Research reportSchool-based intervention with children. Peer-modeling, reward and repeated exposure reduce food neophobia and increase liking of fruits and vegetables☆
Introduction
Over the past few decades, there has been a steep rise in obesity worldwide, with one-third of children becoming overweight or obese by the time they are 2 years old. Given that child obesity and its health impacts last into adulthood, preventing obesity from an early age has become a major public health priority in the developed world (WHO, World Health Organization, 2012). Data on Italian children show that the prevalence of overweight and obesity is about 30%, indicating an increase of 10–15% in the last 10 years (Italian Ministry of Health, 2012). The origins of obesity are manifold and complex: although there are some genetic causes, most of them are related to lifestyle and the dietary habits of the children and their families. Currently, the everyday environment provides a surfeit of inexpensive, energy-dense foods that humans are biologically predisposed to choose over less caloric options (Ostan, Poljsak, Simcic, & Tijskens, 2010). At the same time, lifestyles have become increasingly sedentary.
It is well known that regular consumption of fruits and vegetables (FV) is associated with health benefits (Antova et al, 2003, Kraak et al, 2013). Also, emerging evidence suggests that increasing FV consumption is one of the factors which may assist dietary weight management strategies to prevent obesity (Ledoux, Hingle, & Baranowski, 2010). Despite this, children's consumption of FV is far below the five recommended servings per day (Baranowski et al, 2000, Coulthard, Blissett, 2009). Increasing FV consumption has been reported as a global public health nutrition priority (WHO, World Health Organization, 2003). However, minimal progress has been made in developing effective means to ensure an adequate intake of these foods because FV continue to be among the most disliked foods by children (Chapman, Armitage, 2012, Skinner et al, 2002).
Over the past 30 years, research on children's food habits has identified several variables that can influence their liking and consumption of different foods. According to the social learning account of Bandura (1977), modeling by significant others can be highly influential in establishing food behavior changes. Models that have been shown to be effective with children include cartoon characters, peers, mothers, unfamiliar adults and teachers. In contexts other than food consumption, research has also shown that children are more likely to imitate a model whose behavior they see is being rewarded, who is of the same age or slightly older than themselves or who they like or admire. Children are also more likely to imitate the behavior of multiple rather than single models (Lowe, Horne, Tapper, Bowdery, & Egerton, 2004). Another influential variable for modifying food habits is to induce prolonged exposure to a stimulus. According to Zajonc's “mere exposure” theory (Zajonc, 1968), repeated exposure to a specific food increases the liking and consumption of that food (Cooke et al, 2011, Wardle et al, 2003b). The mechanism by which repeated exposure increases liking is thought to be a “learned safety” behavior (Kalat & Rozin, 1973). This hypothesis proposes that repeated ingestion of an unfamiliar food without negative consequences leads to increased acceptance of that food. The importance of familiarity related to food choices can be explained with reference to Rozin's concept of “neophobia” (Rozin, 1976). Neophobia is a protective mechanism that prevents animals and humans from eating something that could be harmful to them. At the same time, it leads humans to choose familiar and safe foods instead of new and unfamiliar ones (Mustonen, Rantanen, & Tuorila, 2009). Although food neophobia was evolutionarily useful, in a modern society where food safety is guaranteed, it can have a negative effect on food choices, as individuals avoid new food experiences and thus lack dietary variety (Carruth et al, 1998, Nicklaus et al, 2005). This maladaptive behavior may be of particular relevance for children who show a strong neophobic attitude toward food, especially FV (Cooke et al, 2006, Rubio et al, 2008).
For several years, researchers have been focusing on establishing psycho-educational programs aimed at improving eating habits and lifestyles in children. For example, recent studies reported a positive influence of sensory education on French and Finnish children's food-related behavior (Mustonen et al, 2009, Mustonen, Tuorila, 2010, Reverdy et al, 2008, Reverdy et al, 2010).
The program used in the present paper, the ‘Food Dudes’ program, is based on the previously mentioned core principles derived from the literature on the determinants of children's food preference, namely modeling, reward and repeated exposure, which encourage children to taste FV. The ‘Food Dudes’ program has been applied in countries such as Ireland, the United Kingdom and the United States (Horne et al, 2009, Lowe et al, 2004, Wengreen et al, 2013) with encouraging findings. The results showed a large and lasting increase in children's FV consumption, which can be generalized to the home setting. This intervention has never been tested in Italy, except Sicily (Presti, Cau, & Moderato, 2013). Therefore, in view of the differences in food habits between the Italian population and British and American people, it might be interesting to apply this program to children with a different food cultural heritage.
The present study is part of a larger research program funded by Regione Lombardia aimed at improving healthy food consumption in primary school-aged children. This research project consisted of the application of the ‘Food Dudes’ intervention in a large cohort of Italian children and the measurement of the impact of such an intervention on several variables, such as FV intake and liking, food neophobia, nutritional status and food behavior. The specific aim of the present study was to verify the effectiveness of the intervention in reducing food neophobia and increasing liking for FV among children who were exposed to the program compared with a control group of children.
Section snippets
Participants
Parents were asked to read a short study explanation, to complete an informative questionnaire and to sign a consent form. Only children who returned the consent form completed by one of the parents or a legal guardian were considered for the study. In total 620 consent forms were distributed and 591 were returned, with a response rate of about 90%. Thirty-one children were excluded because their parents reported that their children suffered from food allergies, followed a specific diet or
Evaluation at baseline
Significant differences were found for Gender (F = 4.82, p < 0.05) and Age (F = 8.67, p < 0.001). Boys (M = 21.6) were more neophobic than girls (M = 20.5). The four age classes differed significantly from each other, and a reduction of the neophobic attitude was observed with increasing age (mean scores: 6 years = 23.3, 7 years = 21.5, 8 years = 20.7, 9 years = 18.8). The Gender × Age interaction was not significant, as boys were more neophobic than girls in all age groups, although
Discussion
This study investigated whether and how the application of the ‘Food Dudes’ multi-component school-based intervention, consisting of rewards, peer-modeling and repeated exposure to FV, influenced the liking of such food, in addition to food neophobia, in a large cohort of Italian children aged between 6 and 9 years. The main findings of the study were that the intervention is effective in reducing food neophobia and, most importantly, that this effect is also observed over the long term (6
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Acknowledgments: This work was funded by Regione Lombardia (project: “FOOD AND FUN”: Consumi alimentari dei bambini della scuola primaria. Analisi e ricerca su modelli di intervento per la prevenzione dell'obesità e soprappeso, 2011–2012). We are grateful to the children, parents and teachers for their active participation and all their efforts. Sara Carenini, Silvia Cau, Ramona DeAmicis, Francesca De Palma, Michela Di Iorio and Alice Lotterio are acknowledged for their help in delivering the program in the schools (grant number: 03012010).