultures and to assess the quantities of foods consumed by these children (for example, rice). Southeast Asian foods not common in the United States were added to the NDS data base.

Demographics Measures and Procedures
Data on age, gender and ethnicity were collected on the children at each site. In Alabama, age and gender were obtained from the students in the classroom, and ethnicity was obtained from the parents, using self-administered questionnaires. Ethnicity was assessed by means of response categories of "White," "African-American" or "Other". "Other" was used due to the low frequency of non-European-American and non-African-American individuals in the sample school districts. In Georgia, student characteristics were obtained from parental responses to questions on the informed consent form. Since differential bias or error could affect ethnic group comparisons, the few children from ethnicities other than European-American or African-American groups or from mixed ethnicities were deleted from the data contributed by this site. In Louisiana, age, gender and ethnicity were obtained from students in the classroom. Age was assessed by asking students for their date of birth. Ethnicity was determined by having students indicate whether they were African-American, European-American, Hispanic or Other in ethnic background. In Minnesota, ethnicity, age and gender were recorded directly from the administrative records of the school district. Those students who were of Hispanic, American Indian or Other ethnic background were deleted from the dataset due to their small sample size (n=37).

Calculation of Fruit and Vegetable Scores
The definition of a serving of a fruit or vegetable was determined by the National Cancer Institute, 5 A Day guidelines [35]. A serving was defined as a medium piece of fruit, 1/2 cup of fruit or vegetable, 3/4 cup (6 oz.) juice, one cup leafy greens or 1/4 cup dried fruit. The three sites using the NDS system, working in collaboration with the National Cancer Institute and the Nutrition Coordinating Center (NCC) at the University of Minnesota, calculated servings of fruit and vegetables by determining the gram weight equivalent for a serving of each fruit and vegetable contained in the NDS database, as defined by the 5 A Day initiative. The following foods were not counted in the calculation of fruit and vegetable servings because of the addition of fat, salt or sugar: french fried potatos; chips, including corn, potato, vegetable and fruit; popcorn; ketchup, jam and jelley; pickles and pickled foods; candy; fruit-flavored drinks; coconut, nuts, avocados and olives; tofu. The data from each site were then sent to NCC for scoring and were returned to each site. In Georgia, scoring was completed by hand by registered dietitians using the 5 A Day definition of fruit and vegetables.

Statistical Analyses
Parallel analyses were conducted at each site with a model that included gender and ethnicity as predictors and controlled for age of child within each site. The model was estimated at each site using a mixed linear model procedure (PROC MIXED in SAS, Version 6.11; Cary, North Carolina) for all fruit and vegetables combined, for the fruit and juices combined, and for regular and deep-fat vegetables and legumes combined. This model corrects for the correlations within schools [27] and obtains estimates despite missing values. Because of clustering of values by schools [36], the random term for schools was included in all models.

	RESULTS

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Consumption Variables by Site
Mean servings of fruit, vegetables and combined fruit and vegetables correspond to national estimates and support the earlier finding that children and adolescents consume fewer than the NCI-recommended five servings of fruit and vegetables per day. (See Table 1.)

Regression Analyses
Findings from the regression analyses differed across outcome measures and across sites. Significant results were found at the Georgia and Minnesota sites, but not at the Alabama and Louisiana sites. Results for gender are presented in Table 2, and results for ethnicity are presented in Table 3. For fruit and vegetables combined, gender was predictive in Georgia, with females eating more servings. African-Americans consumed more fruit and vegetables than European-Americans in Georgia, although this finding fell below the traditional significance level of .05 (p<.10).

For vegetable consumption, in Georgia an effect was observed for gender, with females eating more servings of vegetables than males, while in Minnesota greater consumption was observed among European-Americans and lower consumption among Asian-American/Pacific Islanders, with African-Americans falling in-between.

	DISCUSSION

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Gender was a significant predictor of fruit and vegetable consumption in the Georgia sample. Consistent with prior studies, females consumed more servings of fruit, vegetables and combined fruit and vegetables, than males [13,15,18]. Previous studies have demonstrated gender effects most frequently as children moved into mid and late adolescence, while a gender effect in younger children was found at the Georgia site. The presence of gender differences in Georgia, but not at the other sites, may be due to the outcome measures used. The food record utilized in Georgia obtained data across seven days, whereas the other sites used single 24-hour recall assessments. Multiple days of assessment minimize intra-individual variability, provide a more reliable estimate of an individual’s typical diet [37] and may have increased the ability of investigators at the Georgia site to detect gender differences among the younger children.

The findings are complex for the association between ethnicity and consumption. Ethnicity was a significant predictor for fruit consumption in Georgia and Minnesota, for consumption of vegetables in Minnesota and for consumption of fruit and vegetables combined in Georgia (p<.10). In Georgia, African-Americans consumed more servings of fruit and vegetables combined. In both Georgia and Minnesota, African-Americans consumed more servings of fruit than European-Americans. In Minnesota, European-Americans consumed the highest number of vegetables while African-Americans consumed more vegetables than Asian-American/Pacific Islanders.

For European-Americans, Asian-American/Pacific Islanders in Minnesota, an interesting reversal occurs with respect to fruit consumption versus vegetable consumption. The Asian-American/Pacific Islanders consumed a higher number of servings of fruit per day than European-Americans. This relationship was reversed for vegetable consumption, with European-Americans consuming the most servings and Asian-American/Pacific Islanders consuming the fewest servings. This difference might be due to variations in cultural preference for fruit or vegetables, since this effect was observed within one site where the methods would be constant across ethnic groups. The Asian-American/Pacific Islander sample in Minnesota consisted largely of families of first generation Americans from Southeast Asia so that caution should be exercised in generalizing this finding to other Asian-Americans and Pacific Islanders. This finding should also be examined more thoroughly in studies with larger and more diverse samples of Asian-Americans and Pacific Islanders. Given the limited data examining Asian-American/Pacific Islander consumption in the U.S., this finding is important and demands further examination.

The results of this study are important for several reasons. Few studies have been conducted relating gender and ethnicity to the consumption of fruit and vegetables. This study adds to this literature in using large samples from four different sites, thereby enhancing confidence in the stability of the findings. This study examined gender and ethnicity effects in multiple subsamples using a shared definition of fruit and vegetable consumption. Prior studies were independent and did not share a definition of the outcome measure, making it more difficult to reach consistent conclusions across studies. We employed a standardized analysis strategy that allowed for a clearer comparison of gender and ethnicity effects across multiple samples than seen in prior research. In contrast to earlier studies, our analyses also examined the contribution of each predictor controlling for other predictors in the model, allowing a test of the unique associations of gender and ethnicity with consumption. For example, the effect of gender on the consumption of fruit and vegetables was examined controlling for ethnicity and age.

Our data suggest that gender and ethnicity may be related to fruit and vegetable consumption in children and adolescents. Future research should examine the influence of socioeconomic status, acculturation, local availability of fruit and vegetables and regional differences in preferences on the association of gender and ethnicity with fruit and vegetable consumption.

	ACKNOWLEDGMENTS

 
Funding for the research described in this manuscript was provided by National Cancer Institute, Grant Numbers: 59776 (Alabama), 61596 (Georgia), 59803 (Louisiana), 59805 (Minnesota). The authors also thank the school personnel at each of the four sites who helped with the conception and execution of the 5 A Day research projects.

Received May 1, 1997. Accepted October 1, 1998.

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