Tuesday, July 16, 2013

Paying kids to eat their vegetables? How US school lunches can help kids' health.

A study published in 2010 by Just and Price has gotten a lot of play lately in the media.  These researchers looked at the effectiveness of various incentives used to encourage kids to eat vegetables. In the 2010 study, they analyzed the effectiveness of monetary incentives in schools, such as a quarter for a broccoli bite. The kids ate more veggies for that quarter (not so much for the nickel); however there is debate about whether this would change eating habits long term.

Very few school age kids eat the recommended amount of fruits and vegetables for their age. Eating a sufficient amount of fruit and vegetables is critical to long-term health and maintaining a healthy weight. For many states and counties, increasing pupil's fruit and vegetable intake is a focus in their fight against childhood obesity.

Just and Price are doing critical work investigating what is a cost-effective approach that results in our kids eating healthier. For instance, they analyzed the popular policy requiring pupils to take a certain number of veggie servings at lunch. They compared veggie consumption before and after the policy.  This popular policy only incrementally increased veggie intake but dramatically increased the amount of vegetables put in the trash.  So what works and what is effective long term?

Ideas that work:

1. Displays and accessibility make a large difference.  Cafeterias report increased fruit consumption when they have prominent, appealing, lit displays.  Additionally, when vegetables are easier to reach it increases intake.  Items like trays make it easier for kids to carry their vegetables and fruit, and have been shown to increase purchases of those items.  The rise in cafeteria salad bars, thanks to Michele Obama’s “Let’s Move Salad Bars to Schools”, has dramatically increased the variety and amount of fruits and vegetables that children are seeing at lunch. Also, having produce stationed in multiple places in the cafeteria line has helped increase intake in hospital cafeterias.

2. Serving it first.  In France, where obesity rates are the lowest in the Western world, school lunches are a teaching moment where children learn to appreciate good food.  Often lunches include an appetizer fruit or vegetable serving.  Therefore, the vegetable is offered first when the child is hungriest (http://www.mamamianutrition.com/2010/07/veggies-first.html). This is instilled in preschool where children are taught to eat in courses, family-style. Similarly, increases in intake are seen in the US in schools where the salad bar is first.

3. Incentives also work. $ for sprouts or the UK's 'Food Dudes' who are super heroes exalting the health benefits of vegetables (considered a social incentive) have been documented as increasing vegetable intake.  Kids eat about 50% more vegetables when they get a sticker or praise for eating them.

I am philosophically hesitant about teaching kids to eat vegetables using external rewards. It seems a short term approach that doesn't lead to long term healthy habits.  More logical would be to teach kids the health value and variety of tastes in produce. However, a recent study on such incentives may justify their use.  In the study incentives (stickers and praise) were provided consistently for two weeks, during which the kids ate more produce.  But interestingly for the following weeks, after the incentives stopped, the kids were still eating more fruits and vegetables. This suggests the change in habits and increased exposure to vegetables during the program increased intake over the long term.

Bottom Line:
Kids will eat more vegetables when they are hungry (see http://www.mamamianutrition.com/2012/09/the-snack-sabotage-raising-healthy-eater.html), offered them frequently, can access them easily and are encouraged to eat them.  Short term reward programs might be necessary in the US where we have incurred poor eating habits over the past two decades. Incentives might provide a window to change pupils' habits and increase their vegetable intake for the long term.

All of this is modeled in other countries where kids have lower obesity rates and greater produce consumption. However, we will have to put our money into this system. The Western countries that are succeeding are paying 5-6$/meal versus 2.25-2.80$/meal in the US.

It may be that we pay now to teach our children while they are young how to keep their bodies healthy; or pay later to undo the damage of years poor eating that can lead to obesity and chronic disease.

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