Elling Bere and Knut-Inge Klepp
Key Points
• Free school fruit is much more effective in increasing school children’s FV intake than a subscription programme.
• Free school fruit might result in a sustained elevated FV intake also after the period of free fruit.
• An increased intake of FV might reduce the consumption of unhealthy snacks.
• The nationwide subscription programme in Norway might contribute to increased social disparities in FV intake.
• Altogether a free school fruit programme appears as an effective effort in order to improve food quality of school children.
FV intakes, preferably throughout life, in order to have maximum health prevention potential.
However, only a few school-based intervention studies evaluate follow-ups longer than 1 year after the end of the intervention [ 6 ]. In addition, eating more FV could mean eating less of some- thing else, and the effect on diet quality of eating more FV will be even more apparent if the increased FV consumption additionally leads to a lower intake of unhealthy snacks high in salt, sugar and fats [ 7 ]. Only a few studies have explored whether interventions aimed to increase intake of FV, also decrease consumption of unhealthy snacks.
School Fruit Programmes in Norway The national Norwegian authorities have con- ducted considerable efforts to increase school children’s fruit and vegetable intake at school the last years. A subscription programme for grades 1–10 was initiated in 1996 and made nationwide in 2003 in collaboration with the Norwegian Marketing Board for Fruits and Vegetables. In this programme the schools initially choose to participate or not, and then the pupils at the par- ticipating schools can decide to subscribe or not.
The cost for the parents is currently NOK 2.50 per school day (approximately EUR 0.30). The pupils who subscribe receive a piece of fruit or a carrot each school day, usually in connection with their lunch meal. Apples, pears, bananas, oranges, clementines, kiwis, carrots and nectar- ines are the most common types. The programme is subsidized by the Norwegian Government with NOK 1.00 per pupil per school day.
It is a great challenge to get schools to partici- pate and parents/pupils to subscribe. In the spring of 2006 did 41 % of Norwegian elementary schools participate, and within these schools did 28 % of the pupils subscribe [ 8 ], giving a total of only 12 % of all Norwegian school children.
Younger pupils tend to subscribe to a greater extend then older pupils.
Despite the Norwegian welfare state and the large Norwegian GDP per-capita, there are large social inequalities in health in Norway [ 9 ].
Social inequalities are also seen in health-related behaviours (e.g., in diet quality), and among ado- lescents in Norway rather large sex [ 10 ] and socio- economic [ 11 ] disparities in FV intake have been reported. For example, boys have been reported to eat FV 11.9 times/week, compared to 14.5 times/
week for girls [ 10 ]. Adolescents of parents with higher education (as an indicator of socioeco- nomic status) have been reported to eat more FV than adolescents of parents without higher educa- tion, and this disparity is increasing with age; 14.0 vs. 12.8 times/week for high and low socioeco- nomic status (SES) at age 12.5 and 15.1 vs. 12.7 times/week respectively at age 15.5 [ 11 ]. There is a governmental desire to reduce these inequalities, and a free school fruit programme has been sug- gested as an effective means of achieving this goal since all adolescents attend school [ 12 ].
From fall 2007, an offi cial free school fruit programme (without parental payment) was implemented in all secondary elementary schools (grades 8–10) and all combined schools (grades 1–10) in Norway. Indeed, it is now legally estab- lished that all pupils in secondary schools are entitled to a free piece of fruit or vegetable every school day [ 13 ]. The subscription program, with parental payment, still runs in primary/elemen- tary schools (grades 1–7).
The Fruits and Vegetables Make the Marks Project
Within the research project Fruits and Vegetables Make the Marks (FVMM) we have evaluated the subscription programme and the effect of receiv- ing free school fruit in two studies. The present paper is a summary of the results previously pre- sented in international journals [ 7 , 14 – 19 ].
Study Design of the FVMM Project A longitudinal school-based intervention study was initiated in 2001 (Cohort 1, Table 11.1 ), and a new repeated cross-sectional survey was con- ducted at the same schools in 2008 (Cohort II, Table 11.1 ).
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STUDY 1: In 2001, 48 elementary schools from Hedmark and Telemark counties (24 schools in each county) were randomly selected and invited to participate in the research project FVMM, and 19 schools from each county agreed to participate. These two counties were chosen because the subscription programme was about to start in these counties during the autumn semester of 2001. All sixth and seventh graders (age 10–12), and one of their parents, in the 38 schools were invited to take part in a question- naire survey in September 2001 (which was the baseline survey for Cohort I, see Table 11.1 ) [ 14 , 15 , 20 ]. In total 1,950 pupils (85 %) and 1,647 parents participated in the baseline survey.
Further two surveys were carried in these schools in May 2002 and May 2003, a fourth survey was carried out in May 2005 (at that time the study population were in ninth and tenth grade in 33 different secondary elementary schools), and a fi fth survey in September 2009 (at that time most participants had fi nished high school).
At the fi rst survey in September 2001 no pupils participated in any school fruit pro- gramme. A total of 9 out of the 38 elementary
schools were offered to participate in the school fruit programme for free from October 2001 to the end of the school year (i.e., June 2002), and all schools wanted to participate, giving all pupils in these schools free school fruit this school year.
Free school fruit for the nine schools was made possible by the Norwegian Fruit and Vegetable Marketing Board through the collective agricul- tural agreement between Norway’s farmers and the agricultural authorities to reduce the price and the administration of the School Fruit Programme. Due to practical reasons only schools from Hedmark could receive free school fruit, and these 9 schools were therefore ran- domly drawn from the 19 participating schools in this county. Of the remaining 29 schools, 9 schools did chose to participate in the subscrip- tion programme starting in these counties this school year (lasting from October to June), while 20 schools opted not to participate.
STUDY 2: The 38 schools were recontacted in 2008 and invited to once more participate in a similar survey [ 19 ]. At that time 27 schools agreed to participate, and all sixth and seventh graders in these 27 schools were invited to take part in the survey (Cohort II, see Table 11.1 ).
Pupils at these 27 schools, both from 2001 to 2008, constitute the study sample of STUDY 2.
A total of 1,488 pupils (out of 1,727 eligible;
86 %) in 2001 and 1,339 pupils (out of 1,712 eli- gible; 78 %) in 2008 completed the questionnaire and brought home a parent questionnaire to be completed by one of their parents. In the case of 1,230 and 996 pupils, respectively, one of their parents completed the parent questionnaire.
The 2008 survey was also conducted in September. In September 2001, no schools had any organized school fruit programme at the sur- vey time. In September 2008, 5 schools partici- pated in the free offi cial nationwide school fruit programme (all schools with grades 1–10) (abbreviated FREE FRUIT 08), while 10 schools participated in the subscription programme (abbreviated SUBSCRIPTION 08) and 12 schools did not participate in any offi cial school fruit programme (abbreviated NO PROGRAM 08). The free fruit programme was implemented from fall 2007 in the fi ve schools.
Table 11.1 Describes the two different study designs for evaluating different school fruit programmes in Norway (Hedmark and Telemark counties) within the FVMM project: (I) A longitudinal design (Cohort I), and (II) two repeated cross-sectional surveys within the same schools (Cohort I vs. Cohort II)
Cohort I (38 schools, n = 1,950) a
Cohort II (27 schools, n = 1,339)
Baseline survey: 2001 First survey: 2008 Intervention: subscription
programme b
Intervention: subscription programme b
Free fruit PILOT c Free fruit nationwide d Follow-up surveys: 2002,
2003, 2005, 2009
a Of which 27 schools also participated in the 2008 survey (cohort II). n = 1,488 in these 27 schools
b The subscription programme (grades 1–10) was initiated in 1996 and made nation-wide in 2003. In Hedmark and Telemark counties this programme was initiated in 2001
c A free school fruit pilot programme was implemented within nine elementary schools (grades 1–7) during the school year of 2001/2002
d A free fruit programme was implemented nation-wide to all secondary elementary schools (grades 8–10) and all combined schools (grades 1–10) in Norway from fall 2007 11 Free Fruit for School Children to Improve Food Quality
Questionnaires in the FVMM Studies A written 24-h fruit and vegetable recall was used to assess pupils’ FV intake. The 24-h recall was read aloud to the pupils by a project worker. FV intake the previous day was recorded for school days (i.e., the survey was conducted on week- days, Tuesday through Friday). The 24-h recall separated the day into fi ve time periods (before school, at school, after school, at dinner, and after dinner). The pupils recalled the types of FV they ate at the different time periods in household measures (e.g., one apple, 12 grapes) or in por- tions (e.g., one portion of mixed green salad).
The household measures were coded into por- tions/day, and one portion was set at about 80 g (ranging from 65 g (one carrot), to 105 g (one apple/one orange)). The conversions from house- hold measures to portions were based on house- hold measures and food weights published by The Norwegian National Association for Nutrition and Health. Juices and potatoes were not included in the fruit and vegetable calcula- tions. F, V and FV intake at school (portions/day) and F, V and FV intake all day (portions/day) were calculated. The 24-h recall is previously presented, and validity and reliability have been reported for FV intake among sixth graders [ 21 ].
In addition, a frequency question was included, asking: How often do you eat fruits and / or vege- tables at school ? Response alternatives were:
Every school day, 4 days a week, 3 days a week, 2 days a week, 1 day a week, less than once a week and never. The FFQ question was dichoto- mized into a new variable; Eating FV at school 4 or 5 days/week vs. less. Eating FV 4 or 5 school days per week was interpreted as consuming FV at school on most school days. Based on data from a previous test–retest study involving 114 children from sixth grade [ 21 ], 93 % of the chil- dren were classifi ed into the same category in the dichotomized variable (4 or 5 days/week vs. less) on two assessments, 14 days apart [ 19 ].
A sum-score of unhealthy snacks was made from the following three items: “How often do you drink soda (including sugar)?”, “How often do you eat candy (e.g., chocolate, mixed candy)”, and “How often do you eat potato chips?” All
items had ten response alternatives (never, less than once a week, once a week, twice a week, … , 6 times a week, every day, several times every day), and they were scored (0, 0.5, 1, 2, …, 7, 10), giving the unhealthy snacks scale a range from 0 to 30 times/week. Based on data from a previous test–retest study involving 114 children from sixth grade (16), scores on the unhealthy snacks scale were signifi cantly ( p < 0.001) correlated (Pearson’s correlation coeffi cient; r = 0.71), and mean values were not signifi cantly different (paired samples t -test; 5.2 vs. 5.5 times/week, p = 0.24), on two assessments with 14 days in between [ 7 ].
The pupils reported their own sex. As an indicator of SES, parents recorded their own level of education (lower: having no college or university education/higher: having attended college or university).
The effect of the interventions is in STUDY 1 reported as the difference between intervention and control groups at the follow-up surveys, adjusted for baseline data (September 2001), or as the difference in FV intake between the inter- vention group and control group in the changes in FV intake from baseline to the follow-up survey.
The effect of the governmental efforts/interven- tions evaluated in STUDY 2 was assesses as the differences in the changes in FV intake over time for the different groups (FREE FRUIT 08, SUBSCRIPTION 08 and NO PROGRAM 08).
The Impact of Free School Fruit on Diet Quality
1. A free fruit programme is more effective than a subscription programme
STUDY 1: Only 9 of 29 schools that were not offered free school fruit, did choose to par- ticipate in the subscription programme. At these 9 schools did 41 % of the pupils in seventh grade choose to subscribe. This was 11 % of the total number of 7 grade pupils at the 29 schools that were offered the subscription programme.
FV intake at school did increase at schools tak- ing part in the subscription programme com- pared to the schools that chose not to take part in the subscription programme (the effect of the
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subscription programme was estimated to be 0.2 portions/school day at school, p = 0.003, and 0.1 portions/day for all day, p = 0.58) [ 14 ]. At the schools that received free school fruit the school year of 2001/2002 there were no seventh graders that did not want to participate (i.e., par- ticipation rate in the free fruit programme was 100 %). The effect of free school fruit was esti- mated to be 0.8 portions/day, both at school ( p < 0.001) and for all day ( p = 0.003), compared to schools not taking part in any school fruit programme. Free school fruit was also signifi - cantly more effective in increasing pupils FV intake than the subscription programme (differ- ence was 0.6 portions/day at school ( p < 0.001), and 0.7 portions/day for all day ( p = 0.03)).
STUDY 2: Unadjusted, FV intake at school for sixth and seventh grade pupils at the 27 schools increased from 0.36 to 0.71 portions/school day from 2001 to 2008 [ 19 ].
FV intake all day increased from 2.45 to 3.07 portions/day over the same period, and the proportion of pupils reporting to eat FV at school 4 or 5 days a week increased from 29 to 59 %. The increase in FV intake, both at school and all day, was largest within the schools that had been included since 2007 in the national free school fruit programme (Free fruit 08), and smallest within the schools not taking part in any of the govern- mental efforts to increase FV intake at school.
The time * group interaction was signifi cant for FV intake at school ( p = 0.02) but not sig- nifi cant for FV intake all day ( p = 0.20). All effects appear to be due to an increase in F intake only. The time * group interactions for both F intake at school and F intake all day were signifi cant; p < 0.001 and p = 0.04, respectively. The increases in F intake at school were 0.49, 0.29 and 0.18 portions/
school day, respectively for the Free fruit 08, Subscription 08 and No programme 08 schools, and the increases in F intake all day were 0.74, 0.39 and 0.16 portions/day, respec- tively. The increase in the proportion report- ing to eat FV at school 4 or 5 days a week increased respectively with 61, 34 and 9 per- centage points.
2. One year of free school fruit—sustained long- term effect
STUDY 1: One year (May 03) after the end of the free fruit programme did the pupils at these schools still eat more FV than the pupils at schools not taking part in the free fruit pro- gramme, both at school (0.2 portions/school day, p = 0.07) and all day (0.5 portions/day, p = 0.03) [ 15 ]. This sustained effect was also apparent 3 years after the end of the free fruit intervention (May 05) [ 16 ]. The sustained effect after 3 years was estimated to be 0.4 por- tions/day for all day ( p < 0.001) and 0.1 por- tions/school day at school ( p < 0.001) [ 16 ].
Some, but not all, of the sustained effect could be explained by a higher participation rate in the subscription programme among those receiving free fruit in the school year of 2001/2002 in the following years; e.g., 31 % of those receiving free school fruit in 2001/2002 did subscribe in May 03 compared to 7 % of the pupils in the control schools [ 15 ]. Similar fi gures for May 05, while the participants were in secondary elementary school, were 16 % compared to 1 % [ 16 ]. Preliminary analyses from a new follow-up survey conducted in September 2009 indicates sustained effects of the free school fruit programme also 7 years after the end of the free fruit programme [ 22 ].
3. Free school fruit reduced consumption of unhealthy snacks
STUDY 1: Those receiving free school fruit did reduce consumption of unhealthy snacks, but this was only apparent for the chil- dren of parents without higher education (i.e., the low SES group) [ 14 ]. The pupils of par- ents without higher education did initially consume unhealthy snacks more often than pupils of parents with higher education (1.1 times/week more often ( p = 0.005)). The reduction in consumption of unhealthy snacks in the group of pupils of parents without higher education for those receiving free school fruit compared to those not receiving free school fruit was estimated to be 1.0 times/
week ( p = 0.04). This difference was sustained also 1 year after the end of the free fruit pro- gramme [ 15 ], but not after 3 years [ 16 ].
11 Free Fruit for School Children to Improve Food Quality
STUDY 2: From 2001 to 2008 consumption of unhealthy snacks in the study sample of all 27 schools decreased from 6.9 to 4.6 times/
week ( p < 0.001) [ 7 ]. The decrease of unhealthy snack consumption was largest within the schools that had been included in the national free school fruit programme (−2.6 times/week).
The effect of the school fruit programme was again signifi cant in reducing consumption of unhealthy snacks in children of parents without higher education, but not among children of parents with higher education. The decreases in consumption of unhealthy snacks were respec- tively 3.8, 2.5 and 1.6 times/week, respectively for the Free fruit 08, Subscription 08 and No programme 08 schools.
4. The subscription programme increases social disparities while the free fruit programme is effective among all groups
STUDY 1: For the subscription programme it was observed that at participating schools, those that subscribed were in general healthier than non-subscribers [ 8 , 14 , 18 ]. Compared to the non-subscribers, the subscribers were often more girls, more had plans of taking higher education, they ate more FV, they watched less TV, they were less physical active, they ate less often breakfast, lunch and supper, they had a lower BMI and fewer were on a diet. Also par- ents to those subscribing were different from parents of non- subscribers. Parents of subscrib- ing pupils were older, more had higher educa- tion, had higher income, watched less TV and smoked less than parents of non-subscribers.
In the main analyses of free school fruit we did not observe any difference of the effect of free school fruit on FV intake regarding sex, parental education level, ini- tial habitual FV intake and preferences for FV. That is, the effect of the intervention was not different for different groups.
However, we did observe an interaction between sex and the school’s participation in the subscription programme the year follow- ing the free fruit programme: Girls did sustain their elevated FV intake independent of whether the school participated in the subscription programme or not, while boys
only sustained their elevated FV intake if the school participated in the subscription pro- gramme the year following the free fruit programme—indicating that boys might need an elevated accessibility of fruit and vegetables more than girls, in order to sus- tain the increased intake level [ 15 ].
STUDY 2: Also in STUDY 2 the effect the free fruit programme appears to be similar for both boys and girls and for children of parents both with and without higher educa- tion [ 19 ]. For example, the percentage of boys and children of parents without higher education reporting to eat FV at school 4 or 5 days/week within the Free Fruit 08 schools increased from 20 % and 28 % in 2001 to 81 % and 79 % in 2008, respectively, while the same fi gures for girls and for children of parents with higher education increased from 28 % and 30 % in 2001 to 88 % and 90 % in 2008 [ 19 ].
Free School Fruit in a Broader Perspective
Due to low participation rates from schools and low subscription rates from pupils, the subscrip- tion programme do only have a limited effect of increasing school children’s FV intake. In addi- tion, it is in general a healthier group of pupils that choose to subscribe, a fact that might increase the social disparity seen in children’s FV intake.
The effect of the free programme on intake of FV is much larger than for the subscription pro- gramme, and the free programme appears to increase FV intake among all groups of chil- dren—also those that initially eat the least (as boys and pupils in low SES families).
It is diffi cult to state the health impact of a free school fruit programme. We have assessed the effect of 1 year of free school fruit. What effect would a free fruit programme for all 10 years of elementary school give? Research indicates that repeated exposure for FV increase children’s preferences for these foods [ 23 , 24 ]. That those given free fruit for 1 year also 1 and 3 years later still eat more FV than the control condition gives