family meals and exposure to tv during dinner – ass...
TRANSCRIPT
Trabalho de Investigação
Family meals and exposure to TV during dinner – ass ociation
with fruit and vegetable intake among school childr en
Refeições em família e exposição a TV durante o jan tar –
associação com o consumo de fruta e hortícolas em c rianças em
idade escolar
Tânia de Jesus Jorge
Supervised by: Patrícia Padrão
Co-supervised by: Agneta Yngve
Porto, 2010
i
Dedicated to
My family.
ii
Acknowledgments
I would like to thank Associate Professor Agneta Yngve for giving me the chance
to use the data of the current study.
A special thanks for my supervisor, Patrícia Padrão, for your support and essential
guidance through the development of this thesis.
Thank you to Bettina Ehrenblad for your care and to let me know about the
procedures carried out in the Pro Children study and giving me good suggestions
for this thesis. It was due to one of our conversations one day, when you
suggested the importance of having the TV switched on during dinner and family
dinner, that I got motivated to this subject and led me to explore more about it.
I would also like to thank Eric Poortvliet for the suggestions you gave me to
improve this work.
At last but not least, a big thanks to my parents and brother who supported me
from Portugal and always believed in my capacities.
iii
Index
Dedicated to ........................................................................................................ i
Acknowledgments ...............................................................................................ii
Index .................................................................................................................. iii
List of abbreviations ...........................................................................................iv
Abstract .............................................................................................................. v
Resumo.............................................................................................................vii
1. Introduction..................................................................................................... 1
2. Objectives....................................................................................................... 4
3. Methods.......................................................................................................... 5
3.1. Population and Sample ............................................................................... 5
3.2. Ethics........................................................................................................... 6
3.3. Instrument ................................................................................................... 6
3.4. Procedure.................................................................................................... 7
3.5. Outcome Measures ..................................................................................... 8
3.6. Statistical Analysis..................................................................................... 11
4. Results ......................................................................................................... 13
5. Discussion.................................................................................................... 25
6. Conclusions and Recommendations ............................................................ 32
7. References................................................................................................... 33
Annex 1 – Social Class Categories .................................................................. 37
iv
List of abbreviations
BVC = Barnavårdscentralen (Child Health Care Clinic)
FAO = Food and Agriculture Organization
F & V = Fruit and vegetable
MVC = Mödravårdcentral (Maternal Health Care Clinic)
PAWS = Predictive Analytics Software
PRO CHILDREN = Promoting and Sustaining Health through Increased Fruit and
Vegetable Consumption among School children
SCB = Statistiska Central Byrån (Statistics Sweden)
SCT = Social Cognitive Theory
SD = Standard Deviation
SES = Socio-economic status
TV = Television
WHO = World Health Organization
v
Abstract
Background: Fruit and vegetable (F&V) intake is low among European children.
Some recent studies have shown a possible association between family meals
and higher F&V consumption among children. Most studies are focused on dinner,
few studies looked for the family breakfast. TV switched on during mealtime was
shown to be negatively associated with the F&V intake. There is no described
information on this subject regarding Swedish school children.
Aims: To examine the frequency of family meals (breakfast and dinner), TV
switched on during dinner and exposure to TV food commercials as possible
correlates of F&V intake among Swedish school children.
Methods: A cross-sectional survey performed in Sweden, from October to
December 2003, as part of the Pro Children study. A random sample of 1407 11-
year old Swedish children from 49 schools and their parents was included. Data
on F&V intake was assessed by a 24-hour recall. Data on the frequency of family
meals and presence of TV during dinner, exposure to TV food commercials and
socio-demographic characteristics was collected by a self-administered
questionnaire. Non-parametric tests (Mann-Whitney U and Kruskal-Wallis H) were
performed to determine whether the F&V consumption was different between
genders and among the frequency of family meals, exposure to TV during dinner
and exposure to TV food commercials. Chi-square statistics were computed for
the frequency of family meals and TV switched on during dinner by
sociodemographics. Binary logistic regression models were fitted to quantify the
association between the F&V recommendations accomplishment and the
frequency of family meals, exposure to TV during dinner and exposure to TV
commercials, adjusting for confounders.
vi
Results: The mean F&V intake was 260.5 grams per day. Girls eat more F&V
than boys (p=0.001) and reported to accomplish more the vegetable
recommendations (22.2% vs. 17.4% boys, p=0.027). Having dinner with parents
every day showed a 21% increased vegetable intake among girls. Moreover, girls
having breakfast and dinner with parents every day were more likely to accomplish
the vegetable recommendations (7% more girls). The exposure to TV during
dinner was negatively associated with the F&V intake among boys (p=0.014) and
with the vegetable intake among girls (p=0.001). Lower accomplishment of the fruit
recommendations for boys (less 5%) and vegetables for girls (less 10%) was
observed for a frequent exposure to TV during dinner. The negative effect of TV
during dinner was independent from the family dinner. Exposure to fruit
commercials on TV was associated with increased fruit intake (p=0.001) and
higher accomplishment of the fruit recommendations (p=0.019) among boys.
Parental education was inversely associated with TV during dinner (p=0.001) but
no association was found for the F&V intake. Higher social class was associated
with less TV during dinner (p=0.015). An association between social class and the
F&V recommendations accomplishment was observed, although it did not show a
consistent pattern of variation.
Conclusions: Family meals were associated with higher vegetable intake and
accomplishment of the recommendations among girls, while TV switched on
during dinner was linked with decreased F&V consumption and accomplishment of
the recommendations. Fruit commercials may increase the fruit consumption.
Frequent family meals and no TV during the mealtime should be promoted.
Keywords: Family breakfast, family dinner, televisi on, TV food commercials,
sociodemographics, school children, fruit intake, v egetable intake.
vii
Resumo
Introdução: O consumo de fruta e hortícolas é baixo em crianças na Europa.
Alguns estudos recentes têm mostrado uma possível associação entre refeições
em família e um maior consumo de fruta e hortícolas em crianças. A maioria dos
estudos reportam-se ao jantar, poucos concernem o pequeno-almoço. Ter a
televisão ligada durante as refeições tem sido apontado como tendo uma
associação inversa com esse consumo. Não há informação neste tema em
crianças suecas.
Objectivos: Estudar a frequência das refeições em família, TV ligada durante o
jantar e exposição a anúncios televisivos como possíveis factores do consumo de
fruta e hortícolas em crianças suecas em idade escolar.
Métodos: Estudo de desenho transversal realizado na Suécia, entre Outubro e
Dezembro de 2003, integrado no estudo europeu “Pro Children”, com uma
amostragem randomizada de 1407 crianças suecas com 11 anos de idade,
provenientes de 49 escolas, e os seus pais. A informação acerca da ingestão de
fruta e hortícolas foi obtida através de um questionário 24h. A informação sobre a
frequência das refeições em família, presença de TV durante o jantar, exposição a
anúncios televisivos e características sócio-demográficas foram recolhidos por um
questionário auto-administrado. Recorreu-se a testes não paramétricos (Mann-
Whitney U e Kruskal-Wallis H) para determinar se o consumo de fruta e hortícolas
era diferente entre sexos, categorias de frequência de refeições em família,
exposição a TV durante o jantar e exposição a anúncios televisivos. Testes chi-
square foram usados na relação entre refeições em família, TV ligada durante o
jantar e características sócio-demográficas. Através de modelos de regressão
logística binária, quantificou-se a associação entre o cumprimento das
viii
recomendações de fruta e hortícolas e a frequência de refeições em família, TV
ligada ao jantar e exposição a anúncios televisivos, ajustando para confundidores.
Resultados: O consumo médio de fruta e hortícolas foi 260,5 g/dia. As raparigas
apresentaram um maior consumo de fruta e hortícolas que os rapazes (p=0.001) e
reportaram maior cumprimento das recomendações de hortícolas (22.2% vs.
17.4% dos rapazes, p=0.027). Jantar com os pais todos os dias associou-se a um
aumento do consumo médio de hortícolas em raparigas na ordem dos 21%. Para
raparigas que tomavam o pequeno-almoço e jantavam com os pais todos os dias,
a prevalência do cumprimento das recomendações de hortícolas foi maior (cerca
de 7% mais). A exposição a TV durante o jantar associou-se negativamente com
o consumo de fruta e hortícolas em rapazes (p=0.014) e com o consumo de
hortícolas em raparigas (p=0.001). Para a exposição frequente a TV durante o
jantar, uma menor proporção de rapazes (5% menos) atingiu as recomendações
de fruta e 10% menos raparigas atingiram as recomendações para os hortícolas.
Este efeito negativo da TV durante o jantar mostrou ser independente do jantar
em família. A exposição a anúncios de fruta em rapazes registou um aumento do
seu consumo médio de fruta (p=0.001) e uma maior prevalência do cumprimento
das recomendações de fruta (p=0.019). A educação dos pais relacionou-se
inversamente com a frequência de TV ligada ao jantar (p=0.001) mas não se
associou com o consumo de fruta e hortícolas. Classe social mais elevada
associou-se com ter a TV ligada ao jantar menos frequentemente e com o
consumo embora para este não se tenha observado um padrão consistente de
variação.
Conclusões: As refeições em família associaram-se a um maior consumo e
cumprimento das recomendações de hortícolas em raparigas. A TV ligada durante
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o jantar mostrou uma diminuição do consumo e cumprimento das recomendações
de fruta e hortícolas. Anúncios televisivos de fruta podem fazer aumentar o
consumo de fruta. As refeições em família frequentes e o desligar da TV durante o
jantar devem ser promovidos.
Palavras-chave: Pequeno-almoço em família, jantar e m família, televisão,
anúncios televisivos alimentos, características sóc io-demográficas,
crianças idade escolar, consumo fruta, consumo hort ícolas.
1
1. Introduction
The importance of an adequate consumption of fruit and vegetables has been
emphasized by several reports (1-6) , both from Sweden (7-8) and from international
organizations such as WHO(9) and FAO (10). Fruits and vegetables are good
sources of important nutrients and nutritive compounds such as vitamins
(especially vitamin C and folate), carotenoids, minerals, fibre and other important
bioactive components (11). An adequate F&V intake may be a very important step
for a healthy life (12). When in a low fat diet, it may help in the energy balance of
the body (13) , preventing from chronic diseases as diabetes or obesity (14-16). It has
been suggested that the minimum recommended F&V intake, set as 400 g per day
by the joint FAO/WHO (10), can also decrease the risk of certain cancers (1, 17) and
cardiovascular diseases (11, 18) .
Epidemiological studies have shown that most of the world’s population does not
reach the recommended population goal of 400 g F&V per day (10, 19-20).
There are some studies regarding children’s F&V consumption, mostly regional or
national, but some were developed at the European level (21-22). The Pro Children
study, which specifically assessed the F&V consumption among school children in
Europe, showed that the majority of the school children across different European
countries (Sweden included) did not meet the recommendations (23).
This highlights the importance of developing effective dietary programs addressed
to children in order to improve their F&V intake. There are several reasons why
children should be a main target of these programs: many diseases reported to be
linked with a low F&V intake typically manifest themselves only in midlife or later,
but the diet in childhood may have crucial physiologic influences associated with
chronic diseases that track from childhood into adulthood (24). For instance,
2
childhood overweight and obesity, which might possibly be prevented by
promoting F&V consumption, is suggested as a predictor for adult obesity (25).
Moreover, food preferences and habits are developed in childhood and are likely
to influence long-term food behaviours (26).
Hence, it is important to understand which factors are associated with children’s
dietary habits in order to develop effective strategies to improve their F&V intake.
In the Social Cognitive Theory (SCT), the “reciprocal determinism” postulates that
behaviour (including dietary behaviour) is the result of environmental and personal
factors and, in turn, it affects these factors in constant reciprocal relationships (27).
Many studies tried to examine the correlates of F&V consumption at the personal
influence level, such as children’s preferences (28-29) or at the environmental level,
as family correlates, school environment, peer influence and physical environment
(26, 28, 30-34).
The importance of family meals on children’s eating habits has received recent
attention (34). Evidence showed that more frequent family meals were associated
with healthier dietary patterns, higher in energy-adjusted intakes of fruit,
vegetables, grains, calcium-rich foods and several micronutrients and lower in soft
drinks (34-36), higher self-efficacy to consume F&V (34, 37), improved school and
psychological performance (38) and protection against dieting and disordered
eating behaviours (39). The frequency of family meals has been found to decrease
from childhood to adolescence, particularly between 9-years-old and 14-years-old
(35-36, 40). In addition, it was observed that the frequency of family meals may vary
among socio-demographic characteristics (36). There was also a great diversity
among the family meal patterns, concerning not only the frequency but also the
place, the food that is served and the presence of TV during meals (41).
3
Increased TV viewing has been associated with poorer quality diets, low in F&V
(42). Moreover, when studying the relationships between the presence of TV during
meals and children’s food consumption, lower intakes of fruit, vegetables, grains
and higher intakes of read meat, pizza and salty snacks were reported, comparing
to when TV is not present during the mealtime (41, 43-45). The independent effect of
TV switched on during the mealtime and family meals, when TV is turned on
during meals versus not having family meals, is not very clear and poorly studied.
In one study (41) watching TV during family meals was associated with a healthier
diet than not eating regular family meals.
Exposure to food commercials may be associated with children’s dietary intake (32,
42, 46), the advertised food being consumed more. Most studies examined the
association between unhealthy food commercials and dietary intake, since the
unhealthy food commercials are the prevalent food commercials on TV (32). There
are few studies regarding the impact of other types of advertised food, such as
fruit and vegetables. In one study (32), a positive association between the exposure
to TV commercials for healthy food and the F&V consumption among European
school children was reported.
In the present study, it was hypothesized that a higher frequency of family meals
(not only dinner as studied in most of the previous reports, but also breakfast) is
associated with higher F&V consumption among 11-year old children. Moreover, it
was also hypothesized that this association might be compromised or decreased
by the presence of TV during the mealtime due, in part, to the influence of food
commercials.
4
2. Objectives
The main objectives of this study were:
• To describe the F&V consumption in a representative sample of 11-year old
Swedish children, according to the gender of the child, frequency of family
meals (breakfast and dinner), exposure to TV during dinner and exposure
to food commercials on TV;
• To quantify the association between F&V intake recommendations
accomplishment and the sociodemographics, frequency of family meals
(breakfast and dinner), exposure to TV during dinner and exposure to food
commercials on TV.
5
3. Methods
3.1. Population and Sample
The data used in the present study was obtained from the cross-sectional survey
set in Sweden as part of the Pro Children study (21) carried out in nine European
Countries (Austria, Belgium, Denmark, Iceland, the Netherlands, Norway,
Portugal, Spain and Sweden). The Pro Children study was designed to assess the
F&V consumption among school children born between 1990 and 1992 and its
potential determinants as well as, develop, implement and test the effectiveness of
a school-based intervention in three of the Pro Children countries (Norway,
Netherlands and Spain).
The cross-sectional survey in Sweden was conducted from October to December
2003, involving a national representative sample of children (N= 2212), with the
schools being primary sampling units. Sixty-five schools were randomly selected
by Statistics Sweden (SCB). From these, 49 schools were included, corresponding
to 1752 eligible participants. However, filled in questionnaires were obtained only
from 1476 children (response rate of 84.2%) and 1232 parents (response rate of
70.3%). At the end, after entering, double-checking, controlling for quality and
processing the data, 1407 children’s questionnaires and 1164 parents’
questionnaires were considered valid and useable. There were different drop-out
reasons, as the withdraw of children’s questionnaires when parents refused the
participation of their children, incomplete or invalid questionnaires, sickness of the
child or children that were abroad at the day before filling in the questionnaire.
The sample consisted of 11-year old children, 95% were born in 1992 and 50.1%
were boys.
6
3.2. Ethics
The Pro Children study adheres to Helsinki Declaration and to the conventions of
the Council of Europe on Human Rights and Biomedicine.
Ethical approval for the cross-sectional survey at Sweden was obtained from the
Swedish Research Ethic Committee at Karolinska Institutet (23). In the parents’
questionnaire, parents were given the possibility to refuse the participation of their
children by crossing a box if they wanted to refuse, leading then to the withdrawal
of their children’s questionnaires.
Children’s and parents’ participation was voluntary and anonymous. Child and
parental questionnaires were matched by a numeric code.
3.3. Instrument
A self-reported questionnaire was developed to assess F&V intake and its
possible psychosocial factors. Initially, it was developed in English but then
translated to Swedish and re-translated to English again in order to double-check
for translation mistakes. The questionnaires used in the present study were in
Swedish. Data was obtained both from children (child questionnaire) and from
one of the parents/guardian (parental questionnaire) (21).
Dietary data was derived from 2 components of the children’s questionnaire: a
precoded 24-hour recall, asking in detail about the F&V intake in the day before (a
weekday and not on a Monday in order to not get a recall from Sunday) and a food
frequency questionnaire, measuring the usual F&V intake. In the present study
only data from the 24-hour recall was analyzed. The validity and reproducibility of
the questionnaire were tested and are reported elsewhere (47).
7
The determinants’ questionnaire was developed from qualitative and quantitative
pilot studies, literature reviews, theoretical models derived from social cognitive
theory and social ecological frameworks, focus group interviews with children,
individual interviews with parents and school staff. The questionnaire can be
divided in three main categories: personal factors (knowledge, attitudes, liking),
perceived social-environmental factors (parents and peers influence as: parental
attitude, parental dietary knowledge and parental intake, active parental
encouragement, parental facilitation, family rules, watching TV and peer intake)
and perceived physical-environment (F&V availability and accessibility at home, at
school and at friends’ home) (21).
Socio-demographic data as the child sex, parents’ education and occupational
status were also assessed.
3.4. Procedure
Children filled in the questionnaires in their classrooms supervised by their class
teacher who prior received standardized instructions to collect the data. Children
were also asked to bring the parental questionnaire home to be completed by one
of their parents/guardian and to return it to the teacher once filled (21).
Both parental and child questionnaires were collected by schools and sent to the
national research center (21) where the data was entered, double-checked and
cleaned according to standardized instructions received from the Data
Management Center at the University of Vienna. All data, from all countries, was
then transferred to this center at the University of Vienna, where it was merged,
processed and quality controlled.
8
3.5. Outcome Measures
Socio-demographic data
Gender, year of birth of the child, parents’ education and socio-economic status
were the variables included in this study. They were considered as there are
known associations, shown in the literature, between them and the F&V intake
among children (48-49), being possible confounders in the association between the
variables analyzed in the present study.
Gender and the year of birth were obtained from the child questionnaire. Parental
education and occupational status were obtained from the parental questionnaire.
The parental education variable assessed the school degree of the respondent
and was categorized in (1) Primary school not completed (< 9 years), (2) Primary
School completed, (3) High-school (gymnasium) completed (12 yrs), (4) University
degree, (5) Other education. This last category was excluded from the statistical
analysis. Due to the low percentage of people in the category 1, a new category
was computed by grouping category 1 and 2. Primary school completed or not
was the new category 1. At the end, we had 3 categories instead of 5.
Socio-economic status (SES) was given by social class categories that were
assessed by asking both parents and children about the parents’ occupation
(occupation of the respondent parent and partner). Children and parents were
coded separately in order to check the validity of children’s reports of their parents’
occupation. Occupations were categorized into five social classes (I-V) and two
extra categories (VI-VII) according to the classical Registar General model (Annex
1). Class I as the highest social class, including top managers, top level civil
servants, medical doctors, lawyers, and others, through class V, the lowest which
9
included unskilled and semi-skilled workers. The extra categories (VI-VII) were
attributed to the participants economically active but with insufficient information to
code their occupation (class VI) or for the economically inactives (class VII) as
housewives or retired people. These two last extra categories were excluded from
the analysis.
Fruit and vegetable intake of the children
Measures of F&V consumption among children were assessed by self-reported
24-hour recall forms specifically developed to assess the F&V consumption.
Children were asked how many pieces/portions of specific fruit and vegetables
they had consumed on the previous day, which was then converted into grams
according to standardized principles (47) . The sum amount of fruit excluded fruit
juice, due to possible misunderstandings about what belongs under the term of
natural fruit juice. The total amount of vegetables was obtained by the sum amount
of salad, raw and cooked vegetables (potatoes excluded). A sum measure of the
total amount of F&V was then calculated. To correct for over-reporting a maximum
value of 1000 grams was set for both the total daily intake of fruit and intake of
vegetables (2.1% participants, N = 30) (47).
Fruit and vegetable recommendations accomplishment categories were defined
according to the established by the joint FAO/WHO (10) of the minimum daily intake
of 400g. As there are no specific recommendations for fruit and vegetables
separately, the cut-point of 200g/day was set.
Frequency of family meals
Two questions were included: “How often do you have breakfast with your mother
and/or father?” and “How often do you have dinner with your mother and/or
10
father?”. Both questions had the follow response categories: (1) every day, (2) 4-6
days a week, (3) 1-3 days a week, (4) less than 1 day a week, (5) never. In both
questions, response categories were recoded to “every day” (category 1) and “not
every day” (categories 2 to 5).
TV viewing
Frequency of TV switched on during dinner
This exposure was assessed through the question: “How often is the TV on during
dinner?”. Response categories were: (1) every day, (2) 4-6 days a week, (3) 1-3
days a week, (4) less than 1 day a week, (5) never. These categories were then
recoded to “every day or most days” (categories 1 and 2), “3 or less days a week”
(categories 3 and 4) and “never”.
Exposure to food advertisements
Children were asked about the type of TV food commercials they had seen in the
previous month. The question was “During the past month, have you seen any TV
commercials advertising”, followed by a list of food items with a “Yes or No”
answer. The food categories were “candy/ chocolate bars”, “biscuits/ sweet buns/
cakes”, “fresh fruits”, “water”, “soda/soft drinks”, “vegetables”, “chips/ savoury
snacks”, “fast-food”, “fruit juices”.
11
3.6. Statistical Analysis
All analyses were performed using the Predictive Analytics Software, version 18
(PAWS Statistics 18). Descriptive statistics were used to calculate the overall
mean intakes of fruit, vegetables and the sum amount of F&V. Non-parametric
Mann-Whitney U tests were used to compare F&V intake between genders,
across the frequency of family meals (breakfast and dinner) and according to the
exposure to food commercials, due to the absence of normal distribution of
consumption data even after logarithmic transformation. Kruskal-Wallis H tests
(non-parametric) were used to compare F&V intake between the frequency
categories of TV switched on during dinner. Intake values were given as means (±
Standard Deviation (SD)). Cross tabulations between the frequency of family
meals, TV switched on during dinner and socio-demographic characteristics
(gender, parental education and social class) were performed. Chi-square tests
were conducted to investigate potential differences among the frequency of family
meals and TV switched on during dinner by the sociodemographics.
Chi-square tests were performed to compare the prevalence of the
accomplishment of fruit, vegetable and F&V intakes according to the frequency of
having breakfast and dinner with family, TV switched on during dinner, exposure to
F&V commercials, parental education and SES (respondent and partner).
Binary logistic regression models were fitted to compute parental education- and
SES-adjusted odds ratios (OR) and respective 95% confidence intervals (95%CI)
for the association between fruit, vegetable and F&V consumption (baseline
outcomes: fruit≥200g/day, vegetables≥200g/day and F&V≥400g/day) and the
frequency of family breakfast and dinner (independent variable, with the frequency
of having breakfast and dinner every day as reference), TV switched on during
12
dinner (independent variable, reference: TV switched on during dinner every day
or most days) and exposure to F&V commercials (independent variables,
reference: not being exposed to F&V commercials). Binary logistic regression
models were also fitted to compute the odds ratios for the association between
fruit, vegetable and F&V consumption and TV switched on during dinner, adjusting
for family dinner, education and SES. All analyses were conducted separately for
boys and girls and the level of significance was set at 0.05.
13
4. Results
Socio-demographic data
In this study, 1407 children at the age of 11-years-old were included. They were
equally divided by gender (50.1% boys). Almost every child was born in 1992
(95%). Parents were also included (N= 1164). The parents’ questionnaire was
completed mainly by mothers (83.3 %).
Most of the parents had completed high-school (12 years) (45.2%) or university
degree (41%). Eighty-five percent had a paid job at the time of the study.
Most of the participants belonged to the middle class. Regarding the social class
of the respondent, 7.4% were classified as belonging to social class I, 15.6% to
class II, 30.1% to social class III, 23.2% to social class IV and 13% to social class
V. Six-percent of the participants did not have a paid job and 0.7% was in
education. Concerning to the social class of the partner, it was similarly distributed:
9.0% belonging to class I, 16.8% to class II, 32.9% to class III, 19.5% to class IV
and 15.9% to class V. Only 1.9% of the partners did not have a paid job and 0.1%
was in education.
Fruit and vegetable intake of the children
The total mean F&V intake of the sample was 260.5 grams per day (Standard
Deviation (SD) = 240.4). Mean fruit intake was 139.2 grams per day (SD ± 154.2),
and the mean vegetable intake was 121.3 grams per day (SD ± 152.1). Girls,
compared to boys had significantly higher intakes of fruit (144.1±151.8 g/day vs.
134.3±156.6 g/day, p= 0.021), vegetables (130.6±152.4 g/day vs. 112.1±151.2
g/day, p< 0.001), and F&V (274.7±237.2 g/day vs. 246.4±242.8 g/day, p= 0.001)
(Table 1).
14
Regarding the accomplishment of the recommendations, 20.0% of children met
the recommended 400g/day of F&V, 33.0% met the minimum value established of
200g/day for fruit and 19.8% met the minimum value of 200g/day for vegetables.
Gender differences were observed for vegetables (22.2% in girls vs. 17.4% in
boys, p= 0.027).
Table 1. Fruit and vegetable intake in grams per day, mean (± SD) by gender.
P. percentile;
* p value derived from Mann-Whitney test used for the comparison of F&V intake between boys and girls.
Frequency of family meals and fruit and vegetable i ntake
Approximately 47% of the children (49.3% for boys and 44.4% for girls) reported to
have breakfast with family every day. Most of the children reported having dinner
with parents every day (70.1% boys and 66.2% girls).
Associations between the frequency of family meals and F&V intake were
examined separately for boys and girls by comparing the mean intakes across the
frequency of breakfast with parents and the frequency of dinner with parents
(Table 2). Differences were statistically significant for the vegetable intake among
girls when reporting to have dinner with parents every day: a 21% higher
Girls N = 702
Boys N = 705
Mean ± SD Median P25 P75 Mean ± SD Median P25 P75 p*
Fruit 144.1 ± 151.8 100 44 200 134.3 ± 156.6 100 0 200 0.021
Vegetable 130.6 ± 152.4 85 30 180 112.1 ± 151.2 65 5 145 0.000
Fruit & Vegetable
274.7 ± 237.2 230 100 360 246.4 ± 242.8 200 67 340 0.001
15
consumption was observed (142.4±157.2 g/day for every day vs. 112.4±143.2
g/day for not every day, p= 0.006).
TV viewing
Frequency of TV switched on during dinner
The frequency of TV switched on during dinner was widely distributed: around
37% children reported it to be every day or most days and 27% reported it to be
never.
The mean fruit intake and the mean vegetable intake (and consequently the total
mean F&V intake) increased with the decrease of the frequency of TV switched on
during dinner among boys (fruit: 116.2±144.9 g/day for every or most days vs.
146.0±154.8 g/day for ≤ 3 days vs. 137.6±149.0 g/day for never, p= 0.030;
vegetables: 93.1±123.2 g/day for every or most days vs. 109.3±125.2 g/day for ≤ 3
days vs. 136.4±191.9 g/day for never, p= 0.031; F&V: 209.3±203.2 g/day for every
or most days vs. 255.3±221.8 g/day for ≤ 3 days vs. 273.9±269.3 g/day for never,
p= 0.014). For girls a significant increase was only observed for vegetables
(106.4±135.9 g/day for every day or most days vs. 141.8±151.2 g/day for ≤ 3 days
vs. 150.3±172.8 g/day for never, p= 0.001) (Table 2).
Exposure to food advertisements
Children reported being exposed to food commercials as follows: fresh fruits
(54.0%), fruit juices (46.1%), vegetables (39.6%), water (44.5%), candy/chocolate
bars (69.0%), biscuits/sweet buns/cakes (70.5%), chips/savoury snacks (86.1%),
soda/soft drinks (76.2%) and fast-food (81.5%).
16
Boys who reported to had watched fresh fruit commercials in the previous month,
had a higher mean fruit intake (151.6±163.3 g/day vs. 112.2±132.7 g/day, p=
0.001) and higher F&V intake (265.7±250.9 g/day vs. 222.0±219.7 g/day, p=
0.020). No significant differences were found among girls (Table 2). Regarding the
exposure to vegetable commercials, only the mean fruit intake among boys was
higher when they reported to had been exposed (150.2±169.6 g/day vs.
123.5±138.6 g/day, p= 0.05) (Table 2). No differences in the F&V intake were
observed across the exposure to the other 7 items of food commercials.
Frequency of family meals and TV switched on during dinner by socio-
demographic characteristics
Family meals and TV habits by socio-demographic characteristics are shown in
Table 3. The percentage of girls reporting to never have TV switched on during
was higher when parents had a university degree, compared to those with primary
school or high school (34.3% vs. 23.5% for high-school vs. 24.6% for primary
school, p= 0.001). No association was found between the frequency of family
meals (breakfast and dinner) and parental education.
Regarding the social class, no significant differences were observed for TV
switched on during dinner across the social class of the respondent and partner for
boys. However, the percentage of girls who never had TV switched on during
dinner was higher for parents from higher social class (respondent) than for
parents from lower social class (41.5% for class I vs. 35.3% for class II vs. 26.3%
for class III vs. 20.9% for class IV vs. 30.0% for class V, p= 0.015). No significant
differences were observed between the frequency of family meals and the social
class among boys and girls.
17
Tab
le 2
. F
ruit
and
vege
tabl
e in
take
in g
ram
s pe
r da
y, m
ean
(± S
D)
by t
he f
requ
ency
of
havi
ng b
reak
fast
and
din
ner
with
fam
ily,
TV
switc
hed
on d
urin
g di
nner
and
exp
osur
e to
frui
t and
veg
etab
le c
omm
erci
als.
B
oys
G
irls
Fru
it V
eget
able
F
ruit
and
Veg
etab
le
F
ruit
Veg
etab
le
Fru
it an
d V
eget
able
N
Mea
n ±
SD
M
ean
± S
D
Mea
n ±
SD
N
M
ean
± S
D
Mea
n ±
SD
M
ean
± S
D
Bre
akfa
st
Eve
ry d
ay
335
137.
4 ±
157.
6 11
4.8
± 14
6.2
252.
2 ±
234
.1
304
149.
3 ±
159.
0 15
1.0
± 17
7.9
300.
4 ±
268.
0 N
ot e
very
day
34
4 13
2.2
± 15
7.0
107.
2 ±
153.
9 23
9.4
± 2
49.0
38
1 14
2.3
± 14
6.9
117.
3 ±
129.
1 25
9.5
± 21
0.3
p= 0
.833
p=
0.1
50
p= 0
.343
p= 0
.723
p=
0.0
98
p= 0
.124
D
inne
r
Eve
ry d
ay
475
139.
1 ±
162.
4 11
5.4
± 16
2.5
254.
5 ±
258
.7
456
145.
5 ±
157.
2 14
2.4
± 15
7.2
287.
9 ±
247.
6 N
ot e
very
day
20
3 12
5.2
± 14
4.2
100.
9 ±
115.
9 22
6.1
± 1
95.3
23
3 14
2.6
± 14
2.4
112.
4 ±
143.
2 25
5.0
± 21
7.1
p= 0
.604
p=
0.9
64
p= 0
.682
p= 0
.908
p=
0.0
06
p= 0
.077
T
V d
urin
g di
nner
Eve
ry d
ay/
Mos
t day
s 25
7 11
6.2
± 14
4.9
93.1
± 1
23.2
20
9.3
± 20
3.2
244
147.
9 ±
147.
8 10
6.4
± 13
5.9
254
.3 ±
212
.7
≤ 3
day
s 23
2 14
6.0
± 15
4.8
109.
3 ±
125.
2 25
5.3
± 22
1.8
25
7 14
1.1
± 13
4.6
141.
8 ±
151.
2 28
2.9
± 22
0.9
Nev
er
185
137.
6 ±
149.
0 13
6.4
± 19
1.9
273.
9 ±
269.
3
178
150.
1 ±
182.
4 15
0.3
± 17
2.8
300.
4 ±
291.
2
p=
0.0
30
p= 0
.031
p=
0.0
14
p=
0.8
44
p= 0
.001
p=
0.2
48
Fru
it co
mm
erci
als
No
282
112.
2 ±
132.
7 10
9.8
± 14
5.7
222.
0 ±
219.
7 31
8 13
7.8
± 14
6.9
126.
1 ±
143.
9 26
3.9
± 22
9.4
Yes
36
7 15
1.6
± 16
3.3
114.
1 ±
154.
7 26
5.7
± 25
0.9
338
15
1.2
± 15
6.8
137.
4 ±
162.
9 28
8.6
± 24
4.6
p= 0
.001
p=
0.7
30
p= 0
.020
p= 0
.276
p=
0.4
25
p= 0
.190
V
eget
able
co
mm
erci
als
No
387
123.
5 ±
138.
6 11
8.0
± 15
7.3
241.
6 ±
236.
3 39
5 14
0.7
± 13
2.2
134.
5 ±
154.
5 27
5.1
± 21
8.1
Yes
25
9 15
0.2
± 16
9.6
104.
0 ±
144.
8 25
4.2
± 24
3.0
254
14
9.4
± 17
2.5
128.
1 ±
153.
5 27
7.6
± 25
8.0
p= 0
.050
p=
0.0
97
p= 0
.398
p= 0
.677
p=
0.2
67
p= 0
.356
18
Tab
le 3
. F
requ
ency
of
fam
ily m
eals
and
TV
sw
itche
d on
dur
ing
dinn
er b
y so
cio-
dem
ogra
phic
cha
ract
eris
tics
- %
with
in g
ende
r,
pare
ntal
edu
catio
n an
d so
cial
cla
ss.
B
oys
Girl
s
B
reak
fast
with
fa
mily
D
inne
r w
ith fa
mily
T
V O
n du
ring
dinn
er
Bre
akfa
st w
ith
fam
ily
Din
ner
with
fam
ily
TV
On
durin
g di
nner
N
E
very
da
y N
E
very
da
y N
E
very
/ M
ost
days
≤ 3
da
ys
Nev
er
N
Eve
ry
day
N
Eve
ry
day
N
Eve
ry/
Mos
t da
ys
≤ 3
da
ys
Nev
er
Tot
al
679
49.3
%
678
70.1
%
674
38.1
%
34.4
%
27.4
%
685
44.4
%
689
66.2
%
679
35.9
%
37.8
%
26.2
%
Par
enta
l E
duca
tion
Prim
ary
Sch
ool
40
40.0
%
40
72.5
%
38
31.6
%
42.1
%
26.3
%
62
37.1
%
64
70.3
%
61
45.9
%
29.5
%
24.6
%
Hig
h S
choo
l 24
2 48
.3%
24
1 67
.6%
24
1 41
.9%
30
.3%
27
.8%
24
4 45
.1%
24
4 65
.2%
23
8 40
.8%
35
.7%
23
.5%
Uni
vers
ity d
egre
e 21
1 55
.0%
21
1 72
.0%
20
9 29
.7%
40
.7%
29
.7%
23
0 47
.4%
23
2 66
.4%
23
3 24
.9%
40
.8%
34
.3%
p=
0.1
42
p= 0
.556
p=
0.0
62
p= 0
.352
p=
0.7
40
p= 0
.001
Soc
ial C
lass
Cla
ss I
31
48.4
%
31
71.0
%
30
23.3
%
46.7
%
30.0
%
42
45.2
%
42
71.4
%
41
12.2
%
46.3
%
41.5
%
Cla
ss II
73
64
.4%
73
67
.1%
73
27
.4%
34
.2%
38
.4%
83
51
.8%
84
66
.7%
85
31
.8%
32
.9%
35
.3%
Cla
ss II
I 14
1 51
.1%
14
1 74
.5%
14
2 33
.1%
41
.5%
25
.4%
15
7 49
.0%
15
7 69
.4%
15
6 34
.0%
39
.7%
26
.3%
Cla
ss IV
12
0 44
.2%
11
9 63
.9%
11
6 35
.3%
37
.9%
26
.7%
11
0 45
.5%
11
0 63
.6%
11
0 41
.8%
37
.3%
20
.9%
Cla
ss V
55
41
.8%
55
65
.5%
56
41
.1%
33
.9%
25
.0%
72
33
.3%
74
60
.8%
70
42
.9%
27
.1%
30
.0%
p=
0.0
55
p= 0
.419
p=
0.4
59
p= 0
.172
p=
0.6
38
p= 0
.015
Soc
ial C
lass
pa
rtne
r
Cla
ss I
37
62.2
%
37
78.4
%
36
19.4
%
50.0
%
30.6
%
39
59.0
%
39
66.7
%
41
19.5
%
48.8
%
31.7
%
Cla
ss II
62
53
.2%
62
74
.2%
60
35
.0%
35
.0%
30
.0%
81
51
.9%
82
70
.7%
80
27
.5%
38
.8%
33
.8%
Cla
ss II
I 14
4 50
.0%
14
3 64
.3%
14
2 26
.1%
42
.3%
31
.7%
14
1 43
.3%
14
2 60
.6%
13
9 29
.5%
41
.7%
28
.8%
Cla
ss IV
74
52
.7%
74
68
.9%
77
40
.3%
38
.9%
20
.8%
88
40
.9%
89
56
.2%
89
44
.9%
33
.7%
21
.3%
Cla
ss V
70
48
.6%
70
71
.4%
67
44
.8%
31
.3%
23
.9%
64
43
.8%
64
76
.6%
63
44
.4%
31
.7%
23
.8%
p=
0.7
10
p= 0
.413
p=
0.0
91
p= 0
.264
p=
0.0
56
p= 0
.053
19
Accomplishment of fruit, vegetable and F&V recommen dations by the
frequency of family meals, TV switched on during di nner, exposure to fruit
and vegetable commercials and socio-demographic cha racteristics
No variation in the prevalence of the recommendations commitment within the
education level was observed (Table 4). Concerning the social class, boys whose
respondent parent belonged to the class I were more likely to eat at least the
200g/day of fruit (48.5% vs. 28.0% in class II vs. 41.6% in class III vs. 27.4% in
class IV vs. 24.1% in class V, p= 0.011). Similar results were observed across the
social class of the partner (36.8% vs. 28.1% in class II vs. 26.9% in class III vs.
49.4% in class IV vs. 28.7% in class V, p= 0.010). For girls, only the social class of
the respondent showed to be associated with the accomplishment of the vegetable
recommendations (Table 4). A statistical difference was observed, however there
was not a consistent pattern of variation across the social classes (18.6% in class I
vs. 18.8% in class II vs. 26.9% in class III vs. 10.5% in class IV vs. 24.0% in class
V, p= 0.019).
Table 4 also shows a higher proportion of girls meeting the 200g/day intake of
vegetables within having breakfast with parents every day than not every day
(26.3% vs. 19.7%, p= 0.039) and within an every day family dinner (25.2% vs.
17.6%, p= 0.024). No statistical significant results were found for boys (Table 4).
After parental education- and-SES- adjustment (Table 6), similar results were
observed for the family dinner among girls: the odds (OR) of eating at least
200g/day of vegetables decreased with the decreasing of the frequency of family
dinner (OR in not every day= 0.58, 95%CI: 0.32-0.98) (Table 6). When adjusting
for the frequency of TV switched on during dinner, beyond the parental education
and SES, the odds for the association between the family dinner and the
20
vegetable intake among girls lost the statistical significance (OR= 0.62, 95%CI:
0.32-1.19).
Regarding the association between TV switched on during dinner and the
accomplishment of the recommendations among boys, a lower accomplishment of
the fruit recommendations was possibly observed when having the TV switched on
during dinner every day or most days (28.4% vs. 38.8% in ≤ 3 days and 33.5% in
never, p= 0.052) (Table 5). After education- and SES-adjustment, this association
remained positive and became statistically significant, both for the ≤ 3 days
category (OR= 1.91, 95%CI: 1.09-3.36) and for the never category (OR= 2.28,
95%CI: 1.25-4.15) (Table 6). Similar results were observed for the vegetable
intake among girls. Higher frequency of TV switched on during dinner was
associated with a lower prevalence of the vegetable cut-point commitment (16.4%
vs. 24.5% in ≤ 3 days vs. 26.4% in never, p= 0.025) (Table 5). Again, these results
remained similar after adjustment for the parental education and SES (OR for ≤ 3
days= 2.32, 95%CI: 1.19-4.52; OR for never= 2.35, 95%CI: 1.17-4.75) (Table 6).
For the vegetable and F&V consumption among boys, a tendency for the
increasing of the recommendations accomplishment with the decrease of the
frequency of TV switched on during dinner was observed, although it did not reach
statistical significance when the analysis was not adjusted (Table 5). These
associations became stronger and with statistical significance after adjustment for
the parental education and SES (vegetables: OR for never= 2.05, 95%CI: 1.01-
4.16; F&V: OR for never= 2.42, 95%CI: 1.19-4.94) (Table 6). The association
between the accomplishment of the fruit recommendations among boys and the
frequency of TV switched on during dinner was also observed after adjustment for
21
the family dinner beyond the parental education- and SES-adjustment (OR for
never have TV switched on= 1.95, 95%CI:1.00-3.81).
A higher proportion of boys met the fruit and F&V recommendations when
exposed to fruit commercials (fruit: 37.6% vs. 28.7% in not exposed, p= 0.019;
F&V: 21.3% vs. 14.5% in not exposed, p= 0.032). For girls, no significant
differences were observed (Table 5). The results for the fruit consumption among
boys remained similar after education- and SES-adjustment (OR= 1.75, 95%CI:
1.10-2.79) (Table 6). No associations were observed between the exposure to
vegetable commercials and the accomplishment of the recommendations, both for
boys and girls (Table 5).
22
Tab
le 4
. A
ccom
plis
hmen
t of
fru
it, v
eget
able
and
F&
V r
ecom
men
datio
ns b
y th
e so
cio-
dem
ogra
phic
cha
ract
eris
tics
and
freq
uenc
y of
fam
ily m
eals
. B
oys
G
irls
Fru
it ≥ 2
00g/
day
Veg
etab
le ≥
20
0g/d
ay
F&
V ≥
400
g/da
y F
ruit ≥ 2
00g/
day
Veg
etab
le ≥
20
0g/d
ay
F&
V ≥
400
g/da
y
N
n %
n
%
n %
N
n
%
n %
n
%
Par
enta
l Edu
catio
n
Prim
ary
Sch
ool (
9 yr
s)
41
12
29.3
%
4 9.
8%
5 12
.2%
64
24
37
.5%
13
20
.3%
15
23
.4%
H
igh
Sch
ool (
12 y
rs)
251
90
35.9
%
47
18.7
%
55
21.9
%
250
82
32.8
%
47
18.8
%
50
20.0
%
Uni
vers
ity d
egre
e 22
0 72
32
.7%
36
16
.4%
37
16
.8%
23
5 65
27
.7%
59
25
.1%
46
19
.6%
p=
0.6
21
p= 0
.347
p=
0.1
92
p=
0.2
40
p= 0
.233
p=
0.7
87
Soc
ial C
lass
C
lass
I 33
16
48
.5%
8
24.2
%
7 21
.2%
43
13
30
.2%
8
18.6
%
8 18
.6%
C
lass
II
75
21
28.0
%
7 9.
3%
12
16.0
%
85
22
25.9
%
16
18.8
%
12
14.1
%
Cla
ss II
I 14
9 62
41
.6%
34
22
.8%
38
25
.5%
16
0 53
33
.1%
43
26
.9%
32
20
.0%
C
lass
IV
124
34
27.4
%
20
16.1
%
18
14.5
%
114
35
30.7
%
12
10.5
%
20
17.5
%
Cla
ss V
58
14
24
.1%
9
15.5
%
9 15
.5%
75
28
37
.3%
18
24
.0%
18
24
.0%
p=
0.0
11
p= 0
.106
p=
0.1
54
p=
0.6
14
p= 0
.019
p=
0.5
90
Soc
ial C
lass
Par
tner
C
lass
I 38
14
36
.8%
5
13.2
%
6 15
.8%
41
15
36
.6%
11
26
.8%
9
22.0
%
Cla
ss II
64
18
28
.1%
10
15
.6%
13
20
.3%
83
26
31
.3%
18
21
.7%
19
22
.9%
C
lass
III
145
39
26.9
%
33
22.8
%
28
19.3
%
143
43
30.1
%
25
17.5
%
27
18.9
%
Cla
ss IV
79
39
49
.4%
14
17
.7%
19
24
.1%
92
33
35
.9%
19
20
.7%
17
18
.5%
C
lass
V
74
22
29.7
%
10
13.5
%
13
17.6
%
64
18
28.1
%
9 14
.1%
11
17
.2%
p=
0.0
10
p= 0
.394
p=
0.8
18
p=
0.7
85
p= 0
.506
p=
0.8
99
Bre
akfa
st w
ith fa
mily
E
very
day
33
5 11
1 33
.1%
60
17
.9%
67
20
.0%
30
4 98
32
.2%
80
26
.3%
69
22
.7%
N
ot e
very
day
34
4 11
6 33
.7%
56
16
.3%
57
16
.6%
38
1 12
7 33
.3%
75
19
.7%
81
21
.3%
p=
0.8
74
p= 0
.572
p=
0.2
47
p=
0.7
06
p= 0
.039
p=
0.6
51
Din
ner
with
fam
ily
Eve
ry d
ay
475
165
34.7
%
82
17.3
%
91
19.2
%
456
150
32.9
%
115
25.2
%
103
22.6
%
Not
eve
ry d
ay
203
62
30.5
%
34
16.7
%
33
16.3
%
233
75
32.2
%
41
17.6
%
47
20.2
%
p= 0
.289
P
= 0
.871
p=
0.3
71
p=
0.8
52
p= 0
.024
p=
0.4
67
23
Tab
le 5
. A
ccom
plis
hmen
t of
fru
it, v
eget
able
and
F&
V r
ecom
men
datio
ns b
y th
e fr
eque
ncy
of T
V s
witc
hed
on d
urin
g di
nner
and
expo
sure
to fr
uit a
nd v
eget
able
com
mer
cial
s.
B
oys
G
irls
F
ruit ≥ 2
00g/
day
Veg
etab
le ≥
20
0g/d
ay
F&
V ≥
400
g/da
y F
ruit ≥ 2
00g/
day
Veg
etab
le ≥
20
0g/d
ay
F&
V ≥
400
g/da
y
N
n
%
n %
n
%
N
n %
n
%
n %
T
V d
urin
g di
nner
E
very
day
/ M
ost d
ays
257
73
28.4
%
39
15.2
%
36
14.0
%
244
83
34.0
%
40
16.4
%
56
23.0
%
≤ 3
day
s 23
2 90
38
.8%
41
17
.7%
47
20
.3%
25
7 84
32
.7%
63
24
.5%
55
21
.4%
N
ever
18
5 62
33
.5%
39
21
.1%
40
21
.6%
17
8 57
32
.0%
47
26
.4%
36
20
.2%
p=
0.0
52
p= 0
.275
p=
0.0
77
p=
0.9
04
p= 0
.025
p=
0.7
92
Fru
it C
omm
erci
als
N
o 28
2 81
28
.7%
42
14
.9%
41
14
.5%
31
8 10
0 31
.4%
69
21
.7%
63
19
.8%
Y
es
367
138
37.6
%
72
19.6
%
78
21.3
%
338
116
34.3
%
77
22.8
%
77
22.8
%
p= 0
.019
p=
0.1
20
p= 0
.032
p= 0
.455
p=
0.7
78
p= 0
.391
V
eget
able
Com
mer
cial
s
No
387
127
32,8
%
66
17,1
%
69
17,8
%
395
133
33,7
%
90
22,8
%
84
21,3
%
Yes
25
9 92
35
,5%
45
17
,4%
51
19
,7%
25
4 81
31
,9%
56
22
,0%
57
22
,4%
p=
0.4
98
p= 0
.916
p=
0.6
06
p=
0.6
69
p= 0
.848
p=
0.7
70
24
Tab
le 6
. O
dds
ratio
s fo
r fr
uit
and
vege
tabl
e in
take
acc
ordi
ng t
o th
e fr
eque
ncy
of f
amily
mea
ls,
TV
sw
itche
d on
dur
ing
dinn
er a
nd
expo
sure
to fr
uit a
nd v
eget
able
com
mer
cial
s.
† A
djus
ted
for
pare
ntal
edu
catio
n, s
ocia
l cla
ss o
f the
res
pond
ent a
nd p
artn
er.
B
oys
Girl
s
F
ruit ≥ 2
00g/
day
Veg
etab
le ≥
20
0g/d
ay
F&
V ≥
400
g/da
y F
ruit ≥ 2
00g/
day
Veg
etab
le ≥
20
0g/d
ay
F&
V ≥
400
g/da
y
O
R†
CI 9
5%
OR
† C
I 95%
O
R†
CI 9
5%
OR
† C
I 95%
O
R†
CI 9
5%
OR
† C
I 95%
B
reak
fast
with
fa
mily
Eve
ry d
ay
1 (r
efer
ence
) 1
(ref
eren
ce)
1 (r
efer
ence
) 1
(ref
eren
ce)
1 (r
efer
ence
) 1
(ref
eren
ce)
Not
eve
ry d
ay
0.96
(0
.61
– 1.
49)
0.98
(0
.57
– 1.
68)
0.91
(0
.53
– 1.
54)
1.20
(0
.78
– 1.
85)
0.82
(0
.49
– 1.
37)
1.04
(0
.62
– 1.
73)
Din
ner
with
fa
mily
Eve
ry d
ay
1 (r
efer
ence
) 1
(ref
eren
ce)
1 (r
efer
ence
) 1
(ref
eren
ce)
1 (r
efer
ence
) 1
(ref
eren
ce)
Not
eve
ry d
ay
0.72
(0
.44
– 1.
17)
0.83
(0
.46
– 1.
52)
0.68
(0
.37
– 1.
24)
1.09
(0
.70
– 1.
70)
0.56
(0
.32
– 0.
98)
0.95
(0
.55
– 1.
61)
TV
dur
ing
dinn
er
Eve
ry d
ay /
Mos
t of
day
s 1
(ref
eren
ce)
1 (r
efer
ence
) 1
(ref
eren
ce)
1 (r
efer
ence
) 1
(ref
eren
ce)
1 (r
efer
ence
)
≤ 3
day
s 1.
91
(1.0
9 –
3.36
) 1.
43
(0.7
3 –
2.82
) 1.
91
(0.9
6 –
3.81
) 1.
21
(0.7
3 –
2.02
) 2.
32
(1.1
9 –
4.52
) 1.
11
(0.6
2 –
2.01
) N
ever
2.
28
(1.2
5 –
4.15
) 2.
05
(1.0
1 –
4.16
) 2.
42
(1.1
9 –
4.94
) 1.
12
(0.6
5 –
1.94
) 2.
35
(1.1
7 –
4.75
) 0.
72
(0.3
7 –
1.42
) F
ruit
Com
mer
cial
s
No
1 (r
efer
ence
) 1
(ref
eren
ce)
1 (r
efer
ence
) 1
(ref
eren
ce)
1 (r
efer
ence
) 1
(ref
eren
ce)
Yes
1.
75
(1.1
0 –
2.79
) 1.
23
(0.7
0 –
2.16
) 1.
35
(0.7
7 –
2.35
) 1.
02
(0.6
6 –
1.58
) 1.
17
(0.7
0 –
1.98
) 1.
15
(0.6
9 –
1.95
) V
eget
able
C
omm
erci
als
No
1 (r
efer
ence
) 1
(ref
eren
ce)
1 (r
efer
ence
) 1
(ref
eren
ce)
1 (r
efer
ence
) 1
(ref
eren
ce)
Yes
1.
29
(0.8
1 –
2.06
) 0.
75
(0.4
2 –
1.34
) 0.
88
(0.5
1 –
1.54
) 0.
79
(0.5
0 –
1.25
) 1.
22
(0.7
2 –
2.07
) 1.
00
(0.5
9 –
1.71
)
25
5. Discussion
The mean F&V intake in this study was 260.5 grams per day, which is far below
from the minimum recommended by the joint FAO/WHO (10) and the Swedish
recommendations (400 g of F&V per day for children below ten years and 500 g
per day for adults, excluding potatoes and fruit juice counted as maximum 100g)
(50). Fruit and vegetable consumption in children is reported in the literature to be
far below the recommendations as an overall trend all over the world (10, 23). The
mean fruit intake was slightly higher than the vegetable intake and girls reported to
consume more F&V than boys, which has also been reported in other studies (23,
32-33). The sweeter taste of fruit may be one of the reasons why children often
prefer fruit rather than vegetables.
Roughly half of children reported to have breakfast with parents every day, while
for dinner the proportion was slightly higher (around 2/3 of children reported it to
be every day). Dinner is thought to be the most socially significant and largest
meal of the day (37). Moreover, a higher frequency of dinner with family may be
linked with higher frequency of family breakfast, which may support the current
findings (37). In the present study, no significant differences in the F&V intake were
seen across the frequency of having breakfast with parents. However, a higher
frequency of dinner with family was associated with increased vegetable intake
among girls. Higher frequency of family meals has been shown to be associated
with better dietary patterns, including a higher consumption of fruit, vegetables,
grains, calcium-rich foods and several micronutrients, and lower intake of soft
drinks and fried food (34-37). Most of the literature on family meals and its
association with dietary patterns are focused on dinner and not breakfast. Our
results suggest that it probably matters which meal is considered when analyzing
26
the overall association between family meals and their possible outcomes, since
was shown to be different.
Regarding the TV habits, higher frequency of TV switched on during dinner was
associated with a decrease in the F&V intake among boys, while for girls it was
only associated with the vegetable intake. It is concordant with the results from
other studies that showed not only the decrease in F&V intake, but also an
increase in the consumption of snacks, pizzas and soft drinks (41, 43-45)
We may speculate about the independent effect of the family dinner and TV
switched on during dinner since they were differently associated for boys. While
the mean fruit and vegetable intakes among boys were not different when having
dinner with parents every day, TV switched on during dinner every day was
associated with its decreasing. For girls, family dinner was associated with an
increase in the mean vegetable intake, while TV on during dinner decreased it. We
may speculate that the positive effect of family dinner was overlapped by the
influence of having the TV switched on during dinner for boys but not for girls.
There was previous evidence that watching TV during family meals was
associated with poorer quality diet, with fewer fruit and vegetables, when
compared to family meals without watching TV (41).
One potential mechanism to explain the association between TV switched on
during dinner and dietary intake might be the influence of commercials. Findings
from this study revealed that children were more exposed to unhealthy food
commercials on TV (as candy/chocolate bars, biscuits/sweet buns/cakes,
chips/savoury snacks, soda/soft drinks and fast-food) than to F&V commercials.
Food is the most heavily advertised product category during children’s television
27
programming (51) and the unhealthy food is the most advertised (43), which supports
the high exposure to unhealthy food found among the children in this study. No
significant differences were observed in the F&V consumption among the
exposure to unhealthy food commercials, but the exposure to fresh fruit
commercials was associated with higher mean intakes of fruit and F&V (due to the
increase of fruit consumption, since no differences were observed for vegetables)
among boys. It has been described in the literature an association between
watching TV and the consumption of the advertised food (46), children’s food
preferences and parental purchasing behaviour (52). Children exposed to fresh fruit
commercials might increase their intake by choosing them and/or consequently
asking their parents to buy it. However, we may question about the veracity of the
reported exposure to fruit commercials and its association with the fruit intake. The
increased fruit intake was only observed for boys and also when they reported to
had been exposed to vegetable commercials. It is important to consider the
possible over-reporting for the exposure to F&V commercials, with children
answering according to what they think it would be expected since this was a
study to assess the F&V intake. Moreover, as described in the literature (51, 53), the
F&V commercials are not so frequent and, in Sweden, there is a policy that
regulates and restricts the food advertising to children, not allowing any television
advertising to be specifically directed to children under 12 or to have
advertisements during children’s programming (54). However, these facts would
explain a similar effect for both fruit and vegetable mean intakes (and not only for
fruit as it was observed) if it is in fact associated with the exposure to F&V
commercials. It is also important to point out the frequent commercials containing
fruit pictures without being advertising the fruit (for example, fruit juice
28
commercials or breakfast cereals containing fruit) or as a marketing strategy, as
described in one study reporting that more than one-third of all the commercials for
children on the US broadcast network used a fruit appeal or association (55). It may
lead to a misunderstanding among children about what are the real fruit
commercials.
When analyzing the frequency of family meals and TV habits by socio-
demographic characteristics, it was shown a variance across gender, parental
education and SES. Girls whose parents had higher education level were more
likely to report less TV during dinner. Higher SES of the respondent was
associated with less TV during dinner among girls and, possibly, associated with
the frequency of family breakfast. Variations for the frequency of family meals and
TV switched on during dinner by gender, parental education and SES have been
reported in the literature (34, 36, 41, 49).
Regarding the F&V recommendations accomplishment, the parental education did
not show to be associated, while the SES was associated with the fruit
recommendations accomplishment among boys and with the vegetable
recommendations accomplishment among girls. No consistent patterns of variation
in the F&V consumption were observed, but it seemed that higher social classes
(when comparing the highest ones with the lowest ones) were associated with
higher fruit recommendations accomplishment (Table 4). The high price of fruits
may support this association, not being affordable for people from lower social
classes, as also shown in other studies (20, 56).
These observed variations in family meal patterns and F&V intake across the
socio-demographic characteristics highlight the importance of adjusted analyses
29
when studying the association of family meals and TV during mealtime on the F&V
intake among children.
Frequent family meals (breakfast and dinner) were associated with higher
accomplishment of the vegetable minimum established value (200g/day) among
girls and not confounded by the parental education and social class (for the family
dinner). However, the positive association between family dinner and vegetable
intake among girls disappeared when adjusting for the TV switched on during
dinner. The association between lower frequency of TV switched on during dinner
and the increased fruit (boys) and vegetable (girls) recommendations
accomplishment was independent from the sociodemographics and dinner with
family. The influence of the exposure to fruit commercials on the fruit consumption
(by establishing a minimum intake value as reference) was the same than when
comparing the mean fruit intake: the fruit recommendations accomplishment was
higher among boys reporting to had been exposed (conducting to an increase in
the total F&V, since no differences were observed for the vegetable intake). The
education- and SES- adjusted analysis showed no confounding effect for this
increased fruit consumption among boys exposed to fruit commercials.
Having meals with family has been considered positive by parents. For most of
them it is an important family time, when they can talk with their children and
enhance the family togetherness (34, 57). Knowing or not the behind mechanisms,
studies are consistent in showing positive outcomes among children or
adolescents concerning the frequency of family meals: a high quality diet, less
disturbing dietary behaviours and an improved psycho-social well being. The
question is, is it due only to the family meals? Or are the family meals a marker of
30
an overall good family environment? Are not them inter-associated, not being
possible to attribute the effects specifically to each one? Family meals can
contribute to higher family cohesion, by promoting a time when the family
members interact and talk between them. Or, looking from other perspective, the
positive effect of family meals may be a marker of a good family environment that
promotes frequent family meals with structures and rules, as turning off the TV
during the mealtime (overruling the bad influence of the exposure to TV
commercials) and preparing and serving healthy food according to the preferences
of the family members.
Further research is needed to know what is really about the family meals that
explain its positive association with the F&V intake among children and to explore
if there are other factors concerning the family environment that also contribute to
the association with the consumption, since the current findings were not
consistent across the child’s sex and the F&V consumption separately.
Strengths of this study include the representativeness of the sample, leading in
high probability to representative results at the national level. The large and
diverse nature of the sample in terms of socio-demographic characteristics, family
meals patterns and dietary intake is other strength, which enhances the ability to
reach associations between them. The study is also strengthened by the high
response rates, which was probably due to the use of the schools and classes as
sample units. The fact of being a school-based survey might have lead to less bias
for over-representativity of healthy and educated individuals.
This study is not free of limitations. First, the cross-sectional nature of the study
does not allow to show causality and to make predictions. Second, it was used
31
only one 24-hour recall, which may not reflect the usual intake and it is a self-
reported questionnaire. However, it was specifically validated to this study with
satisfactory results (47) and it is described to be reasonably accurate when
assessing group mean estimates of children’s dietary intakes (58). Third, the data
regarding the frequency of family meals, the frequency of TV switched on during
dinner and the extent of exposure to food commercials was self-reported by
children and was integrated in a questionnaire with more than 100 items, which
can be quite demanding to respond to for 11-year olds. Fourth and lastly, the
season of data collection, between October and November, is when the national
and local fruit (grown fruit, berries) and vegetables are available in high quantities.
This suggests that there is a possibility that the mean intake would be even lower
if the data was collected in other season of the year.
32
6. Conclusions and Recommendations
A higher frequency of family meals was associated with increased F&V intake
among 11-year old children, particularly the vegetable intake and accomplishment
of the recommendations among girls. TV switched on during dinner was shown to
be linked with decreased F&V intake and recommendations accomplishment for
both genders. The exposure to fresh fruit commercials may increase the fruit
intake and accomplishment of the recommendations, particularly among boys.
Moreover, the analyses should be adjusted for sociodemographics, since it
showed to be different.
Hence, the frequency of family meals and its context should be a subject to be
assessed and discussed among the population, at maternal and child health-care
clinics (MVCs and BVCs in Sweden), pre-school / day-care centres, schools and
community. It is important to address interventions to the parents, regarding their
potential capability to positively influence their children’s consumption, particularly
the F&V intake through the provision of high quality family meal patterns.
Regarding the TV commercials, it might be important not only to set policies that
regulate and restrict certain food commercials addressed to children, but also
increase healthy food commercials as F&V commercials.
Frequent family meals and the TV turning off during the mealtime should be
promoted.
33
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Annex 1 – Social Class categories
