Consumption of vegetables at dinner in a cohort of Norwegian adolescents

Consumption of vegetables at dinner in a cohort of Norwegian adolescents

Available online at www.sciencedirect.com Appetite 51 (2008) 90–96 www.elsevier.com/locate/appet Consumption of vegetables at dinner in a cohort of ...

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Available online at www.sciencedirect.com

Appetite 51 (2008) 90–96 www.elsevier.com/locate/appet

Consumption of vegetables at dinner in a cohort of Norwegian adolescents Kristine Vejrup a, Nanna Lien a, Knut-Inge Klepp a, Elling Bere b,* b

a University of Oslo, Department of Nutrition, Oslo, Norway University of Agder, Faculty of Health and Sport, Serviceboks 422, 4604 Kristiansand, Norway

Received 26 October 2007; received in revised form 11 December 2007; accepted 12 December 2007

Abstract This longitudinal study examined the frequency of consumption of vegetables for dinner by Norwegian adolescents and their parents. Associations of perceived availability, correlations and stability were explored. The longitudinal cohort consist of 1950 adolescents attending 6th/ 7th (2002) and 9th/10th (2005) grade, and their parents (n = 1647). Only 40% of the adolescents and 60% of the adults reported to have eaten vegetables for dinner yesterday, the reported frequency of vegetables for dinner were 3.7 and 4.1 times/week in 2002 and 2005, respectively, and 4.8 times/week for parents. Girls ate more than boys, and high SES adolescents ate more than low SES adolescents. There were significant differences between adolescent and parent report of both frequency of consumption and perceived availability of vegetables for dinner. Adolescent’s frequency of consumption of vegetables was related to the parent’s consumption, and the adolescent response from 2002 to 2005 showed strong correlations. There were good tracking in the frequency of consumption of vegetables for dinner, and 25% of the adolescents showed a stable high frequency. To conclude, few adolescents and their parents consumed vegetables for dinner. Interventions are needed to meet the recommendations, and parents should be targeted in intervention programs. # 2007 Elsevier Ltd. All rights reserved. Keywords: Adolescents; Vegetables; Dinner; Stability; Availability

Introduction It is well known that an increased fruit and vegetable consumption would have great health impacts (Danaei, Vander, Lopez, Murray, & Ezzati, 2005; Key et al., 2004; World Health Organization, 2003). The recommendation for fruit and vegetable consumption in Norway is at least two portions of fruit and three portions of vegetables per day (Statens ernæringra˚d, 1996) including fruit juice and potatoes, which has been interpreted as 750 g (Statens ernæringra˚d, 1996; World Health Organization, 2004). Children are also recommended to eat at least five portions a day, but with somewhat smaller portions than for adults (World Health Organization, 2003; Sosial- og helsedirektoratet, 2005; Statens ernæringra˚d, 1996). The latest dietary survey among children and adolescents in Norway found that 4th and 8th graders had an average fruit and vegetable consumption of 250 and 255 g/day,

* Corresponding author. E-mail address: [email protected] (E. Bere). 0195-6663/$ – see front matter # 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.appet.2007.12.004

respectively (including juice and potatoes) (Øverby & Andersen, 2002). Consumption of fruit was somewhat larger than consumption of vegetables (Øverby & Andersen, 2002), despite the recommendations of at least three portions of vegetables a day. The typical meal pattern in Norway is one hot meal (dinner) and two or three cold meals (Makela et al., 1999). The cold meals usually contain bread or cereals, and the possibility for eating vegetables are rather low. In between meals fruit is more practical to eat than vegetables as they come in convenient portion sizes, in their own package, and compared to vegetables, they need little treatment prior to eating (Bere, Veierod, & Klepp, 2005). Vegetables are therefore mostly eaten at dinner in Norway (Andersen, Bere, Kolbjornsen, & Klepp, 2004; Lien, Lytle, & Klepp, 2001). Because dietary behaviours are complex and difficult to explain and change, Baranowski et al. have suggested to explain more situational behaviours for better explanations of dietary behaviours (Baranowski, Lin, Wetter, Resnicow, & Hearn, 1997; Baranowski, Cullen, & B, 1999). Vegetables eaten at dinner is such a situational dietary behaviour.

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There are numerous studies on fruit and vegetable consumption in adolescents, but few that specifically focus on vegetable consumption at dinner, and all found were US studies. One US study, investigating patterns in children’s fruit and vegetable consumption by meal and day of the week (Baranowski, Smith, et al., 1997), found that fruits and vegetables are most frequently consumed at weekday lunch, and second most frequently at dinner. Other studies showed that family meals appear to play an important role in promoting positive dietary habits including vegetable consumption among adolescents (Gillman et al., 2000; Neumark-Sztainer, Hannan, Story, Croll, & Perry, 2003; Neumark-Sztainer, Story, Resnick, & Blum, 1996; Videon & Manning, 2003). Hanson and coworkers reported no association between how often vegetables were served at dinner (parent reports) and adolescent’s vegetable consumption at dinner (Hanson, Neumark-Sztainer, Eisenberg, Story, & Wall, 2005). As availability and accessibility of fruits and vegetables are seen as the two strongest predictors of fruit and vegetable consumption (Rasmussen et al., 2006), vegetables served at dinner should indicate good availability of vegetables at dinner. Availability is defined as foods of interest being present in an environment, and accessibility are defined as foods being available in a form, location and time that facilitates their consumption (Cullen et al., 2003). Using longitudinal data, the objectives of the present study are to; report how often adolescents and their parents eat vegetables for dinner, to assess the relationship between adolescent and parental consumption and perceived availability of vegetables at dinner, to assess the stability of consumption over time, and to explore potential gender, age and socio economic differences. Methods Study design This study is a part of the project Fruits and Vegetables Make the Marks (FVMM). FVMM is an intervention project including 38 randomly selected elementary schools in two Norwegian counties. A total of 18 schools, 9 schools from both counties, were randomly chosen as intervention schools, while the remaining 20 schools were control schools (Bere & Klepp, 2004). For the 2005 follow-up survey 33 secondary schools participated. The FVMM interventions were conducted in 6th and 7th grade classes in the school year of 2001/2002, with follow-up surveys in May 2002, 2003 and 2005. The survey questionnaire was completed by adolescents in the classroom, in the presence of a trained project worker. One school lesson (45 min) was used to complete the questionnaire. For adolescents that were not present at school the day of the survey, a questionnaire (and a pre-stamped envelope) was left for them to fill in and return. The participating adolescents brought home a questionnaire to be completed by a parent. Informed consent was obtained from the parents and the adolescent prior to the first survey. Research clearance was obtained from The Norwegian Social Science Data Services.

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Study sample Adolescents data from the first follow-up (May 2002) and third follow-up (May 2005) surveys, and parental data from baseline and the 2002 survey were used in the present study (Table 1). Attrition analyses showed that there was a 16% dropout of participants from the 2002 to the 2005 survey. Adolescent’s frequency of consumption and perceived availability of vegetables at dinner were not significantly different in the participant and dropout groups, neither was parent’s frequency of consumption. Only parent educational level was significantly associated with dropouts. A total of 64% of the dropouts had parents with a low educational level compared to 57% in the study sample ( p < 0.05). Instrument The FVMM questionnaires included a 24-h fruit and vegetable recall, a food frequency questionnaire, questions assessing potential correlates of adolescents’ fruit and vegetable consumption, demographic questions and questions concerning health related behaviours. Both the 24-h recall and the food frequency questions for all day consumption are previously presented, and their validity and reliability have been reported for FV intake among 6th graders (Andersen et al., 2004). The specific items for vegetable consumption at dinner have previously not been separately presented. The 24-h recall question for vegetables for dinner were as follow; ‘‘Did you eat vegetables for dinner/at dinner time yesterday?’’ (yes/no). The frequency of vegetable consumption at dinner was assessed by; ‘‘How often do you eat vegetables for dinner?’’ (10 response categories ranging from never = 0 to several times a day = 10). For some of the analyses, this frequency item was categorised into three groups; 2 times/week, 3–4 times/week and 5times/week. Availability of vegetables at dinner was measured by one statement; ‘‘At home we usually have vegetables at dinner every day’’ (five response categories ranging from totally disagree to totally agree). This variable was coded 2 to 2, with 0 as neither disagree or agree. Socioeconomic status (SES) was measured as the educational level of the parent answering the baseline 2001 questionnaire (lower: no college or university education/higher: having attended college or university). Statistics There were no significant difference between adolescents from the intervention and control group in either the 2002 or the 2005 surveys; therefore the analyses were conducted on the whole group. Paired-samples t-test were used to measure difference over time within the cohort and also between adolescent and parent reports. Person’s correlation coefficients were computed to show the relationship between the adolescent consumption and perceived availability of vegetables for dinner. Stability in consumption was calculated by crosstabulating the frequency data. The adolescents were categorised into five groups depending on their stability or increase/

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Table 1 Characteristics of the study population in 2002 survey and 2005 survey Characteristics of the study population

Baseline 2001

2002

2005

2002 and 2005

Adolescens Total participants

1950

1794

1601

1504

Gender at 2002 and 2005 survey Boys Girls

890 (50.1%) 885 (49.9%)

Anticipated education level of adolescents at 2005 survey High Low Parents Number of parents participating Missing % of parents of adolescents participating Education level of parents High Low

782 (49.4 %) 800 (50.6%)

732 (48.7%) 753 (51.3%)

743 (52.2%) 673 (47.5%)

1647 327 (16.8%)

1326 468 (26.1%)

679 (41.8%) 944 (58.2%)

Missing (of total participants at baseline) 2002 = 156 (8%); 2005 = 349 (18%).

decrease in frequency of consumption of vegetables for dinner from 2002 to 2005 (Lien et al., 2001). Finally, a step-wise multiple regression analyses were performed separately for 2002 and 2005. These analyses were first performed including the independent variables age, gender and parent education (model 1), and then again also including adolescents’ perceived availability of vegetables for dinner in addition (model 2). The statistics were conducted using SPSS for Windows, version 14. Results The 24-h recall data showed that over 90% of the adolescents and parents reported to have eaten dinner yesterday (Table 2). A total of 38% and 39% of the adolescents, in the 2002 and 2005 survey, respectively, and 60% of the parents, reported to have eaten vegetables for dinner/at dinner time yesterday. The 24-h recall showed no significant difference in consumption of vegetables for dinner from 2002 to 2005 ( p = 0.8), but there was a significant difference in the 24-recall

between adolescent 2002 and parent 2002 ( p < 0.001). The FFQ showed that the frequency of vegetable consumption for dinner was 3.7 times/week and 4.1 times/week, for the 2002 and 2005 survey, respectively, and the parents reported a frequency of 4.8 times/week. The increase in frequency of consumption for adolescents from 2002 to 2005 was statistically significant ( p < 0.001). The adolescents’ frequency of consumption in 2002 was significantly lower than the parents’ frequency of consumption in 2002 ( p < 0.001). For the adolescents, the mean perceived availability was 0.44 and 0.69 in the 2002 and 2005 surveys, respectively. For the parents the mean perceived availability was 0.96 in the 2002 survey. There was a significant increase in mean perceived availability reported by adolescents from 2002 to 2005 ( p < 0.001). The adolescents’ mean availability in 2002 was significantly lower than the parents’ mean availability in 2002 ( p < 0.001). Adolescents’ reports in 2002 and 2005 of frequency of consumption of vegetables for dinner (r = 0.52, p < 0.001) and

Table 2 Vegetable intake at dinner by description of different methods Variable

24 h-recall; Had dinner yesterday (%) 24 h-recall; Had vegetables at dinner yesterday (%) Frequency of vegetables for dinner (times/week) 2 times/week 3–4 times/week 5 times/week Perceived availability of vegetables for dinner ( 2/2) Low perceived availability of vegetables for dinner Neither low or high perceived availability of vegetables for dinner High perceived availability of vegetables for dinner

Adolescent 2002

Adolescent 2005

Parent

n

Mean or % 95% confides interval

n

Mean or % 95% confides interval

n

Mean or % 95% confides interval

1787 1794 1779 510 612 657 1779 455 315 1009

91.7 (1.07–1.10) 38.3 (0.36–0.41) 3.7 (3.6–3.8) 28.7 34.4 36.9 0.44 (0.37–0.50) 25.6 17.7 56.7

1595 1601 1584 356 525 703 1594 303 271 1020

91.7 (0.90–0.93) 39.4 (0.37–0.42) 4.1 (4.0–4.2) 22.5 33.1 44.4 0.69 (0.63–0.75) 19.0 17.0 64.0

1307 1326 1320 136 431 753 1318 231 113 974

92.2 (1.06–1.09) 59.7 (0.57–0.62) 4.8 (4.7–4.9) 10.3 32.7 57.0 0.96 (0.90–1.03) 17.5 8.6 73.9

Reports from adolescents and parents in 2002 and 2005. Perceived availability of vegetables for dinner defined/measured by the statement: at home we usually have vegetables for dinner every day. The response category is a 5-point scale from 2 = I fully disagree to 2 = I fully agree. There was a significant increase in frequency and perceived availability from 2002 to 2005 among adolescents. There was a significant difference in adolescent and parent frequency and perceived availability.

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Table 3 Correlations between adolescent and parent report of intake of vegetables for dinner and adolescent and parent perceived availability of vegetables for dinner

All correlations are significant at the 0.01 level (two-tailed).

perceived availability (r = 0.35, p < 0.001) were significantly correlated (Table 3). Correlations from the 2002 survey between the adolescent’s and parent’s consumption (r = 0.25) and adolescents’ and parents’ perceived availability (r = 0.23) were lower, but both were statistical significant ( p < 0.001). Correlation within groups between consumption and availability for adolescents in the 2002 survey (r = 0.46), adolescent in the 2005 survey (r = 0.59) and parents in the 2002 survey (r = 0.60) were all significant at the p < 0.001 level. A total of 53% of adolescents were in the same category of consumption of vegetables for dinner in 2002 and in 2005 (Table 4). The share of adolescents that increased their frequency of consumption from 2002 to 2005 were 29%, and 18% of the adolescents decreased their frequency from 2002 to 2005. A comparison of the adolescents that reported a change in frequency from 2002 to 2005 showed that there is a larger tendency of adolescents with medium frequency in 2002 to change to higher frequency in 2005. In 2002, girls had vegetables for dinner 0.41 times/week more frequent than boys, and those with high SES had vegetables for dinner 0.61 times/week more frequent than those with low SES (Table 5). In 2005 the gender differences was 0.37 times/week and the SES difference was 0.76 times/ week. These gender and SES differences declined when

perceived availability was included in the models (models 2) (Table 5). Perceived availability increased the models’ explained variance in pupils’ fruit and vegetable intake from 3% to 25% and from 4% to 35%, respectively for 2002 and 2005 data (Table 5). Discussion In order to meet the national recommendation, all Norwegians should eat vegetables for dinner every day. Findings from this study show that few adolescents and parents reported to have vegetables for dinner a given weekday. Vegetables are typically eaten for dinner in Norway, and not having vegetables for dinner would make it difficult, if not impossible, to reach the recommended 3-a-day. This study therefore gives evidence to the fact that Norwegian adolescents’ and their parents’ consumption of vegetables for dinner are to low. The Norwegian adolescents consume fewer vegetables than recommended, and parent reports also show that vegetables are not served at dinner every day. There are no studies with data on vegetables consumed for dinner among adolescent in the Nordic countries, but studies on the overall consumption of vegetables by adolescents indicate an overall low intake (Samuelson, 2000).

Table 4 Stability in adolescent individual response from 2002 to 2005 in frequency of consumption of vegetables for dinner

Out of the total 18.3% that reported a decreased consumption of vegetables for dinner, and the 28.8% that reported an increase in consumption of vegetables for dinner, this is how the adolescents reported their frequency of consumption in 2002 and 2005.

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Table 5 Multiple regressions of frequency of consumption of vegetables at dinner by gender, parent education and age (models 1) and also including perceived availability (models 2), respectively in 2002 and 2005 Adolescents FFQ May 2002

Model 1 N = 1485

Step 1 Gender Parent education Age

Model 2 N = 1479

B

b

p-Value

0.41 0.61 0.32

0.10 0.14 0.08

<0.001 <0.001 0.003

B

p-Value

b 0.09 0.34 0.353

0.02 0.08 0.08

0.36 0.001 <0.001

0.75 0.25 0.25

0.47

<0.001

Step 2 Perceived availability of vegetables for dinner 0.035 0.033

R2 Adj R2 Adolescents FFQ May 05

Step 1 Gender Parent education Age

Model 1 N = 1345

Model 2 N = 1342

B

b

p-Value

0.37 0.76 0.22

0.09 0.19 0.06

0.001 <0.001 0.041

B

p-Value

b 0.10 0.35 0.17

0.02 0.08 0.04

0.28 <0.001 0.06

0.95 0.35 0.35

0.57

<0.001

Step 2 R2 Adj R2

Perceived availability of vegetables for dinner 0.044 0.042

B: Differences for gender. Boys = 1; girls = 2.

The adolescent’s response in 2002 and 2005 showed strong correlations and good tracking. There was a large portion of the adolescents that had a stable frequency of vegetables for dinner from age 12 to 15 years and there was a trend of increasing both frequency of consumption and perceived availability of vegetables for dinner by age. Contrary to other studies that indicate a decrease in consumption of vegetables in the transition from childhood to adolescence (Lien et al., 2001; Lytle, Seifert, Greenstein, & McGovern, 2000; Samuelson, Bratteby, Enghardt, & Hedgren, 1996) a total of 29% of the adolescents reported an increase in their consumption of vegetables for dinner. This increase could be due to changes in society where there is an overall trend for an increased consumption of vegetables (Helse-og Omsorgsdepartement, 2007; Schmidhuber & Traill, 2006). In the regression analyses the age factor showed that both in 2002 and in 2005 the 1 year older adolescents reported slightly lower frequencies of consumption, but from 2002 to 2005 there was an overall increase in frequency of consumption in the cohort. This indicates that there was an overall increase in consumption of vegetables over time. An increase in the perceived availability was also observed with time. As the adolescents were 3 years older in 2005, an increased consciousness of the importance of vegetables for healthy eating as well as improved observation skills might possibly contribute to explain the increase in perceived availability. The adolescent’s and parent’s frequency of consumption of vegetables for dinner was correlated. The fact that the correlations were only moderate (r = 0.25) might be due to several reasons. Parents might over-report their vegetable

consumption, creating a pleasing bias (Mahan & Escott-Stump, 2000). Parents and adolescents might not eat dinner together because of different schedules, or the adolescents do not eat vegetables for dinner even if it is available. Adolescents might not perceive vegetables as available if they dislike the types served or the preparation methods used, or they do not think of vegetables in mixed dishes as vegetables. Family meals appear to play an important role in promoting positive dietary consumption among adolescents (Gillman et al., 2000). One study showed that frequency of consumption of vegetables increased with numbers of family meals pr week (Videon & Manning, 2003). Parents have the possibilities to influence their offspring. By providing vegetables and serving them in a way that appeal to the children parents might increase vegetables consumption in the family. Changing the home food environment can be difficult, and families’ decisions about foods available in the home are influenced by complex factors including taste preference, cultural preference, SES, and work and school schedules (Lytle et al., 2006). A key actor is the person in the household that provide and prepare the dinner (Hannon, Bowen, Moinpour, & McLerran, 2003). Interventions targeting the family member in charge of preparing meals might lead to an increased intake of vegetables for the whole family, however few such interventions have been reported. There are some other studies that also show an inconsistency between parents and adolescents reports of availability of vegetables (Bere & Klepp, 2004; Hanson et al., 2005; Tak, te Velde, de Vries, & Brug, 2006). In the present study parents and adolescents seemed to perceive the availability at home differently and also to have differences in frequency of

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consumption of vegetables for dinner. Focusing on vegetable availability in one specific meal, we might expect the parents and the adolescents to give similar situation report, but differences could occur due to individual differences as dislike of vegetables served (type or cooking method), difference in comprehension and knowledge or differences in meal patterns. Several studies focus on the importance to address home availability of vegetables because of its strong association with vegetable consumption (Bere & Klepp, 2004, 2005; Hanson et al., 2005; Neumark-Sztainer, Wall, Perry, & Story, 2003; Rasmussen et al., 2006), it is assumed role in influencing taste preferences and findings that availability influence consumption, even if taste preference is low (Neumark-Sztainer, Wall, et al., 2003). One study that assessed availability, accessibility and preferences for fruit and vegetables (Cullen et al., 2003), found that for children with high preference, availability was the only significant predictor, but for children with low preference both availability and accessibility were significantly connected to consumption. A resent review from Jago and colleagues (Jago, Baranowski, & Baranowski, 2007) brings up the importance of a greater understanding of the mechanisms of how availability influence consumption of fruit and vegetables. An important key issue discussed was the direction of causality; ‘‘Do children eat more fruit and vegetables because they are available, or do parents make fruit and vegetables available because they know their children will eat them?’’ (Jago et al., 2007). Girls reported to eat vegetables for dinner more frequently than boys and those with high SES reported to eat vegetables for dinner more frequently than those with low SES. These differences declined when perceived availability was entered into the models, which means that perceived availability mediated parts of the gender and SES differences in this study population. Recent studies from the FVMM project analysing mediators of gender and SES differences in frequency of (all day) fruit and vegetable intake reported perceived availability to be a mediator for both the gender difference (Bere, Brug, & Klepp, 2007) and for the SES disparity (manuscript submitted). As parents did not report any difference in availability for boys or girls, the findings suggest that the gender difference was not due to the actual availability, but rather to differences in the perceptions of the availability between the genders (Bere et al., 2007). Factors causing the gender difference in vegetable intake and also in the perceived availability of vegetables served at dinner is important to investigate closer in order to be able to make good interventions with effect also among boys. The SES disparity in consumption of vegetables at dinner is more likely to be due to the actual availability, since it has been reported that high SES parents also report higher availability of fruit and vegetables at home than low SES parents (manuscript submitted). Efforts to increase availability of vegetables for dinner among the low SES groups are therefore clearly needed. It is a challenge to increase availability in low SES families because vegetables are expensive (Darmon, Ferguson, & Briend, 2003; Drewnowski, Darmon, & Briend, 2004). The results from the present study should be viewed in light of some limitations. First, we have reported data on percentage

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of adolescents and their parents eating vegetables at dinner a given week-day, and also on the frequency of the consumption of vegetables at dinner. The exact amount (e.g. in g) of vegetables eaten at dinner would also have been valuable. However, these data are not available in the present project. The participating adolescents were from two of Norway’s 19 counties, but as Norway is a rather homogeneous country we assume that the results can be generalized to the entire country. The FVMM project was initially focusing on a general fruit and vegetable intake, therefore only a few questionnaire items assessed vegetables at dinner. We only have parental data from 2002, and could therefore not assess changes over time among the parents. Strength of the study is that it is one of the first European studies targeting a situation specific vegetable intake. Conclusions Few adolescents and their parents reported to consume vegetables for dinner. Those seldom eating vegetables at dinner at age of 12 also tend to seldom do it at age of 15. There were gender and SES differences in vegetable consumption at dinner, which were partly mediated by perceived availability. To increase consumption of vegetables among Norwegian adolescents, in order to meet the recommendations, interventions to increase vegetable consumption at dinner is clearly needed. Acknowledgement This study was funded by the Norwegian Research Council. References Andersen, L. F., Bere, E., Kolbjornsen, N., & Klepp, K. I. (2004). Validity and reproducibility of self-reported intake of fruit and vegetable among 6th graders. Eur. J. Clin. Nutr., 58, 771–777. Baranowski, T., Cullen, K. W., & Baranowski J, (1999). Psychosocial correlates of dietary intake: Advancing dietary intervention. Annu. Rev. Nutr., 19, 17– 40. Baranowski, T., Lin, L. S., Wetter, D. W., Resnicow, K., & Hearn, M. D. (1997a). Theory as mediating variables: Why aren’t community interventions working as desired? Ann. Epidemiol., 7, 89–95. Baranowski, T., Smith, M., Hearn, M. D., Lin, L. S., Baranowski, J., Doyle, C., et al. (1997b). Patterns in children’s fruit and vegetable consumption by meal and day of the week. J. Am. Coll. Nutr., 16, 216–223. Bere, E., Brug, J., & Klepp, K. I. (2007). Why do boys eat less fruit and vegetables than girls? Publ Health Nutr. Published online ahead of print August 1, 2007 at http://journals.cambridge.org/. Bere, E., & Klepp, K. I. (2004). Correlates of fruit and vegetable intake among Norwegian schoolchildren: parental and self-reports. Public Health Nutr., 7, 991–998. Bere, E., & Klepp, K. I. (2005). Changes in accessibility and preferences predict children’s future fruit and vegetable intake. Int. J. Behav. Nutr. Phys. Act, 2, 15. Bere, E., Veierod, M. B., & Klepp, K. I. (2005). The Norwegian School Fruit Programme: evaluating paid vs. no-cost subscriptions. Prev. Med., 41, 463– 470. Cullen, K. W., Baranowski, T., Owens, E., Marsh, T., Rittenberry, L., & de Moor, C. (2003). Availability, accessibility, and preferences for fruit, 100% fruit juice, and vegetables influence children’s dietary behavior. Health Educ. Behav., 30, 615–626.

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