JPediatr(RioJ).2014;90(5):437---439
www.jped.com.br
EDITORIAL
Early
life
factors
among
the
many
influences
of
child
fruit
and
vegetable
consumption
夽
,
夽夽
Fatores
nos
primeiros
anos
de
vida
que
influenciam
o
consumo
de
frutas
e
verduras
entre
crianc
¸as
Benjamin
W.
Chaffee
UniversityofCalifornia,SanFrancisco,UnitedStates
Measuredindisability-adjustedlifeyears,one-tenthofthe worldwideburdenofdiseasecanbeattributedtodietaryrisk factors and physical inactivity, outweighing the contribu-tionoftobaccouse,hypertension,oranyotherpredisposing riskfactor.1In particular,lowdietaryintakesof fruitsand
vegetablesareassociatedwithgreater occurrenceof car-diovasculardisease2andcertainformsofcancer,3together
accountingfor6.7millionannualdeathsglobally.1Muchof
whatdrivesthehighvolumeofglobalmorbidityand mortal-ityattributedtoinadequateintakeoffruitsandvegetables isthepervasivenesswithwhichrecommendedstandardsfor consumptionarefailingtobemet.
Inwealthyandpoorcountriesalike,mostadultsdonot consumetheWorldHealthOrganization recommendedfive dailyservingsoffruits andvegetables.Across52low- and middle-incomecountries,nearly80%ofadultsfallshortof fivefruitsorvegetableseachday,4andadultssimilarlymiss
the mark in Canada5 and the United States.6 Most adults
DOIoforiginalarticle:
http://dx.doi.org/10.1016/j.jped.2014.02.002
夽 Pleasecitethisarticleas:ChaffeeBW.Earlylifefactorsamong
themanyinfluencesofchild fruitandvegetableconsumption. J
Pediatr(RioJ).2014;90:437---9.
夽夽
SeepaperbyValmórbida&Vitoloinpages464---71.
E-mail:benjamin.chaffee@ucsf.edu
alsodo not reach recommended levelsfor fruit and veg-etable intake in Brazil, with the least socioeconomically advantaged the most likely to founder.7 Among Brazilian
childrenandadolescents,recentstudieshavereported dis-maldietaryfigures forfruits andvegetables:only 2.7%of 6-10year olds reached five combinedservings per day in southernBrazil;8frequencyofconsumingvegetablestrailed
well behindthat of soft drinks, sweets, cakes, and cook-iesforadolescentsnationally.9This isacomplexproblem,
withdeeprootsinglobaleconomicforcesthatdictatethe cost,accessibility,andmarketingofhealthyandunhealthy foods,asmuchasitisaquestionofconsumerbehaviorand personaldecision-making.10
Feeding
habits
in
infancy
and
childhood
InthecurrentissueoftheJornaldePediatria,Valmórbida& Vitolo,11investigatorsattheUniversidadeFederalde
Ciên-ciasdaSaúdedePortoAlegre(UFCSPA),deliveryetanother doseofsombernews.Ofthe388low-incomepreschool chil-drentheystudiedinsouthernBrazil(age2-3years),forboth fruitsandvegetables,themajoritydidnotobtainevenone dailyserving, letaloneachieve thethreeservings recom-mendedforthisagegroup:abenchmarkreachedbyjust9% oftheirstudypopulationforfruitsandbyonlyonechildfor vegetables.Strikingis how early in life children’sdietary
http://dx.doi.org/10.1016/j.jped.2014.06.001
438 ChaffeeBW
habitsappeartoform.The UFCSPA investigatorsfollowed abirthcohortofchildrenwhosemothershadenrolledina separate study thathad offerednutrition-related training forhealthprofessionalsemployedatmunicipalhealth cen-tersinPortoAlegre.Inthepresentpublication,Valmórbida &Vitoloreportthatthechildfeedinghabitstheyobserved intheircohortatage12-16monthscastashadowonchild fruitandvegetableconsumptionatage2-3years.Themore frequentlyfruitswereconsumedat12-16months,theless likelyachilddroppedbelowonedailyservingoffruitasa preschooler;11 providinghigh-sugar contentbeverages
ini-tiallywasassociated withalower chance ofconsuming a fullservingofvegetablesinthefuture.11
Theseresultshaveimplicationsforhowwedesign strate-gies for ameliorating poor dietaryhabits inchildren. In a recentsystematic review and meta-analysis,school-based interventions,onaverage,haveproducedmodest improve-ments in child fruit consumption and little change in vegetableintake.12Thebarrierstothesuccessofany
school-basedprogramarenumerous,13includingbutnotlimitedto
theneed todevelop interventions that canbe affordably sustainedbeyondaone-timeundertaking.12 ThePorto
Ale-grefindings suggestthat, for manychildren, school-based programsmightarrivetoolatetoaddressinfullanydietary deficienciesthattracetheiroriginstothefirstyearoflife.
Socioeconomic
forces
At leastpart of the well-documented yet arresting socio-economic inequitiesin diet qualitycouldbe explainedby the generallyhigher costs associated withnutrient dense foods.14Thishaskeyimplicationsforpublichealtheffortsto
improvenutritioninlow-resourcecommunities,as interven-tionsthat stresseducation andindividualdecision-making might not be effective if families view healthier diets as inaccessible or cost-prohibitive.14 It has been argued
thatwithout corresponding effortstoimprove community environments, such as by increasing the availability of affordable,freshproduceindisadvantagedneighborhoods, individual-levelchangesinknowledgeandattitudeswilldo littletoaddresslong-standinghealthinequalities.15
Counterintuitively, Valmórbida & Vitolo report that amongthe predominantlylow-incomefamiliesfeaturedin theirstudy,reachingatleast amodestlevel ofchild fruit consumption was inversely related to household financial resources.11Childreninhouseholdsearningmorethanfour
timesthemonthly minimumsalary hadalowerchance of achievingafullservingoffruitsthanchildreninhouseholds earningless.11Thereexistssomecontroversyastowhether
low-incomehouseholdsseektomaximizespendingpowerby purchasingfoodsthatofferthegreatestamount ofenergy perunitcost,giventhatpresumablyhealthier,low-energy densedietsmightactuallycostlessinabsoluteterms.16 In
low-incomehouseholds,betterchildhealthoutcomesmight notrequiregreaterexpendituresonchildfeeding.For exam-ple,inoneBrazilianstudy,familiesofchildrenwhoremained free of dental caries through age 4 years did not have greaterexpendituresonfeedingfortheirchildren;17infact,
presumably tooth-unfriendlydiets featuring moresweets, suchassodaandchocolate, wereassociatedwithgreater householdexpendituresonfoodfor children.17 Valmórbida
&Vitolospeculatethatamongsocioeconomically disadvan-taged communities, rises in family income might lead to replacementofstapleandtraditionalfoodswithmorehighly processed and energy-dense options. This hypothesis has majorhealthramificationsfornations,suchasBrazil, seek-ingtotierapideconomicgrowthtohigherearningpotential forthepoor.
ThecurrentUFCSPApublicationhassignificantstrengths. Dietarydatawerecollectedprospectivelyfromanearlyage, providingarelativelyrareopportunitytoexaminepatterns inchildfeedinghabitsinacommunity-basedpopulationover time.Dailyservingsoffruitsandvegetableswerecalculated using24-hourdietaryrecallsandexcludedtheconsumption ofpotatoesandfruitjuice,foodsrelativelyhighinenergy but not necessarily dense in nutrients. This study is not withoutlimitations.Eight-sevenparticipants,nearly20%of the potential sample, were excluded due to the absence of at least one 24-hour recall, which reduced statistical power and could have addedselection biasif the factors thatcontributedtomissingdatadidnotoccurrandomly.The principaloutcomesofthestudy---dailyservingsoffruitsand vegetables--- allowedforanyconsumedfruitorvegetablein anyform(potatoesandartificialjuiceaside)tocounttoward anaccumulatedserving.Thisisaperfectlyreasonableway toconductadietaryanalysis,especiallyprovidedthatmost expertguidelinesimploreconsumerstoraisetheirintakeof fruitsandvegetablesintermsofservingnumbers.However, thisraisesarelatedquestionabouthowrecommendations arecommunicatedtothepublic.Wemightaskwhether cer-tainfoods,suchascannedfruitsandsmoothies,whichoften deliver large amountsof refinedsugar, should have equal standing with lower sugar, more nutrient dense options, whenstrivingtoreachserving-numberbenchmarks.18
Looking
ahead
ThesenewfindingsfromSouthernBraziloffercriticalinsight intoearly-lifedeterminantsoffruitandvegetable consump-tion in children. Itis clear thatearly experiencesmatter whenshapingalifetimeofhealthyeating,andthestudy’s resultsofferhopethatfamily-focusedinterventions target-ing children andtheir caregivers from infancywill take a vitalplaceinthepublichealtharmamentariumfor reduc-ing theglobal burden of nutritionally-related diseases.As withmanypublichealthefforts,however,enhancing knowl-edgeandawarenessamongthetargetpopulationismerely one step in the complexprocess of achieving sustainable behavioral change. Forexample, the parentingstylewith which caregiversattempt tofacilitatefruitand vegetable consumption in theirchildren isa criticalfactor in deter-miningwhetherchildren’sfeedingbehaviorswillrespondas intended.19
Beyond family-level determinants, long-term improve-ments in fruit and vegetable intake level will require widespread changes to policy and food environments.15
Aggressive marketing of energy-dense, non-healthy foods is a major barrier to increasing fruit and vegetable con-sumption and will require coordinated efforts between governments and other stakeholders toincrease account-abilityandtolimitor otherwisecountersuchmarketing.13
Earlylifefactorsamongthemanyinfluencesofchildfruitandvegetableconsumption 439
standardsareinplacetoassurethatunprocessedandlocally sourcedfoodswillbeservedinschools,butmajorchallenges incontrollingjunkfoodadvertisingremain.20Formostofthe
world,standardsforfruitandvegetableconsumptionarefar frombeingmet.TherecentworkofValmórbida&Vitolo sug-geststhatakeyelementtowardachievingourdietarygoals willbetogetanearlystart.
Conflicts
of
interest
Theauthordeclaresnoconflictsofinterest.
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