Lessons still unlearned

It’s incredible what studies are ignored by the media. Researchers recently released a study evaluating the effectiveness of “the largest scale intervention in English children’s diet since the introduction of free school milk in 1946.” Called the School Fruit and Vegetable Scheme, it’s part of the 5 A-Day programme to teach children about healthy eating and increase fruit and vegetable consumption. Since November 2004, every child aged four to six years of age has received a free piece of fruit or vegetable each school day. This massive program has distributed 440 million pieces of produce each year to more than two million children in 18,000 schools, at a cost of $284.24 million (in U.S. dollars) just during its first two years.

With all of the attention on getting kids to eat healthy, you would think this study would be newsworthy...

The School Fruit and Vegetable Scheme (SFVS) program took years to develop. According to the NHS ministers, the program was designed to create lifelong healthy eating habits and complement the National Healthy School Standard to include diet and nutrition issues in all aspects of students’ school life. Surveys of the pilot programs reported that 97% of the schools had used it to teach children about healthy eating and 78% had incorporated it into classroom nutrition educational activities.

But even the pilot programs, involving 500 schools during the spring of 2001, were reporting little more than anecdotal successes. To look at actual effectiveness, a small, cross-sectional study of pupils in eight of the pilot schools was published in 2005. It found that the free fruit program had only modest, short-term effects (equivalent to 2/3 of an apple) but failed to improve fruit intake longer term among 7-8 year olds who were no longer receiving free fruit. There was no evidence to suggest that the program would actually work to change children’s continued diets. In fact, the researchers at King’s College in London, who’d conducted the pilot study analysis, had cautioned: “If the scheme is to affect dietary habits and improve health in the long term, further interventions will be needed.”

The full SFVS program for all school youngsters was launched in 2004 and just evaluated by researchers, led by Jane Ransley, lecturer with the Nutritional Epidemiology Group, Centre for Epidemiology and Biostatistics, University of Leeds, UK. They randomly sampled 2,681 - 2,045 children in 98 of the participating schools three times throughout the program, administering 24-hour dietary assessments completed by their parents or guardians. The results were compared to 2,143 - 1,648 children of the same ages and initial diets who acted as controls. Three months into the program, the kids in the intervention group were eating one-half serving more of fruits and vegetables. By 7 months, the changes had waned to 0.2 serving difference and disappeared entirely in year two. After that time the kids were no longer eligible for the program.

In other words, even giving children free produce didn’t change their diets or prove effective in instilling longer-term changes in their eating. The researchers concluded:

The findings of this evaluation showed that a short term increase in fruit intake can be achieved in young children who remain in the scheme; however, further interventions may be needed to prevent the waning of this effect….

The findings of our study and those of Wales and Nelson [of the pilot study] cast doubt on the effectiveness of the SFVS to sustain long term increased fruit and vegetable intake in children.

So, what did Ransley and her colleagues propose?

To have a greater impact on fruit and vegetable intake we hypothesise that the intervention would need to be more structured and target other meal events such as school dinners, packed lunches, and meals eaten at home. It would also need to be sustained throughout a child’s education...[and include] teachers, parents, the local community and canteen staff.

Here again, is another costly and extensive public health initiative targeting children that’s been shown not to work, so the recommended solution is to expand it.

It’s similar to the extensive and costly 5-A-Day for Better Health Program launched here in 1991. Recently, it was reported that after 15 years, the entire 5-A-Day campaign has been a dismal failure. The response to this evidence, too, was that we need to spend more and make the program bigger.

The justifications for 5-A-Day programs in the UK, as here, are claims of the horrible diets of today’s children and the need to promote more produce to reduce cancer, heart disease and obesity. As we’ve seen, generations of parents have wished their kids ate better, but stories of the dire states of children’s diets are overstated. Children also grow up and studies have shown that so do their diets, as they embrace greater varieties of foods and their tastes mature. More importantly, the most well-conducted studies following hundreds of thousands of people for decades continue to show “no relationship between fruits and vegetables and cancer and no statistically significant associations with major chronic disease or cardiovascular disease.” There have also been no efforts to learn what adverse effects the 5-A-Day programs might be having on children.

The title caption of the Ransley-led study was “Evidence-based Public Health Policy and Practice.” It's yet to be seen if it will prove to have been accurately named.

© 2007 Sandy Szwarc