Knowledge of recommendations

Dietary counseling should include discussion of FV recommendations for families. Although knowledge alone is not sufficient to alter dietary behaviors among children and adolescents, it has been associated with higher FV intake in children. Two observational studies of the determinants of FV intake among 11-year-old children in several European countries found positive associations with FV intake among those with knowledge of national recommendations. A review of studies from the United States and Europe examining the determinants of FV consumption and FV interventions among children 6 to 12 years old found evidence of a positive association between knowledge of FV recommendations and FV intake.

Taste preferences

Children’s and adolescents’ taste preferences are associated with FV intake. A 2006 review found that, in all studies identified that analyzed the influence of taste preferences (n = 11), there was a positive association with intake of fruit and/or vegetables. Research suggests that infants have a genetic predisposition to prefer certain tastes, such as those that are sweet, and therefore may initially reject food that tastes bitter, including vegetables. However, such preferences may be altered as children become more familiar with foods through multiple exposures (10 or more), modeling by parents and caregivers, and positive experiences with these foods. Pediatric practitioners can advise caregivers to provide opportunities, such as those discussed later, for children’s FV preferences to develop.

Hands-on experiences: gardening and cooking

Practitioners can advise caregivers to engage children in hands-on experiences, such as growing and preparing FV. These experiences may help children cultivate a lasting, healthy relationship with food, and a lifetime of healthy eating behaviors. Youth participation in gardening can positively influence FV consumption and related factors, such as willingness to taste fruits and/or vegetables ; increased knowledge of, positive attitudes toward, and preferences for fruits and/or vegetables ; and improved availability of FV at home. Although most evidence linking gardening to FV consumption has focused on youth settings outside the home (eg, school, after school, and community settings) and in conjunction with nutrition education, home gardening may also be an effective way to encourage children’s FV consumption. A telephone survey in rural Missouri found that parents and their preschool children who frequently ate homegrown produce ate significantly more FV than those who rarely or never ate it. Increased frequency of eating homegrown FV was also associated with more home availability of produce, preschooler’s preference for FV, and parental role modeling of eating FV. Involvement in community gardens has also been associated with increased FV intake among adults, thus families could consider community gardening as well. Additional experiential activities that caregivers may share with their children to promote FV include visiting farmers markets and farms (eg, pick-your-own farms) and participation in community-supported agriculture to receive produce boxes on a regular basis.

Involvement in the selection of, preparation of, and cooking of FV increases children’s exposure to, and familiarity with, these foods, 2 important factors in the development of food preferences. A cross-sectional study of middle school and high school students found that students who frequently assisted with dinner preparations had higher intakes of FV, fiber, folate, and vitamin A, as well as lower intakes of less healthy foods. Developing children’s cooking skills may have lasting impacts as they become independent adults. A cross-sectional study of young adults 18 to 23 years old, found that more frequent food preparation was associated with higher FV intake.

Caregiver feeding practices

Caregiver-child interactions around food, meals, and nourishment can have a major impact on children’s food preferences, their ability to regulate food intake, and FV consumption. Caregiver feeding practices, such as pressure to finish all food provided, may be rooted in historical threats of undernutrition and the economic significance of food, both of which may be less relevant in contemporary society. For example, overnutrition is a growing problem among youth, with 32% of youth being overweight or obese. The percentage of disposable income spent on food has decreased from 21% in 1950 to 9% in 2010. Pediatric practitioners should be aware of the historical and cultural meanings of food, and feeding and parenting practices used among the racial/ethnic groups they serve.

Child feeding is a reciprocal interaction between children and caregivers in which each party has a distinct role. Caregivers are responsible for determining what, where, and when children are served to eat, whereas children determine how much and whether or not they do eat. A caregiver’s role is to establish clear eating guidelines that support children in making healthy choices, not to overly restrict or pressure children to eat certain foods or all the food served.

In attempts to ensure healthful eating patterns in their children, caregivers may use controlling strategies, such as restriction or pressuring to eat. However, these strategies often have unintended, negative effects when used with preschool-aged children. Restriction refers to limiting children’s access to certain foods, usually foods deemed unhealthy, such as sweets and energy-dense snacks. In general, evidence indicates that overly restricting foods consumed by preschool children, especially those that are highly palatable, often leads to increased selection and consumption of the restricted foods when they are available. Research indicates that this feeding practice disrupts children’s ability to self-regulate their food intake, which may lead to overconsumption and excess weight gain over time. Appropriate clinical advice to caregivers is to make FV readily available and provide children with opportunities to experience and consume foods in moderation without overly restricting foods deemed to be less healthy. As with restriction, pressuring children to eat is also counterproductive. Studies of preschool children have shown that pressuring children to eat (eg, ignoring comments regarding satiety, begging them to eat) is associated with negative feelings toward, and low consumption of, the pressured foods. In contrast, feeding practices such as encouraging children to try new foods, encouraging children to eat FV (eg, offering praise or congratulations for trying FV), and providing children with a variety of healthy food options have been linked to healthy dietary patterns among children.

Caregivers may use controlling behaviors in response to individual characteristics of their children, such as neophobia (fear or reluctance to try new foods). Feeding practices that may help overcome or lessen food neophobia include breastfeeding and repeated exposure to, and parental modeling of, eating the refused foods.

Caregiver influence on FV consumption through feeding practices may be especially salient during early childhood but become less important as children’s autonomy increases and they begin to exert more developmentally appropriate control over their own eating. Among children aged 6 to 18 years, evidence indicates that neither parental restriction nor parental pressure to eat is associated with children’s FV intake. However, caregivers can still positively affect their children’s FV consumption in a variety of ways, including modeling healthy eating habits.

Role modeling

Caregivers are important role models in shaping children’s dietary intake, including FV consumption. Pediatric practitioners should advise caregivers that their personal healthy behaviors have the potential to positively shape their children’s food preferences and behaviors. Parental FV intake is positively associated with children’s FV intake, which may be a result of parental modeling. Although this relationship may be mediated by other factors such as FV availability, practitioners should encourage caregivers to increase their own consumption of FV as a way to encourage the consumption of such foods among children. Thus, intervention programs and other resources that promote FV intake among adults may subsequently be helpful in improving children’s FV intake.

Family meals

The Expert Committee advises practitioners to encourage parents to eat family meals with their children. A 2011 meta-analysis found that children and adolescents who shared family meals 3 or more times per week were more likely to eat healthy foods (including FV) than those who shared fewer family meals (increased odds of 24%). In addition, regular family meals can have positive long-term benefits on FV consumption. During family meals, caregivers have an opportunity to repeatedly expose children to a variety of FV and to model and encourage healthy eating behaviors. Furthermore, family meals have been associated with a host of other benefits for children, including academic achievement, language development, and reduced risk for substance abuse and eating disorders. Research suggests that television viewing during family meals has a negative impact on FV consumption and therefore should be avoided. Thus, pediatric practitioners should encourage caregivers not only to increase the frequency of family meals but also to promote the quality of the family meal experience through positive mealtime interactions.

Availability and accessibility

Caregivers can create a supportive environment for children to make healthy choices by ensuring that a variety of FV are available in the home, easily accessible (eg, washed, cut, at eye level in the refrigerator), and served to children during meals and snacks. Availability and accessibility are positively associated with FV intake in children and adolescents and may be able to overcome low taste preferences. For example, a study of middle school and high school students found that, even when children’s taste preferences for FV were low, greater home availability was associated with higher intake. The amount of FV in the home compared with less healthy foods may also be an important factor in consumption. A recent cross-sectional study found that the ratio of more-healthful to less-healthful foods and FV availability and accessibility in the home were both positively associated with higher intake of FV among children and adolescents. Thus pediatric practitioners can assist caretakers in understanding the importance of their role as gatekeepers who control the foods that are brought into the home.

Practitioners should encourage caregivers to serve a variety of FV prepared in appealing ways to their children during meals and snacks. Current recommendations encourage individuals to fill half their plates with FV during meals, which can be done in a variety of ways, such as topping cereal with fruit, serving a salad with dinner, and adding vegetables to pastas. In addition, caregivers should be advised to pack FV for children to take to school, ECE, community venues such as pools, playgrounds, and sporting events, and other places where children spend time outside the home, because this may influence them to eat more FV. Caregivers can also encourage and support efforts to make FV more available within these settings.