EMGO Institute - Care and Prevention Evidence-based promotion of - - PDF document

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EMGO Institute - Care and Prevention Evidence-based promotion of - - PDF document

Change in fruit intake between 2003 and 2009 for 11-year old boys and girls from mothers with higher (HE) and lower education (LE), grams per day (Fischer et al. In preparation) 5 0 4 0 3 0 2 0 Boys HE 1 0 Boys LE 0 Girls HE Girls LE -


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EMGO Institute - Care and Prevention

Change in fruit intake between 2003 and 2009 for 11-year old boys and girls from mothers with higher (HE) and lower education (LE), grams per day (Fischer et al. In preparation)

  • 4 0
  • 3 0
  • 2 0
  • 1 0

1 0 2 0 3 0 4 0 5 0 2 0 0 3 - 2 0 0 9 Boys HE Boys LE Girls HE Girls LE

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EMGO Institute - Care and Prevention

EMGO Institute for Health and Care Research

Lifestyle, Overweight and Diabetes

Evidence-based promotion of fruit and vegetable consumption: the importance of socio- economic determinants

Johannes Brug, EGEA, 2010

Planned Planned Promotion of Promotion of Population Population Health Health (Brug et al. Am J

(Brug et al. Am J Clin Clin Nutr Nutr 2003; Int J 2003; Int J Beh Beh Nutr Nutr Phys Phys Act 2005; Act 2005;

A: Analysis of health and quality of life B: Analysis of personal and environmental risk factors C: Analysis of determinants of exposure to risk factors D: Intervention development E: Intervention implementation E E v v a a l l u u a a t t i i

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EMGO Institute - Care and Prevention Planned Planned Promotion of Fruit and Promotion of Fruit and Vegetable Vegetable intakes intakes A: What are the important population health issues? B: Is fruit and vegetable intakes associated with these issues? C: Who eats too little F&V and why? D: Intervention development E: Intervention implementation E E v v a a l l u u a a t t i i

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n Planned Planned Promotion of Fruit and Promotion of Fruit and Vegetable Vegetable intakes intakes A: What are the important population health issues? B: Is fruit and vegetable intakes associated with these issues? C: Who eats too little F&V and why? D: Intervention development E: Intervention implementation E E v v a a l l u u a a t t i i

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EMGO Institute - Care and Prevention

Who? Differences according to socio-demographics

  • Age: very young < young < adults (< older)
  • Ethnicity: …

.

  • Sex: Men > Women; Women > Men
  • Socio-econom ic Position: Low SES < High

SES

Planned Planned Promotion of Fruit and Promotion of Fruit and Vegetable Vegetable intakes intakes A: What are the important population health issues? B: Is fruit and vegetable intakes associated with these issues? C: Who eats too little F&V and why? D: Intervention development E: Intervention implementation E E v v a a l l u u a a t t i i

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EMGO Institute - Care and Prevention Planned Planned Promotion of Fruit and Promotion of Fruit and Vegetable Vegetable intakes intakes A: What are the important population health issues? B: Is fruit and vegetable intakes associated with these issues? C: Who eats too little F&V and why? D: Intervention development E: Intervention implementation E E v v a a l l u u a a t t i i

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Who: Socioeconomic position…

  • An individual’s social and economic ranking within society
  • based on access to resources (such as material and social

assets, including income, wealth, and educational credentials) and prestige

  • proxy indicators for SEP include education level; own or

household income; and occupational status

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EMGO Institute - Care and Prevention

Life expectancy according to level of education, the Netherlands

6 8 7 0 7 2 7 4 7 6 7 8 8 0 8 2 8 4 8 6 Men W om en Prim ary education Secondary education Vocational training College/ University training

SES differences in lifestyle, the Netherlands

1 0 2 0 3 0 4 0 5 0 6 0

Sm oking Alcohol abuse I nactivity Overw eight Primary school University training

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EMGO Institute - Care and Prevention Differences (g/ day) in fruit and vegetable intakes according to level of education (high vs low) of main provider in household

5 1 0 1 5 2 0 2 5 3 0 3 5 Fruit Vegetables Adult m en Adult w om en Children

Likelihood of daily use of vegetables (OR= Odds Ratio, low level of education as reference group) (Prättälä et al. PHN 2009)

0 ,5 1 1 ,5 2 2 ,5 OR high vs low education Finland Denm ark Germ any Estonia Latvia Lithuania France I taly Spain

* * * = not significant *

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EMGO Institute - Care and Prevention

… systematic reviews…

  • Irala-Estevez et al, EJCN, 2000; Kamphuis et al.,

BJN 2006 (adults)

  • Van der Horst et al., HER 2006; Rasmussen et al.

IJBNPA 2006 (children)

Why?

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EMGO Institute - Care and Prevention

Three ‘broad’ categories of determinants

  • Motivation
  • Ability
  • Opportunity

Motivation and Free choice I:

People just do what they like…

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EMGO Institute - Care and Prevention We eat what we like…

Sweet, fatty, salty, energy-dense

..but taste preferences are modifiable…

Mere exposure, Social learning, Taste-environment Learning; may all contribute to SES differences…

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EMGO Institute - Care and Prevention Preventive action THREAT = Perceived susceptibility X Perceived severity Evolution of a theory… (1): People change when you scare them?

Free choice II: people act sensibly

Preventive action THREAT = Perceived susceptibility X Perceived severity Increase In F&V THREAT = Low F&V intake puts ME at risk for heart disease (which is bad!)

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EMGO Institute - Care and Prevention Beliefs X evaluations Attitudes Behaviour

  • There is more than risks and health…
  • Beliefs are not knowledge…
  • Affective rather than cognitive?

Klepp et al. IJBNPA 2007

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EMGO Institute - Care and Prevention

Vereecken et al., PHN 2006

higher exposure to TV ads is associated with lower F&V intakes…

Lower SES youth watch more TV

and are thus exposed more…

  • Klepp et al. IJBNPA, 2007: …

but exposure to healthy food ads may have some benefits:

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EMGO Institute - Care and Prevention

The ‘environment’

  • Ecological ‘model’…

– Making healthy choices easy choices – Making healthful nutrition/ F&V intakes:

  • Easier
  • Better facilitated
  • More necessary
  • Unavoidable

Environmental opportunities

Physical environment Social-cultural environment Political environment Economical environment

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EMGO Institute - Care and Prevention The overall conclusions from the six systematic reviews - 1 (Brug & Van

Lenthe 2005; Brug et al Am J Prev Med, 2006; Brug et al. Proc Nutr Society 2008)

  • More evidence for the im portance of social environm ents than for physical

environm ents: – Social support and m odelling appears to be important for physical activity, in youth as well as in adulthood. – Parents have a crucial role in the health behaviour of their children. They should not only provide a good exam ple by eating right and being physically active themselves, but also by using parenting practices and styles that encourage and support healthy habits in their offspring.

  • Availability and accessibility of healthy and less healthy foods are important for

nutrition behaviours, in youth and adulthood; schools and worksites offer good

  • pportunities to improve availability of healthful foods.
  • From the reviews of intervention studies it appeared that increasing physical activity
  • pportunities makes a difference, and schools and w orksites offer good settings to

do that. Especially increasing the amount of hours of physical education/ physical activity in schools can make a difference for youth. Improving opportunities for walking can make a difference in adults.

  • Children and adolescents from more deprived fam ilies are likely to have unhealthier

diets and less physical activity, and lower household income is associated with less healthy diets in adults.

  • Macro: country availability
  • Meso: neighbourhood availability
  • Micro: household/ school availability
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EMGO Institute - Care and Prevention

Likelihood of daily use of vegetables (OR, low level of education as reference group (OR= 1) (Prättälä et al. PHN 2009)

0 ,5 1 1 ,5 2 2 ,5 OR high vs low education Finland Denm ark Germ any Estonia Latvia Lithuania France I taly Spain

Trends in the per capita supply of vegetables 1993–2003 (kg/ year) in the countries studied

Macro availability

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EMGO Institute - Care and Prevention Individual and neighbourhood SES indicators (Giskes et al PHN 2006)

Meso availability

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EMGO Institute - Care and Prevention

Reported vegetable availability outside the home 1= never 5= always

Micro availability

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EMGO Institute - Care and Prevention Bere et al, Eur J Clin Nutr 2008, analytical model

Independent variable

(parental education)

Mediator

(availability/acce ssibility, modelling, intention, preferences, self-efficacy, knowledge)

Outcome variable

(FV intake) a b c

Parental educational differences in adolescents’ fruit and vegetable (FV) intake in 2002 and 2005 (Bere et al., Eur J Publ Health, 2008). 1 1 ,5 1 2 1 2 ,5 1 3 1 3 ,5 1 4 1 4 ,5 1 5 1 5 ,5 2 0 0 2 2 0 0 5 Low education High education

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EMGO Institute - Care and Prevention

Parental educational differences in adolescents’ determinants of FV intakes in 2005 (Bere et al., Eur J Publ Health, 2008). 1 2 3 4 5 6

Accesibility I ntention Knowledge Preferences Self- efficacy Modelling

Low education High

In the multiple mediator model:

  • the mediators together explained 92% (2002) and

60% (2005) of the educational disparity,

  • with perceived accessibility contributing the

largest amount [ 45% in 2002 and 14% in 2005]

  • each of the other factors contributed little to the

explanation in the multiple mediator models

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EMGO Institute - Care and Prevention

… why lower availability at home and/ or outside the home?

lack of knowledge, health values… ? (e.g. Ball et

  • al. PHN 2006; Turrell Aus J Nutr Diet 1997)

lack of financial means… ? (e.g. Darmon & Drewnowski Am J Clin Nutr 2008)

’food deserts’… ? … why lower availability at home and/ or outside the home?

lack of knowledge, health values… ? (e.g. Ball et

  • al. PHN 2006; Turrell Aus J Nutr Diet 1997)

lack of financial means… ? (e.g. Darmon & Drewnowski Am J Clin Nutr 2008)

’food deserts’… ? Evidence for the US, but not for UK, other EU countries, Australia, Canada (e.g. Cummins & McIntyre, Urban Studies 2002.)

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EMGO Institute - Care and Prevention

… where we are so far

SES disparities in F&V most countries across Europe

because of differences in motivation, abilities, and opportunities – (… but evidence-base is weak, not because of evidence for no association, but because of lack

  • f studies…

)

interventions to promote F&V among lower SES groups should target these groups of determinants

Planned Planned Promotion of Promotion of Population Population Health Health (Brug et al. Am J

(Brug et al. Am J Clin Clin Nutr Nutr 2003; Int J 2003; Int J Beh Beh Nutr Nutr Phys Phys Act 2005; Act 2005;

A: Analysis of health and quality of life B: Analysis of personal and environmental risk factors C: Analysis of determinants of exposure to risk factors D: Intervention development E: Intervention implementation E E v v a a l l u u a a t t i i

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EMGO Institute - Care and Prevention School

School-based Intervention program

Family Community Classroom School meals School environment

Pro Children: Intervention Pro Children: Intervention

Worksheets Educational Activities Computer Tailoring Web site Fruit break Special school Events School Project committees School Policy Worksheets Newsletters School Events Computer tailoring School Health Mass Media Grocery stores

www.prochildren.org

Pérez-Rodrigo et al., Ann Nutr Metab, 2005

Evaluation, design

  • Cluster randomised controlled trial
  • Norway, Spain, the Netherlands

Baseline, sept 2003 FU1, may 2004 FU2, may 2005

Intervention schools Control schools

Intervention:

  • Curriculum
  • Provision of FV
  • family component

Intervention:

  • Provision of FV
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EMGO Institute - Care and Prevention Knowledge of recommended daily fruit intake (% )

55,6 73,5 53,9 59,1 10 20 30 40 50 60 70 80 90 100 Intervention Control Baseline Follow-up II * Sign. effect at Follow-up II when adj. for baseline values & age; p<0.001) * %

Knowledge of recommended daily vegetable intake (% )

38,6 50,7 35 31,1 10 20 30 40 50 60 70 80 90 100 Intervention Control Baseline Follow-up II * Sign. effect at Follow-up II when adj. for baseline values & age; p<0.001) * %

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EMGO Institute - Care and Prevention Fruit availability at school (Can you get fruit at school either by buying it or getting it for free?) (scale 0-4)

1,31 2,5 1,34 1,23 1 2 3 4 Intervention Control Baseline Follow-up II * Sign. effect at Follow-up II when adj. for baseline values & age; p<0.001) * Never Always

Vegetable availability at school (Can you get fruit at school either by buying it or getting it for free?)

1,06 1,06 1,12 1,12 1 2 3 4 Intervention Control Baseline Follow-up II Never Always

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EMGO Institute - Care and Prevention

Reported total fruit & vegetable intake at baseline (Sept. 03) and follow-up II (May 05) (24 hour recall; gram per day; n= 1493)

243,1 242,1 237,7 202,2 150 170 190 210 230 250 270 290 Intervention Control Baseline Follow-up II Gram per day * Sign. effect at Follow-up II when adj. for baseline values & age; p<0.001) *

100 150 200 250 300 350 400

BL FU 1 FU 2 gram/day

Intervention Norw ay Control Norw ay Intervention Spain Control Spain Intervention Netherlands Control Netherlands

*** *** Norway

Results: total fruit and vegs intake

Te Velde et al, BJN, 2008

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EMGO Institute - Care and Prevention

100 125 150 175 200 225 250 275 300

BL FU 1 FU 2 gram/day

Intervention Norw ay Control Norw ay Intervention Spain Control Spain Intervention Netherlands Control Netherlands

Results: total fruit intake

Te Velde et al, BJN, in press

25 50 75 100 125

BL FU 1 FU 2 gram/day

intervention Control

***

Results: total vegetable intake

Te Velde et al, BJN, in press

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EMGO Institute - Care and Prevention

Reported program implementation, parental involvement & student appreciation

  • School curriculum implementation (0-16):

– Norway: 10.9 p< .001 – Spain: 9.4 – The Netherlands: 7.4

  • Parental involvement (0-7):

– Norway 3.4 p= .002 – Spain 3.5 – The Netherlands 2.8

  • Child appreciation (0-3):

– Norway: 2.4 p< .001 – Spain: 2.3 – The Netherlands: 2.2

Wind et al, Health Educ Res 2008

Fruit and Vegetables Make the Marks (FVMM)

  • Subscription vs. free school fruit –

Norwegian experiences

Subscription program: Offered to all Norwegian elementary schools Cost:

– NOK 2.50 per school day (approximately EUR 0.30) – Subsidised by the Norwegian Government by NOK 1.00 per pupil per school day

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EMGO Institute - Care and Prevention

The FVMM project

  • 38 schools, 1950 6th and 7th graders
  • School fruit intervention (October 01 – June 02):
  • Free school fruit: 9 schools
  • Existing subscription program: 9 schools
  • No program: 20 schools
  • Data collections:

– Baseline (September 01) – Follow-up (May 02) – Follow-up (May 05)

Free fruit: more effective than subscription program

0,4 0,8 1,2 sep-01 may 02

FV at school (portions/day) Free fruit Subscription No program

Bere et al., Prev Med, 2005 Δ=0.2, p=0.003 Δ=0.8, p<0.001

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EMGO Institute - Care and Prevention

Free fruit: Showed long term effect

1 1,5 2 2,5 sep-01 may 02 may 05

FV all day (portions/day) Free fruit Control

Bere et al., IJBNPA, 2007

Effect: 0.69, p<0.001 0.44, p<0.001

No differences according to parental education

Challenges in school fruit programs

  • Implementation
  • Parental involvement
  • Participation in subscription programs is low

(Norway, 41% of the schools, 28% of children within schools)

  • Paid subscription programs may increase socio-

economic differences in FV intake

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EMGO Institute - Care and Prevention

“The results suggest that combining educational and environmental components and a focus on both sides

  • f the energy balance issue better and

more relevant effects.”

Conclusions

  • Differences in F&V intakes according to SES/ SEP

are apparent

  • Availability of FV at schools important
  • Evidence-based intervention programs focussing
  • n improving motivation, abilities and
  • pportunities are promising…

– If implemented to the fullest extend

  • Free provision of F&V may be crucial to contribute

to decreasing socio-economic disparities

  • (…

more research is certainly necessary… )

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EMGO Institute - Care and Prevention