561514 research-article2015

HEBXXX10.1177/1090198114561514Health Education & BehaviorBates and Price

Regular Article

Impact of Fruit Smoothies on Adolescent Fruit Consumption at School

Health Education & Behavior 2015, Vol. 42(4) 487­–492 © 2015 Society for Public Health Education Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1090198114561514 heb.sagepub.com

Dylan Bates, BS1 and Joseph Price, PhD1

Abstract We examine the impact of serving fruit smoothies during school breakfast on fruit consumption among middle school and high school students. We draw on observational plate-waste data over a 10-week period during which fruit smoothies were introduced for breakfast at two Utah schools. Our total sample includes 2,760 student-day observations. We find that the fraction of students eating a full serving of whole fruit increased from 4.3% to 45.1%. As such, school districts should consider offering fruit smoothies as part of a set of interventions designed to increase fruit consumption at school. Keywords breakfast, fruit, school nutrition Fruit and vegetable consumption plays an important role in promoting good health. An increase in fruit and vegetable consumption is associated with lower blood pressure, reduced risk of stroke, and lower body mass index (Dauchet, Amouyel, & Dallongeville, 2009; He, Nowson, & MacGregor, 2006; Roseman, Yeung, & Nickelsen, 2007). Despite these benefits, most Americans consume half or less of the daily recommended intake of fruits and vegetables (Centers for Disease Control and Prevention, 2010). Consumption of fruits and vegetables is especially lacking in middle school and high school age children. One study found that among adolescents, only a tiny fraction consume the daily recommended amount of fruits and vegetables: 1.2% of boys aged 9 to 13 years, 0.7% of boys aged 14 to 18 years, 3.6% of girls aged 9 to 13 years, and 1.5% of girls aged 14 to 18 years consume the recommended amount (Guenther, Dodd, Reedy, & Krebs-Smith, 2006). From 2007 to 2010, 60% of children aged 1 to 18 years did not meet U.S. Department of Agriculture (USDA) fruit intake recommendations and 93% did not meet vegetable recommendations (Kim et al., 2014). Another study of more than 5,000 students in middle schools and high schools in Minnesota found that only half of middle school students and 44% of high school students consumed two or more servings of fruit a day, with a median daily intake of 1.8 servings for both boys and girls (Neumark-Sztainer, Story, Hannan, & Croll, 2002). Past studies have documented various ways to increase fruit and vegetable consumption during school lunch and specifically recommend schools as a unique opportunity to promote these items. Successful interventions have included increasing the availability, accessibility, attractiveness, or

variety of fruit and vegetables offered to students (Blanchette & Brug, 2005; French & Stables, 2003; Just, Lund, & Price, 2012; Perry et al., 2004; Raynor & Osterholt, 2012). Different methods of preparing fruits or vegetables (slicing to different sizes and shapes) can also increase consumption of these items during lunch by elementary school children (Jansen, Mulkens, & Jansen, 2010; Olsen, Ritz, Kramer, & Møller, 2012; Swanson, Branscum, & Nakayima, 2009). Many interventions combine multiple treatments including education, parental involvement, small rewards, and environmental changes (Blanchette & Brug, 2005; Story et al., 2000). The intervention described in this article is simple compared with most interventions. This is an advantage because it provides a practical method for increasing fruit consumption in schools that would be easy to implement on a large scale. While much research has focused on increasing fruit and vegetable consumption during lunch, there has been much less research on interventions to increase fruit and vegetable consumption at school breakfast. The USDA School Breakfast Program is a major source of breakfast for children and adolescents in the United States, serving nearly 13 million breakfast meals every school day (USDA, 2012). The program is therefore in a position to greatly influence the nutritional quality of students’ breakfasts. In this article, we 1

Brigham Young University, Provo, UT, USA

Corresponding Author: Joseph Price, Department of Economics, Brigham Young University, 162 FOB, Provo, UT 84602, USA. Email: [email protected]

488 describe the results of offering fruit smoothies as part of the school-provided breakfast.

Method Research Design This was a quasi-experimental study performed at two schools in Utah that introduced fruit smoothies during breakfast for the first time. One school was a middle school (Grades 7 through 9) and the other was a high school (Grades 10 through 12). The smoothie equipment was provided by a grant from the Utah Dairy Council. Smoothies were prepared according to a recipe provided by the school district meal supervisor. The basic batch recipe called for 1¼ cup of liquid such as milk and/or juice, 1¼ cup of vanilla yogurt, and 6 cups of fruit. Each batch made about twelve 5-oz servings, resulting in a little more than 1/10 of a cup of milk and yogurt and a half cup of fruit per smoothie serving. No additional sugar, frozen yogurt, or ice cream was added to the smoothies. The fruits used in smoothies included bananas, strawberries, pineapple, and mandarin oranges. Less frequently, cherries, pears, and spinach were used for green smoothies. Pineapple and orange juice were often included in the mixture in place of milk. Most of the fruit used was either canned or frozen. In some cases items such as bananas were leftover from other meals, frozen, and then blended into the smoothies. Smoothies were served in clear cups and placed in the same area as the other fruit options, which were also served in clear plastic cups and contained a serving of fruit. Smoothie preparation required a substantial amount of time in order to divide fruit into serving sizes and freeze it in addition to mixing and blending the ingredients. The breakfast staff reported that in order to make about 60 smoothies, it took a little more than 30 minutes. This process would be shorter if schools were provided with larger blenders (the schools had one standard size blender) and if schools purchased frozen fruits instead of canned fruits. Nevertheless, the schools cited the time cost of making the smoothies as one impediment to offering the smoothies every day. Data were collected for 4 weeks at both schools prior to the introduction of smoothies referred to hereon as the baseline period. Because smoothies were not offered every day after they became available, it is possible to compare observations during the postperiod based on whether smoothies were offered that day. Our data do not allow us to uniquely identify each individual student; therefore, we do not report the total number of participants in our study. Instead, we report our sample number, where a single observation records the waste and consumption rates across all food items taken by a specific student on a specific day. Over the next 4 weeks, we collected data at 28 school breakfasts, 13 of which were smoothie days. The final sample includes 2,760 student-day observations, including 483 that occurred on days when smoothies were served.

Health Education & Behavior 42(4) USDA guidelines require that a full breakfast include a cup of fruit, 8 to 10 oz of grains, and a cup of milk. As such, the smoothie could not be counted as a full meal but was offered along with the main breakfast entrée each day. A variety of choices of entrees were available to students. Commonly unhealthy choices such as donuts, pop tarts, pizza, corn dogs, French toast, and pancakes were served. Healthier options with less sugar included eggs/omelets, yogurt, and toast. The other items in addition to entreés offered alongside smoothies varied little day to day. These items included milk, juice, and various other fruits such as applesauce, mandarin oranges, mixed fruit cups, peaches, oranges, pears, and pineapple.

Data Collection Data collectors were positioned by trash cans and observed students as they discarded their breakfast trays. Smoothies and other fruit items were all served in preportioned containers, making it possible to identify how much fruit, fruit juice, and smoothie each student both took and ate. Containers for smoothies and fruit were clear and the amount of the item inside was clearly visible. Each container held one serving of its respective item. For each student, data collectors recorded the number of servings of each item that they placed on their tray and the fraction of each item that was consumed. All data were collected postconsumption using a handheld device app called “vproject,” which is available for free in the Apple app store. The app was developed by Just and Price (2013) and allows data collectors to record how many items students both took and ate as part of their school meal based on a visual inspection of each student’s tray at the end of the meal. Data collectors simply looked at a student’s tray, judged how much of each item the student consumed by how much of the item was left, and recorded consumption of each item by marking it in the app. Data collectors also recorded the students’ gender and grade, again based on visual observation. Since grade is based on the data collector’s best guess, it may reflect more the size of the student rather than their actual grade. Each school had only three grades so the range of possible measurement error is small. Date and time of the observations was recorded and tracked by the app. This approach provides measures that are less precise than weighing the items on each student’s tray at the start and end of lunch but has the advantage of providing an unobtrusive way to collect information on all of the students eating a particular meal. This data collection approach has been validated in a recent study by Hanks, Wansink, and Just (2014). They compare the reliability of three different visual inspection methods of measuring food waste (the photograph method, the half-waste method, and the quarter-waste method) by comparing them to results obtained by weighing trays after students finished eating. The photograph method involves photographing food trays immediately following the meal

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Bates and Price and later estimating the amount of waste from the photograph. The quarter-waste and half-waste methods involve an individual estimating waste immediately after a meal using a 0, ½, 1 scale or a 0, ¼, ½, ¾, 1 scale. They find that the quarter-waste method provides the most accurate and reliable results, with a correlation measure of 0.90 (p < .001) compared with the weighing method. Our method of visual inspection most closely resembles the quarter-waste method described by Hanks and colleagues. In fact, the app used to collect the data allowed researchers to specify the amount of waste observed on trays at any increment between 0% and 100%, though quarter estimates were recorded most often. Hanks et al. (2014) also tested the statistical power of all three methods by estimating the minimum combined baseline and follow-up sample size that is required to detect a 10% decrease in waste in an intervention scenario. The total number of observations necessary to detect this change is less than 2,000 observations for each visual inspection method. In our study, we compare consumption rates between baseline days and intervention days using more than 2,500 observations and we find consumption differences well over 10%, so based on the analysis by Hanks et al., our methods and data prove to more than satisfy reasonable standards of reliability and statistical power. Whole fruit and fruit juice are recorded separately in our data, and the main analysis of this article focuses specifically on whole fruit. The USDA recommends that whole fruits be consumed more than fruit juice, as fruit juice does not contain the dietary fiber content of whole fruits. Smoothies contain whole fruit, and recent research indicates that pureed forms of fruit retain more of the dietary benefits of whole fruit, including higher satiety and lower energy intake at meal time (Flood-Obbagy & Rolls, 2009). Since 100% fruit juices do retain some of the health benefits of fruits (Ruxton, Gardner, & Walker, 2006) and because juice was the most common form of fruit consumption during the baseline period of our sample, an alternative analysis is included that extends the definition of fruit to also include fruit juice.

Table 1.  Characteristics of the Participating Schools. Characteristic Enrollment, n Male White Hispanic Other Free or reduced-price lunch Baseline rates   Ate   ≥1 serving of fruit   Servings of fruit eaten  Ate ≥1 servings of fruit or fruit juice   Servings of fruit or fruit juice consumed Days of data  Baseline  Smoothie   No smoothie (after introduction) Breakfasts served per day N

Middle school

High school

1,301 52.0% 84.7% 10.4% 4.9% 37.7%

1,195 48.8% 90.63% 6.44% 2.9% 20.5%

2.4% 0.026 63.3% 1.01

8.6% 0.133 66.2% 1.28

21  4  7 53.4 1,709

18  9  8 30.0 1,051

Note. The ages of middle school students ranges from 12 to 14; the ages of high school students ranges from 15 to 18.

offered for breakfast. For the outcome measures that are an indicator for whether the student ate at least one serving of fruit, the coefficients can be interpreted as a percentage point change in the fraction of students eating at least one serving of the item.1 For the outcome measures of the number of servings consumed, the coefficients can be interpreted as the average increase in the number of servings of the item consumed. In addition, we generate an alternative analysis that is identical except that servings of juice are also counted as fruit consumed. In all of the regressions, we include controls for each student’s grade and gender as well as school and day of week fixed effects. Each observation is recorded at the student-day level and standard errors are adjusted to account for intraclass correlation at the schoolday level.

Statistical Analysis In our analysis, we measure consumption of fruit in two ways. First, we use a continuous measure of the actual number of servings consumed. Second, we use a binary indicator for whether the student consumed at least one serving of fruit. This second measure addresses concerns about whether our data collection approach accurately measures consumption since it is much easier to judge whether or not a serving was eaten than to judge the specific amount of servings eaten. It also has the useful feature of capturing a welldefined benchmark that schools might attempt to pursue: increasing the fraction of children eating at least one serving of fruit for breakfast. We use linear regression analysis to examine the average change in fruit consumption on days that smoothies are

Results Impact on Fruit Consumption Demographic characteristics of each school and a breakdown of the sample are presented in Table 1. Our sample included a total of 68 days of data collection with a total sample of 2,760 student-day observations. The schools we worked with had relatively small breakfast programs with only 30 to 50 students eating breakfast at school on any given day (on any given day 70% to 90% of these students received a free or reduced-price meal). Table 2 presents the average consumption rates of fruit before and after the introduction of smoothies as part of school breakfast. Since smoothies were not offered every day (even after they were introduced),

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Table 2.  Consumption of Fruit Before and After Smoothie Introduction. Number of observations Baseline 1,654   After smoothie introduction  Smoothie 483       No smoothie 623    

Ate at least one serving of fruit

Servings of fruit eaten

4.3% (0.5%)

5.8% (0.6%)

45.1% (2.3%) 0.00 4.2% (0.8%) 0.90

58.3% (2.8%) 0.00 4.8% (0.9%) 0.35

Note. Percentages represent the fraction of total students observed. Standard errors of each mean are reported in parentheses. p Values from a t test of the difference in means relative to the baseline period are reported below the standard errors.

the period after the introduction is reported separately based on whether smoothies were offered that day. The first two columns of Table 2 show the change in whole fruit consumption. The baseline level of fruit consumption at both schools showed low levels of whole fruit consumption (either canned or fresh) and high levels of fruit juice consumption. This is typical of participants in the School Breakfast Program. Condon, Crepinsek, and Fox (2009) found that across all children, from elementary age through high school, participating in the School Breakfast Program: 56% of the children drank 100% juice, while only about 6% ate canned fruit and 5% ate fresh fruit. Across the 25 days of baseline data from our study, only 4.3% of students on any given day consumed at least one serving of whole fruit (only 6.4% consumed any amount of whole fruit). The most common fruits consumed during the baseline period were pineapple, apples, and mandarin oranges. Once smoothies were introduced, the fraction of students consuming at least one serving of whole fruit increased to 45.1% (with 56.9% eating at least some amount of whole fruit). The average number of servings of whole fruit consumed per student also experienced a 10-fold increase, rising from 0.058 at baseline up to 0.583 on days when smoothies were offered. Fruit consumption returned to baseline levels on the days when smoothies were not offered. The first two columns of Table 3 provide regression-based estimates of the change in fruit consumption when smoothies were offered and confirm the patterns in Table 2. The 35 percentage point increase in the fraction of students eating at least one serving of whole fruit and the 0.446 increase in servings consumed per student are both statistically significant at the 1% level. In addition, the coefficients on the control variables indicate that boys consumed slightly less fruit for breakfast on average than did girls. Adding a gender–treatment interaction term shows that the impact of the treatment was higher among boys than

girls. Comparing baseline rates to smoothie day rates, we find that the percentage of boys eating a full serving of fruit jumped from 4.7% to 59.7%. For girls the effect was slightly smaller jumping from 9.3% during the baseline period to 53.9% on the days that smoothies were offered. This difference shows up in average consumption as well. During the treatment period, the average boy ate 0.12 more servings of fruit than the average girl.

Accounting for Fruit Juice Much of the past research on interventions designed to increase fruit consumption at schools distinguishes between an impact on whole fruit consumption and on juice consumption (Cullen et al., 2003; Schwartz, 2007; Subar et al., 1995). In the last two columns of Table 3, the results are extended to include fruit juice as part of the outcome measure (whole fruit is still included). The baseline rates of fruit consumption were much higher once fruit juice was included, with 64% of students consuming at least one serving and average consumption of fruit becoming 1.09 servings per student. Even with the higher baseline levels of consumption, offering smoothies still had a dramatic effect on this more expanded definition of fruit. The fraction of students that consumed at least one serving of fruits increased by 14.3 percentage points and the average number of servings consumed per student increased by 0.316. Both of these increases were statistically significant at the 1% level. In addition, the coefficients on the control variables in these regressions indicate that with this expanded definition of fruit, boys and older students consumed slightly more servings of fruit. However, even under the expanded definition of fruit, the smoothies continued to have a greater impact on boys.

Impact Over Time It is possible that the large impact of the treatment could be attributed to a novelty effect. If the students are consuming smoothies simply because they are a new item, then the impact could wear off over time. To test this, a linear time trend was included in the regression along with an interaction with the treatment. Treatment data were collected for 2 weeks at the junior high school and 4 weeks at the high school. We estimate the same regressions as in Table 3 but include an interaction term between smoothies being offered that day and the number of days since smoothies were first introduced (as well as a main effect for time since introduction). The coefficient on the interaction term is very small in magnitude and not statistically significant (the p values across the same outcomes as in Table 3 are 0.82, 0.72, 0.15, and 0.51, respectively). In addition, the coefficient is actually positive for three of the four outcomes, which is just the opposite of what would be expected if there were a novelty effect that wears off. However, the length of our study period may not have allowed enough time for the novelty effect to have worn off.

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Bates and Price Table 3.  Regression Showing Impact of Offering Smoothies on Fruit Consumption.

Smoothie No smoothie Male Grade Mean (baseline)

Ate at least one serving of fruit

Servings of fruit eaten

Ate at least one serving of fruit (counting juice)

Servings of fruit eaten (counting juice)

0.351** (0.042) 0.004 (0.016) −0.016 (0.013) −0.002 (0.009) 0.043

0.446** (0.057) −0.004 (0.018) −0.033* (0.015) −0.015 (0.013) 0.058

0.143** (0.043) 0.078 (0.045) −0.016 (0.018) 0.023 (0.014) 0.642

0.316** (0.090) 0.075 (0.079) 0.079* (0.039) 0.064* (0.030) 1.089

Note. N = 2,760 for all regressions. The last two columns include juice as a fruit item throughout all periods of the experiment. “Smoothie” indicates a day when smoothies were served. “No smoothie” indicates a day after the introduction of smoothies when smoothies were not served. Regressions include school and day of week fixed effects. Standard errors are reported in parentheses. Standard errors are clustered at the school day level. ** and * indicate statistical significance at the 1% and 5% levels, respectively.

Discussion The introduction of smoothies into the School Breakfast Program increased the percentage of students consuming at least one serving of fruit and the total number of fruit servings being consumed. Our baseline measures highlight the important need for this type of intervention since students were only consuming 0.058 servings of whole fruit on average for breakfast with only 4.3% of students getting at least one serving of whole fruit. The increased consumption of fruit on the days that smoothies were offered does not seem to have changed the students’ preference for fruit (at least in the short term) since consumption of whole fruit on non– smoothie days after smoothies were introduced are very similar to baseline levels and regression analysis shows no statistical difference. One explanation for why offering smoothies had such a dramatic effect on fruit consumption is that fruit consumption is related to accessibility and appeal of the fruit items (Blanchette & Brug, 2005). Smoothies are a convenient way to increase accessibility to fruits for students who do not want to take time peeling or chewing fruits. Smoothies are similar in texture to popular dessert drinks like milkshakes and this similarity may be very appealing to students. Although the large impact of the treatment shows a promising way to increase the nutritional quality of breakfast among adolescents, the current study has some limitations. The sample of this study was limited to two schools from the same school district, and, therefore, it is possible that the results may differ in other settings. However, the large change in behavior that was observed suggests that even if the effect were more muted in other schools, it would still result in a notable change in behavior. The small time period over which the data were collected also makes it difficult to judge the long-term implications of the intervention. While this study finds no evidence of a novelty effect with the effect declining over time, longer observational periods would be needed to confirm this. In fact, the results of this article may understate the overall impact of the intervention if exposure to fruits creates habits in adolescents that carry into the future. Finally, the time it takes to prepare smoothies or the

cost of the equipment may provide a barrier to school districts adopting smoothies as a breakfast option. It is important to point out that the number of students who ate a school-provided breakfast in our sample is actually a small percentage of the total enrollment. The low percentage of enrolled students eating the school-provided breakfast necessarily limits the impact that providing smoothies can have on all students. However, it is likely to target the lowincome students that may benefit the most from increased fruit consumption. While the impact may be low in schools with a low percentage of students eating school-provided breakfasts, it is still extremely relevant at a national level. In addition, since over 13 million students participated in the School Breakfast Program in 2013, offering fruit smoothies at each school in the School Breakfast Program could potentially improve the fruit consumption of millions of children and adolescents. While most past research has focused on interventions designed to increase fruit consumption during lunch, the School Breakfast Program provides another important opportunity to encourage fruit consumption at school. However, this smoothie option does not have to be exclusive to breakfast—it could be extended to lunch as well. In fact, introducing smoothies during lunch could have an even larger impact since there are so many more children than eat lunch at school than that eat breakfast. School districts should consider offering fruit smoothies as part of a set of interventions designed to improve healthy eating among students consuming school meals. The smoothies included in the intervention examined in this article consisted solely of milk, fruit juice, whole fruit, and yogurt with no additional sugar, frozen yogurt, or ice cream. The results of this article indicate that a basic healthy smoothie can be quite popular with students and additional ingredients are not actually needed for the smoothie to produce a dramatic increase in whole fruit consumption. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding for this project was provided by the U.S. Department of Agriculture Economic Research Service.

Note 1.

We obtain similar results based on the average marginal effects of a logistic regression but report results based on a linear probability model for ease of interpretation.

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