"Miffy eats the rainbow!" - A colorful modeling- and reward-based intervention to increase willingness to taste fruit and vegetables in 3-7-year-old children.

Diets rich in fruit and vegetables (F&Vs) improve cognitive functioning and reduce the risk of non-communicable diseases in children. Nevertheless, 59% of Dutch children do not meet recommended intake levels. Given the importance of color in children's food choices, the concept of "eat the rainbow" presents a promising approach. This project aimed to evaluate the effects of a modeling- and reward-based intervention to stimulate the consumption of colorful foods to increase willingness to taste different F&Vs among children aged 3-7 years. 164 children from Dutch elementary schools participated in a nested cluster randomized multi-arm parallel design study. During two morning school breaks, children were invited to choose from ten F&Vs in five different colors. Their willingness to taste and ad libitum intake were recorded. The first session served as a baseline with no intervention, while the second session involved either the Miffy intervention (modeling- and reward-based), a reward-only intervention (reward-based), or a control session. In the Miffy intervention, children listened to a story about Miffy eating the rainbow before tasting F&Vs and they received colored stickers (e.g., red sticker for tomatoes, green sticker for celery) upon tasting them. In the reward-only intervention, children received a sticker upon tasting a food. The Miffy group showed a higher probability (P(tasted) = 0.39) of tasting a food product compared to the control group (P(tasted) = 0.29; OR = 0.63, p = .04). No significant differences were observed between the Miffy and reward-only groups or between the reward-only and control groups. Both interventions did not significantly impact intake or liking of the foods. The Miffy-themed intervention demonstrates potential to enhance children's willingness to taste F&Vs, primarily due to the use of non-food incentives.

The Baby's First Bites RCT: Evaluating a Vegetable-Exposure and a Sensitive-Feeding Intervention in Terms of Child Health Outcomes and Maternal Feeding Behavior During Toddlerhood.

BACKGROUND: Parenting interventions during the first years of life on what and/or how to feed infants during complementary feeding can promote healthy eating habits. OBJECTIVES: An intervention promoting repeated exposure to a variety of vegetables [repeated vegetable exposure (RVE); what] and an intervention promoting responding sensitively to child signals during mealtime [video-feedback intervention to promote positive parenting-feeding infants (VIPP-FI); how] were compared, separately and combined (COMBI), with an attention control condition (AC). Primary outcomes were vegetable consumption and self-regulation of energy intake; secondary outcomes were child anthropometrics and maternal feeding practices (sensitive feeding, pressure to eat). METHODS: Our 4-arm randomized controlled trial included 246 first-time Dutch mothers and their infants. Interventions started when infants were 4-6 mo old and ended at age 16 mo. The present study evaluated effects at 18 (t18) and 24 (t24) mo of age. Vegetable acceptance was assessed using three 24-h dietary recalls, self-regulation of energy intake by an eating-in-the-absence-of-hunger experiment and mother-report, and maternal feeding behavior by observation and mother-report. RESULTS: Linear mixed model and ANOVA analyses revealed no follow-up group differences regarding child vegetable intake or self-regulatory behavior. The proportion of children with overweight was significantly lower in the COMBI group, compared with the VIPP-FI group at t18 (2% compared with 16%), and with the AC group at t24 (7% compared with 20%), although this finding needs to be interpreted cautiously due to the small number of infants with overweight and nonsignificant effects on the continuous BMI z-score measure (P values: 0.29-0.82). Finally, more sensitive feeding behavior and less pressure to eat was found in the VIPP-FI and COMBI groups, compared with the RVE and AC groups, mostly at t18 (significant effect sizes: d = 0.23-0.64). CONCLUSIONS: Interventions were not effective in increasing vegetable intake or self-regulation of energy intake. Future research might usefully focus on risk groups such as families who already experience problems around feeding.This trial is registered at clinicaltrials.gov as NCT03348176.

Influence of choice on vegetable intake in children: an in-home study.

Children's vegetable consumption is still far below that recommended, and stimulating their intake is a challenge for caregivers. The objective of this study was to investigate whether choice-offering is an effective strategy to increase children's vegetable intake in an in-home situation. Seventy children (mean age 3.7; SD 1) randomly assigned to a choice or a no-choice condition, were exposed 12 times to six familiar target vegetables at home during dinner. In the choice group, two selected vegetables were offered each time, whereas the no-choice group only received one vegetable. Vegetable intake was measured by weighing children's plates before and after dinner. A mixed linear model with age, gender, and baseline vegetable liking as covariates was used to compare intake between the choice and the no-choice group. Mixed linear model analysis yielded estimated means for vegetable intake of 48.5 g +/- 30 in the no-choice group and 57.7 g +/- 31 for the choice group (P = 0.09). In addition, baseline vegetable liking (P <0.001) and age (P = 0.06) predicted vegetable intake to be higher when the child liked vegetables better and with older age. These findings suggest that choice-offering has some, but hardly robust, effect on increasing vegetable intake in children. Other factors such as age and liking of vegetables also mediate the effect of offering a choice.

Effectiveness of flavour nutrient learning and mere exposure as mechanisms to increase toddler's intake and preference for green vegetables.

Children's consumption of vegetables is still below recommendations. Since preference is the most important predictor of children's intake and most children dislike vegetables, new strategies are needed to increase their preferences for vegetables. Flavour nutrient learning (FNL) could be an effective mechanism to change preferences. Forty healthy toddlers were included in a randomized intervention study. During an intervention period of 7weeks, they consumed vegetable soups (endive and spinach) twice per week. Half of the group received a high-energy variant of one soup (e.g. HE spinach) and a low energy variant of the other (LE endive), whereas for the other half the order was reversed (HE endive, LE spinach). Primary outcome measures were preference and ad libitum consumption (with a maximum of 200g) of both vegetable products (LE), measured before, shortly after the intervention period, and 2 and 6months following conditioning to assess longer-term effects. After completion of the intervention period, 28 children (14 girls and 14 boys, age 35months; SD±8.3) met criteria for FNL to occur, and were included in further data analysis. Results showed a significant increase (~58g) in ad libitum intake for both vegetable soups (stable over time), but irrespective of the energy content. This indicates a robust effect of mere exposure on intake, but no FNL. For preference, however, results showed a significant shift in liking for the vegetable soup consistently paired with high energy, supporting FNL.

Eating in the absence of hunger in 18-month-old children in a home setting.

BACKGROUND: Eating in the absence of hunger (EAH), the susceptibility to eat despite satiety, may increase overweight. While EAH has been established in school-aged children, less is known about it during toddlerhood. OBJECTIVES: This study assessed to what extent 18-month-old children eat in the absence of hunger, the stability of this behaviour at 24 months and the association of child eating behaviours with EAH. METHODS: Children were presented with four palatable finger foods (total 275 kcal) after dinner. Univariate GLM's assessed the association between EAH, child satiety and eating behaviours and energy intake of dinner at 18 and 24 months (n = 206 and 103, respectively). Another GLM was run to assess the association between EAH at both time points. RESULTS: Mean (±SD) energy intakes from dinner and finger foods were 240 kcal (±117) and 40 kcal (±37), respectively. No association was found between energy intake of dinner and finger foods. Enjoyment of food was significantly related to intake of finger foods (P = .005). EAH at 18 months predicted EAH at 24 months. CONCLUSION: Eighteen-month-old children ate in the absence of hunger, irrespective of satiety. Thus, preceding energy intake was not compensated for. Other factors, for example, enjoyment of food seem to determine finger food intake.

Use of Different Vegetable Products to Increase Preschool-Aged Children's Preference for and Intake of a Target Vegetable: A Randomized Controlled Trial.

BACKGROUND: Children's low vegetable consumption requires effective strategies to enhance preference for and intake of vegetables. OBJECTIVE: The study compared three preparation practices for a target vegetable (spinach) on their effectiveness in increasing preschool-aged children's preference for and intake of the target vegetable in comparison to a control vegetable (green beans). DESIGN: We conducted a randomized controlled trial with four parallel groups: plain spinach, creamed spinach, spinach ravioli, and green beans. During the intervention, children were served the vegetable at their main meal six times over 6 weeks at home. PARTICIPANTS/SETTING: Children aged 2 to 4 years were recruited from six child-care centers located in Wageningen, the Netherlands, and randomly assigned to one of the four groups, with vegetable products provided by the researchers. The study was performed between September 2014 and January 2015. In total, 103 children participated, with 26, 25, 26, and 26 in the plain spinach, creamed spinach, spinach ravioli, and green beans groups, respectively. MAIN OUTCOME MEASURES: Preference for and ad libitum intake of cooked spinach were assessed during a test meal at the day-care center pre- and postintervention. Food neophobia was assessed via the Child Food Neophobia Scale. STATISTICAL ANALYSES PERFORMED: General linear model repeated measures analysis, including food neophobia, spinach liking, exposure, and consumption scores as covariates, was performed to test for effects of group on intake. Logistic regression was used to assess changes in preference between pre- and postintervention. RESULTS: All four groups significantly increased their spinach intake from pre- (53 g) to postintervention (91 g) by an average of 70%. For preference, no significant shift toward the target vegetable was found from pre- to postintervention. The effect on intake depended on the child's neophobia status and preintervention spinach consumption, with children with neophobia being less responsive to the intervention and with children who ate more spinach before the intervention being more responsive to the intervention. CONCLUSIONS: These findings suggest that repeated exposure to differently prepared spinach products, or even another green vegetable, improved children's spinach intake. However, children with neophobia may need a different approach.