Evaluation of a long day care intervention targeting the mealtime environment and curriculum to increase children's vegetable intake: a cluster randomised controlled trial using the multiphase optimisation strategy framework.

OBJECTIVE: To determine the reach, adoption, implementation and effectiveness of an intervention to increase children's vegetable intake in long day care (LDC). DESIGN: A 12-week pragmatic cluster randomised controlled trial, informed by the multiphase optimisation strategy (MOST), targeting the mealtime environment and curriculum. Children's vegetable intake and variety was measured at follow-up using a modified Short Food Survey for early childhood education and care and analysed using a two-part mixed model for non-vegetable and vegetable consumers. Outcome measures were based on the RE-AIM framework. SETTING: Australian LDC centres. PARTICIPANTS: Thirty-nine centres, 120 educators and 719 children at follow-up. RESULTS: There was no difference between intervention and waitlist control groups in the likelihood of consuming any vegetables when compared with non-vegetable consumers for intake (OR = 0·70, (95 % CI 0·34-1·43), P = 0·32) or variety (OR = 0·73 (95 % CI 0·40-1·32), P = 0·29). Among vegetable consumers (n 652), there was no difference between groups in vegetable variety (exp(b): 1·07 (95 % CI:0·88-1·32, P = 0·49) or vegetable intake (exp(b): 1·06 (95 % CI: 0·78, 1·43)), P = 0·71) with an average of 1·51 (95 % CI 1·20-1·82) and 1·40 (95 % CI 1·08-1·72) serves of vegetables per day in the intervention and control group, respectively. Intervention educators reported higher skills for promoting vegetables at mealtimes, and knowledge and skills for teaching the curriculum, than control (all P < 0·001). Intervention fidelity was moderate (n 16/20 and n 15/16 centres used the Mealtime environment and Curriculum, respectively) with good acceptability among educators. The intervention reached 307/8556 centres nationally and was adopted by 22 % eligible centres. CONCLUSIONS: The pragmatic self-delivered online intervention positively impacted educator's knowledge and skills and was considered acceptable and feasible. Intervention adaptations, using the MOST cyclic approach, could improve intervention impact on children' vegetable intake.

Development of an initiatives package to increase children's vegetable intake in long day care centres using the Multiphase Optimisation Strategy (MOST) randomised factorial experiment.

OBJECTIVE: To inform a package of initiatives to increase children's vegetable intake while in long day care (LDC) by evaluating the independent and combined effects of three initiatives targeting food provision, the mealtime environment and the curriculum. DESIGN: Using the Multiphase Optimisation Strategy (MOST) framework, a 12-week, eight-condition (n 7 intervention, n 1 control) randomised factorial experiment was conducted. Children's dietary intake data were measured pre- and post-initiative implementation using the weighed plate waste method (1× meal and 2× between-meal snacks). Vegetable intake (g/d) was calculated from vegetable provision and waste. The optimal combination of initiatives was determined using a linear mixed-effects model comparing between-group vegetable intake at follow-up, while considering initiative fidelity and acceptability. SETTING: LDC centres in metropolitan Adelaide, South Australia. PARTICIPANTS: 32 centres, 276 staff and 1039 children aged 2-5 years. RESULTS: There were no statistically significant differences between any of the intervention groups and the control group for vegetable intake (all P > 0·05). The curriculum with mealtime environment group consumed 26·7 g more vegetables/child/day than control (ratio of geometric mean 3·29 (95 % CI 0·96, 11·27), P = 0·06). Completion rates for the curriculum (> 93 %) and mealtime environment (61 %) initiatives were high, and acceptability was good (4/5 would recommend), compared with the food provision initiative (0-50 % completed the menu assessment, 3/5 would recommend). CONCLUSION: A programme targeting the curriculum and mealtime environment in LDC may be useful to increase children's vegetable intake. Determining the effectiveness of this optimised package in a randomised controlled trial is required, as per the evaluation phase of the MOST framework.

Application of the multiphase optimisation strategy to develop, optimise and evaluate the effectiveness of a multicomponent initiative package to increase 2-to-5-year-old children's vegetable intake in long day care centres: a study protocol.

INTRODUCTION: Globally, children do not eat enough core foods, with vegetable intakes persistently low. Early life is critical for establishing vegetable acceptance and intake. Increased usage of formal childcare has led to the importance of childcare settings shaping children's food intake. This study will use the multiphase optimisation strategy to develop, optimise and evaluate the effectiveness of a multicomponent initiative package to increase 2-to-5-year-old children's vegetable intake in long day care centres. METHODS AND ANALYSIS: The preparation phase will use existing literature and best practice guidelines to develop three initiatives aiming to: (1) increase vegetable provision at mealtimes, (2) deliver a vegetable-focused sensory curriculum and (3) use supportive mealtime practices encouraging children's tasting of vegetables. The optimisation phase (N=32 centres) will use a 12-week, eight-condition factorial experiment to test main and synergistic effects of the initiatives. The optimum combination of initiatives producing the largest increase in vegetable intake will be identified. The evaluation phase (N=20 centres) will test the effectiveness of the optimised package using a 12-week waitlist randomised controlled trial. Primary outcomes are children's vegetable intake and food group intake at long day care. Secondary outcomes are menu guideline compliance, cook and educator knowledge and skills, and reach. Process evaluation will include fidelity, acceptability, barriers and facilitators, and compatibility with practice. Repeated measures ANOVA with interaction effects (optimisation phase) and linear mixed modelling (evaluation phase) will test effects of the initiatives on vegetable intake. ETHICS AND DISSEMINATION: This study has received ethics approval from the Flinders University Research Ethics Committee (Project No: 1873) for the optimisation phase. Approval for the evaluation phase will be obtained following completion of optimisation phase. Findings will be disseminated to stakeholders, including long day care centres and childcare organisations; and to researchers via peer-reviewed journals and conferences. TRIAL REGISTRATION NUMBERS: ACTRN12620001301954, ACTRN12620001323910p.

Supporting strategies for enhancing vegetable liking in the early years of life: an umbrella review of systematic reviews.

BACKGROUND: Many children worldwide do not eat recommended amounts of vegetables. Disliking vegetables is a key factor associated with low intake. OBJECTIVE: This umbrella review synthesized systematic reviews to determine the effectiveness of sensory and behavioral strategies to facilitate liking of vegetables (primary outcome) in young children up to 5 y of age, as key predictors of vegetable intake (secondary outcome). METHODS: Nine databases were searched up to May 2019 (updated in September 2020). Two reviewers independently conducted study screening and selection, data extraction, and assessment of methodological quality using AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews). Eleven reviews (n = 1 rated strong quality, n = 4 moderate quality, n = 6 low/critically low quality) examining 85 primary studies met the review criteria: systematic reviews and meta-analyses of primary studies (any quantitative design) that examined sensory or behavioral strategies on vegetable liking or intake (outcomes reported separately for children ≤5 y). Strategy effectiveness was synthesized into 3 categories based on evidence strength: 1) promising (large and consistent body of moderate quality evidence), 2) emerging (small to moderate body of mixed consistency and quality evidence), and 3) limited (small body of limited consistency and quality evidence). RESULTS: Promising evidence was identified for repeated exposure to a single or a variety of vegetables. Emerging evidence was identified for several strategies that increase familiarity with vegetable flavors (e.g., via exposure in utero and through breast milk, and a "vegetable first" approach to complementary feeding) and/or willingness to try vegetables (e.g., via parental role modeling, nonfood rewards, and vegetable-based story books). CONCLUSIONS: Current evidence supports incorporation of tailored advice into guideline documents for parents and carers to repeatedly expose their children to a variety of vegetables to increase vegetable intake. Ongoing robust research on strategies to facilitate children's liking of vegetables is warranted to strengthen the evidence base underpinning advice for parents and health professionals.