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What are the effects of multi-component compared to single-component nutrition education interventions on children’s dietary intake-related behaviors?

Conclusion

There is inconsistent evidence to suggest that multi-component nutrition education interventions may be more effective for improving children’s and adolescents’ dietary intake-related behaviors than single-component interventions. Limited evidence also suggests that multi-component nutrition education interventions that combine classroom nutrition education with a hands-on educational component may be particularly effective.
 

Grade

III – Limited

 

Evidence Summary Overview

This systematic review includes 14 studies that examined the effects of single- vs. multi-component nutrition education interventions on dietary intake-related behaviors in children and adolescents. An intervention is described as a “single-component” intervention, when subjects are provided nutrition education using one distinct method, while an intervention is described as a “multi-component” intervention when subjects are provided nutrition education via two or more different methods. Several studies included in this systematic review (six studies) found that multi-component nutrition education interventions were better than single-component interventions for improving dietary intake; though, three of these studies had mixed results that differed depending on the outcome being considered. A number of studies showed that multi-and single-component interventions were equally effective for improving dietary intake (two studies, one with mixed results), or, conversely, had no effect on dietary intake (four studies, three with mixed results). In addition, some of the studies included in the review (three studies, two with mixed results) found that single-component nutrition education interventions were better than multi-component interventions for improving dietary intake. Again, several of these studies had mixed results depending on outcome.

Finally, the studies were compared to determine whether any specific component was particularly effective. Three out of six studies that found a multi-component intervention to be better (e.g., there were no mixed results that differed depending on outcome) than a single-component intervention included a “hands-on” component, such as cooking or gardening, combined with classroom-based nutrition education. None of the other studies included in this review included similar hands-on components.

Description of the Evidence

The literature search for studies that tested the effects of multi- vs. single-component nutrition education interventions identified 3,538 articles, 432 of which were selected for review (Figure 4-E.1). Of these 432 articles, 12 were selected for inclusion in the systematic review. In addition, two articles were identified via hand search. Therefore, this systematic review includes a total of 14 articles. A detailed description of literature search results, including the databases searched and the number of articles identified using each database, articles identified using hand search, a list of citations for all included articles, and a table that lists excluded studies with rationale for exclusion can be found in Appendix H.

Click Figure 4-E.1 to see Flow chart of literature search results for Studies Examining the Effects of Multi- vs. Single-Component Nutrition Education Interventions

Of the 14 studies included in this review:

  • Ten studies were randomized controlled trials (RCT) [DeBar, 2006 (positive quality); He, 2009 (neutral quality); Hopper, 2005 (positive quality); Hopper, 1996 (neutral quality); Kitzman-Ulrich, 2009 (neutral quality); McKenzie, 1996 (positive quality); Neumark-Sztainer, 2003 (neutral quality); Prell, 2005 (neutral quality); Reinaerts, 2008 (neutral quality); Sahota, 2001 (positive quality)]
  • Four studies were nonrandomized trials [Long, 2004 (neutral quality); McAleese, 2007 (neutral quality); Olvera, 2010 (neutral quality); Parmer, 2009 (neutral quality)]
  • Four studies received a positive quality rating and ten studies received a neutral quality rating
  • Ten studies took place in the United States (US), and one each took place in Canada, The Netherlands, Sweden and the United Kingdom
  • The majority of studies included in this review were conducted in a school setting, though a few were conducted in other locations, such as an HMO clinic (DeBar, 2006), at home (Kitzman-Ulrich, 2009; McKenzie, 1996), or at neighborhood community centers (Olvera, 2010)
  • Sample sizes of these studies ranged from 35 to 1,277 (three studies had <100 subjects, nine studies had 100 to 500 subjects, one study had 500 to 1,000 subjects, and one study had >1,000 subjects)
  • Ten studies included a mix of boys and girls, with a range of 30% to 56% girls. Four studies included only female subjects (Neumark-Sztainer, 2003; Olvera, 2010; Kitzman-Ulrich, 2009; and Debar, 2006)
  • The mean age of the subjects ranged from seven to 15 years. One study did not report mean age of subjects, but included children ages  four to 11 years.
  • Many studies did not provide information regarding the race/ethnicity of subjects. Five studies reported including a mix of races/ethnicities, with white subjects accounting for 42% to 83% of the population (Debar, 2006; Hopper, 2005; Kitzman-Ulrich, 2009; Long, 2004; Neumark-Sztainer, 2003). One study (Olvera, 2010) included 100% Latino females.
  • None of the studies provided detailed information regarding subjects’ socioeconomic status, though one study indicated that subjects were mainly “middle- to upper-middle income” (DeBar, 2006), and another had mostly “upper class” subjects (McKenzie, 1996).

For this review, an intervention is described as a “single-component” intervention when subjects are provided nutrition education using one distinct method. An intervention is described as a “multi-component” intervention when subjects are provided nutrition education via two or more different methods. Some of the included studies also had a control group that received no intervention.

The nutrition education interventions tested in the studies in this review included a wide range of different components or combinations of components that were intended to facilitate positive dietary intake-related behavior change. Table 4-E.1 provides a description of the components tested in each of the fourteen studies included in this review.


Description of Outcomes

Six out of the 14 studies in this review showed some evidence that multi-component interventions were more effective than single-component interventions in improving dietary intake (DeBar, 2006; Hopper, 2005; McAleese, 2007; Parmer, 2009; Prell, 2005; Sahota, 2001). However, three of these studies had mixed results that differed depending on which outcome was being considered (DeBar, 2006; Hopper, 2005; Sahota, 2001).

Conversely, three of the 14 studies showed some evidence that single-component interventions were more effective than multi-component interventions in improving dietary intake (Kitzman-Ulrich, 2009; Reinaerts, 2008; Sahota, 2001). Two of these had mixed results that differed depending on which outcome was being considered (Reinaerts, 2008; Sahota, 2001).

In addition, eight of the 14 studies showed some evidence that multi-and single-component interventions did not differ (DeBar, 2006; He, 2009; Hopper, 2005; Hopper, 1996; Long, 2004; Neumark-Sztainer, 2003; Olvera, 2010; Reinarts, 2008), with four showing that neither intervention improved dietary intake (DeBar, 2006; He, 2009; Hopper, 2005; Olvera, 2010) and two showing that multi- and single-component interventions are equally as effective for improving dietary intake (Hopper, 1996; Reinaerts, 2008). Two of the studies showed that multi- and single-component interventions did not differ, but did not indicate whether dietary intake improved or not (Long, 2004; Neumark-Sztainer, 2003). Again, several of these studies had mixed results depending on outcome (DeBar, 2006; He, 2009; Hopper, 2005; Reinaerts, 2008).

Finally, two studies indirectly reported results, showing that the multi- or single-component intervention was better than control, but either the multi- vs. single-component comparison was not made (McKenzie, 1996) or there was no statistically significant difference between the multi- and single-component interventions (Prell, 2005).

The studies were compared to determine whether any specific component might be associated with improved outcomes. Three studies that showed the multi-component intervention was more effective than the single-component intervention (McAleese, 2007; Parmer, 2009; Prell, 2005) included a “hands-on” component (i.e., cooking or gardening) combined with classroom nutrition education.

  • McAleese & Rankin (2007) found that combining school gardening with nutrition education was more effective for increasing fruit, vegetable, vitamin A, vitamin C, and fiber intake compared to nutrition education alone
  • Parmer et al (2009) found that combining school gardening with nutrition education significantly increased vegetable intake, while nutrition education alone had no effect on vegetable intake
  • Prell et al (2005) found that combining home economics classes (cooking) with school cafeteria changes significantly increased fish consumption compared to control. Intake did not change in the group that only received changes to the school cafeteria compared to control, and there was no significant difference between the single- and multi-component groups.

The studies were also compared to determine whether any of the following factors may have affected whether an intervention was effective or not, but no clear trends emerged:

  • Duration of the intervention
  • Total number of components included in the intervention
  • ·Subject age or grade level
  • Theoretical framework used to develop the intervention
  • Whether the intervention targeted the dietary intake-related outcomes that were measured.

Evidence Summary Paragraphs

DeBar et al, 2006 (positive quality) conducted an RCT in the US to test the effects of a health plan-based multi-component lifestyle intervention designed to improve diet, increase physical activity, and increase bone mineral density in adolescent girls. Subjects were randomly assigned to one of two groups for two years: (1) Multi-Component: Received annual individual visits, telephone calls, group meetings, weekly self-monitoring, use of a study Web site, youth and parent newsletters, and membership to a fitness center, and (2) Single-Component: Received annual individual visits with a health professional. Dietary behavioral outcomes (calcium, vitamin D, soda, and fruit and vegetables intake) were measured using 24-hour recalls. The final sample included 209 girls (101 girls in the multi-component group, 108 girls in the single-component group; mean age=15 years). Compared with the single-component group, girls in the multi-component group reported significantly greater intake of calcium in both study years (P<0.001), vitamin D in the first year (P<0.02), and fruits and vegetables in both years (P<0.001). However, no effects on soda consumption were found.

He et al, 2009 (neutral quality) conducted an RCT in Canada to measure the influence of the Northern Fruit and Vegetable Pilot Program (NFVPP) on children’s fruit and vegetable consumption. Schools were randomly assigned to one of three groups for the 21 week intervention: (1) Multi-Component: Received a free fruit and vegetable snack (three times per week) and enhanced classroom nutrition education, (2) Single-Component: Received a free fruit and vegetable snack (3 times per week), and (3) Control: Did not receive any intervention. Dietary intake-related outcomes (fruit and vegetable consumption) were measured using a 24-hour fruit and vegetable recall questionnaire. The final sample included 1,277 students (400 children in the multi-component group, 470 children in the single-component group, 407 children in the control group; mean age=12 years). Children in the nutrition education + changes to the school food environment group consumed more fruits and vegetables at school, compared to control (0.49 servings per day; P< 0.05). There were no significant differences in school fruit and vegetable consumption between the school food environment group and the control group. There were no significant differences between any of the groups in fruit and vegetable intake at home or total fruit and vegetable intake.

Hopper et al, 2005 (positive quality) conducted an RCT in the US to test the effects of a school-based cardiovascular health promotion program on children’s dietary intake. Schools were randomly assigned to one of two groups for 20 weeks: (1) Multi-Component: Received enhanced classroom nutrition education, enhanced physical education, and a home program that requested parents and children complete nutrition and exercise activities; and (2) Single-Component: Received nutrition and physical education provided in the regular school curriculum. Dietary intake-related outcomes (intake of calories, protein, carbohydrates, total fat, saturated fat, dietary cholesterol, fiber, sodium, percentage of calories from carbohydrates, and percentage of calories from fat) were assessed before and after the intervention using two 24-hour dietary recalls taken at each time point. The final sample included 238 children (142 children in the multi-component group, 96 children in the single-component group; mean age=nine years). Results showed that the multi-component group had significantly lower total fat intake compared to the single-component group (P<0.05). There were no differences between the groups for any of the other measured outcomes.

Hopper et al, 1996 (neutral quality) conducted an RCT in the US to examine the effects of a school-based exercise and nutrition program on children’s dietary fat intake. Classrooms were randomly assigned to one of three conditions for 10 weeks: (1) Multi-Component: Received classroom-based nutrition education and a parent/home education component; (2) Single-Component: Received classroom-based nutrition education; and 3) Control: Received no intervention. Dietary intake-related outcomes (fat intake) were measured before and after the intervention using one 24-hour dietary recall taken at each time point. The final sample included 132 subjects (45 children in the multi-component group, 43 children in the single-component group, 44 children in the control group; mean age=12 years). Results showed no significant differences in fat intake between the multi-component and single component intervention groups, though both groups decreased fat intake compared to control (P<0.05).

Kitzman-Ulrich et al, 2009 (neutral quality) conducted an RCT in the US to examine the effects of nutrition education delivered using a family-based psychoeducational and behavioral skill-building program on adolescent’s dietary intake. Subjects were randomly assigned to one of three intervention groups for 16 weeks: (1) Multi-Component: Received multiple family therapy sessions, and a family-based psychoeducation curriculum (educational curriculum delivered to subjects and their families that focused on skill-building and psychosocial components related to nutrition), and (2) Single-Component: Received a family-based psychoeducation curriculum; and 3) Control: Received no intervention. Dietary intake-related outcomes (energy intake) were measured before and after the intervention using three 24-hour dietary recalls taken at each time point. The final sample included 42 adolescent girls (15 girls in the multi-component group, 16 girls in the single-component group, 11 girls in the control group; mean age=13 years). Energy intake decreased in the single-component group compared to the multi-component and control groups (P<0.01).

Long, 2004 (neutral quality) conducted a quasi-experimental study in the US to test the effects of a classroom and Web-based nutrition education intervention on adolescents’ dietary intake. Subjects were randomly assigned to one of two groups for 1 month: (1) Multi-Component: Web-based instruction (five hours) plus classroom-based nutrition education (10 hours); and (2) Single-Component: Nutrition education embedded in the standard school curriculum for one month (zero to three hours). Dietary intake-related outcomes (fruit, vegetable, and fat intake) were measured using the validated Youth and Adolescent FFQ. The final sample included 121 adolescents (63 children in the multi-component group, 58 children in the single-component group; median age=13 years). Results showed that there were no differences between the intervention and control groups in consumption of fruit, vegetables, or fat.

McAleese & Rankin, 2007 (neutral quality) conducted a non-randomized controlled trial in the US to investigate the effects of a garden-based nutrition education intervention on fruit and vegetable consumption in adolescents. Schools were assigned to one of three groups for 12 weeks: (1) Multi-Component: Received nutrition education curriculum and corresponding gardening activities; (2) Single Component: Received the nutrition education curriculum only; and (3) Control: Received no intervention. Dietary intake-related outcomes (fruit, vegetable, vitamin A, vitamin C, and fiber intake) were determined using two 24-hour food recalls. The final sample included 99 subjects (45 children in the multi-component group, 25 children in the single-component group, 25 children in the control group; mean age=11 years). The results showed that children in the multi-component group increased fruit (P<0.001), vegetable (P<0.001), vitamin A (P=0.004); vitamin C (P=0.016), and fiber (P=0.001) intake compared to students in the single-component or control groups.

McKenzie et al, 1996 (positive quality) conducted an RCT in the US to determine the effects of a nutrition intervention on dietary intake among children with and without hypercholesterolemia. Subjects were randomly assigned to one of four groups for three months: (1) Multi-Component: Children with hypercholesterolemia received one face-to-face counseling session with a Registered Dietitian, take-home print materials with dietary information, and free telephone access to the dietitian; (2) Single-Component: Children with hypercholesterolemia received home-based nutrition education in the form of a parent-child autotutorial program; (3) At- Risk Control: Children with hypercholesterolemia and did not receive a nutrition intervention; and (4) Not-At-Risk Control: Children with normal cholesterol and did not receive a nutrition intervention. Dietary intake-related outcomes (10 different food groups and fat intake) were determined by three 24-hour dietary recalls. The final sample consisted of 303 children (71 children in the multi-component group, 77 children in the single-component group, 79 children in the at-risk control group, 76 children in the not-at-risk control group; age=four to 10 years). Children in the single-component group significantly decreased fruit intake (~one serving of fruit and fruit juice; P<0.006) compared to baseline. There were no changes in any of the measured dietary-intake related outcomes following the intervention for either the multi-component or control groups, and there were no significant differences between groups.

Neumark-Sztainer et al, 2003 (neutral quality) conducted an RCT in the US to test the feasibility and effects of a multi-component, school-based obesity prevention program (New Moves) among adolescent girls. Schools were randomly assigned to one of two groups for a period of 16 weeks (with an eight-month follow-up period): (1) Multi-Component: Received the New Moves Program which included physical activity sessions, nutrition education sessions, social support sessions, and a parent component; and (2) Single-Component: Received written materials on healthy eating and physical education. Dietary intake-related outcomes (fruit, vegetable, breakfast, soda, and fast food intake) were assessed using an FFQ. The final sample included 190 girls (84 children in the multi-component group, 106 children in the single-component group; (mean age=15 years). The results showed no significant differences between the multi- and single-component groups for any of the dietary intake-related outcomes measured.

Olvera et al, 2010 (neutral quality) conducted a non-randomized controlled trial in the US to assess the effects of a family-based community program (BOUNCE) on dietary intake in low-income Latino mothers and daughters. Subjects were assigned to one of two groups for 12 weeks: (1) Multi-Component: Mothers and daughters received three weekly physical activity sessions, two weekly nutrition sessions, and one weekly behavioral counseling session; and (2) Single-Component: Mothers and daughters received educational materials on nutrition and counseling topics and participated in light intensity activity weekly. Dietary intake-related outcomes (high fat food, sweetened beverage, and fruit and vegetable intake) were determined using the School Physical Activity and Nutrition (SPAN) survey completed by the girls. The final sample consisted of 35 children (18 children in the multi-component group, 17 children in the single-component group; mean age=10 years). The results showed no significant changes in any of the measured dietary intake-related outcomes in either study group.

Parmer et al, 2009 (neutral quality) conducted a non-randomized controlled trial in the US to examine the effects of a school-based gardening program on children’s vegetable intake. Classrooms were assigned to one of three intervention groups for 28 weeks: (1) Multi-Component: Received classroom nutrition education instruction and school gardening; (2) Single-Component: Received classroom nutrition education; and (3) Control: Received no intervention. Dietary intake-related outcomes (vegetable intake) were measured by using structured lunchroom observation. The final sample consisted of 115 subjects (39 children in the multi-component group, 37 children in the single-component group, 39 children in the control group; mean age=seven years). The multi-component group ate significantly more vegetables (P<0.01), the single-component group had no significant change in consumption, and the control group ate significantly fewer vegetables (P<0.001) at post-test, compared to the pre-test.

Prell et al, 2003 (neutral quality) conducted an RCT in Sweden to examine the effects of school-based interventions on fish consumption among adolescents. Schools were randomly assigned to one of three groups for five weeks: (1) Multi-Component: Received changes to the school cafeteria (increased choice, marketing, and improved preparation/appearance of fish) and home economics nutrition education, (2) Single-Component: Received changes to the school cafeteria; and (3) Control: Did not receive any intervention. Dietary intake-related outcomes (fish consumption) were measured using structured observations in the school cafeteria once a week when fish was served. The final sample included 228 subjects (87 children in the multi-component group, 58 children in the single-component group, 83 children in the control group; mean age=14 years). The nutrition education + changes to the school food environment group significantly increased fish consumption following the intervention, compared to the control group (P<0.01). The school food environment only group did not significantly increase fish consumption compared to either the control group or the group that received changes to the school food environment only.

Reinaerts et al, 2008 (neutral quality) conducted an RCT in the Netherlands to assess the effects of school-based interventions designed to improve children’s fruit and vegetable consumption. Subjects were randomly assigned to one of three treatment groups for one year (with one year of follow-up): (1) Multi-Component: Received classroom nutrition education and parental involvement; (2) Single-Component: Received a daily free fruit and vegetable; and (3) Control: Received no intervention. Dietary intake-related outcomes (fruit and vegetable intake) were determined using one 24-hour food recall and an FFQ. The final sample consisted of 436 children (124 children in the multi-component group, 85 children in the single-component group, 227 children in the control group; mean age=8 years). The results showed that both intervention groups increased fruit and total fruit, juice, and vegetable intake compared to control (P<0.05). The single-component group also increased vegetable snack intake (P<0.05) and vegetable intake during dinner (P<0.01), compared to the multi-component and control groups.

Sahota et al, 2001 (positive quality) conducted an RCT in the United Kingdom to assess the effects of a school based intervention on dietary intake among children. Schools were randomly assigned to one of two groups for one year: (1) Multi-Component: Received teacher training, modification of school meals, and school action plans targeting the curriculum, physical education, school stores, and playground activities, or (2) Single-Component: Received the usual health curriculum with no additional intervention. Dietary intake-related outcomes (consumption of high-fat foods, food and drinks high in sugars, fruit, and vegetables) were measured using one 24-hour recall and three-day food records. The final sample consisted of 593 children (292 children in the multi-component group, 301 children in the single-component group; mean age=eight years). Results from the 24-hour recalls showed that the multi-component group had higher vegetable consumption compared to the children in the single-component group (P<0.05). Also, fruit consumption was lower in obese children in the multi-component group (P<0.05) than those in the single-component group. Results from the three-day food records showed that overweight children in the multi-component group consumed more high sugar foods (P<0.05), compared to the single-component group post-intervention.

Click to see Overview Table 4-E.2. Studies Examining the Effects of Multi- vs. Single-Component Nutrition Education Interventions.
 




Research Design and Implementation
For a summary of the Research Design and Implementation results, click here.
Worksheets
DeBar LL, Ritenbaugh C, Aickin M, DeBar LL, Rittenbaugh C, Aickin , Orwoll E, Elliot D, Dickerson J, Vuckovic N, Stevens VJ, Moe E, Irving LM. Youth: A health plan-based lifestyle intervention increases bone mineral density in adolescent girls. Arch Pediatr Adolesc Med. 2006 Dec; 160(12): 1,269-1,276.

He M, Beynon C, Sangster Bouck M, St. Onge R, Stewart S, Khoshaba L, Horbul BA, Chircoski B. Impact evaluation of the Northern Fruit and Vegetable Pilot Programme: A cluster-randomised controlled trial. Public Health Nutr. 2009 Nov; 12(11): 2,199-2,208. Epub 2009 May 28.

Hopper CA, Gruber MB, Munoz KD, MacConnie, S. School based cardiovascular exercise and nutrition programs with parent participation. Journal of Health Education. 1996; 27: S32-39.

Hopper CA, Munoz KD, Gruber MB, & Nguyen KP. The effects of a family fitness program on the physical activity and nutrition behaviors of third-grade children. Research Quarterly for Exercise and Sport. 2005, 76(2), 130-139. 

Kitzman-Ulrich H, Hampson R, Wilson DK, Presnell K, Brown A, O'Boyle M. An adolescent weight-loss program integrating family variables reduces energy intake. J Am Diet Assoc. 2009 Mar; 109(3): 491-496.

Liquori T, Koch PD, Contento IR, Castle J. The Cookshop Program: Outcome evaluation of a nutrition education program linking lunchroom food experiences with classroom cooking experiences. Journal of Nutrition Education 1998; 30: 302-313.

Long JD, Stevens KR. Using technology to promote self-efficacy for healthy eating in adolescents. J Nurs Scholarsh. 2004; 36: 134-139.

McAleese JD, Rankin LL. Garden-based nutrition education affects fruit and vegetable consumption in sixth-grade adolescents. J Am Diet Assoc. 2007; 107(4): 662-665.

McKenzie J, Dixon L, Smiciklas-Wright H, Mitchell S, Shannon B, Tershakovec A. Change in nutrient intakes, number of servings, and contributions of total fat from food groups in four- to 10- year-old children enrolled in a nutrition education study. J Am Diet Assoc. 1996; 96: 865-873.

Neumark-Sztainer D, Story M, Hannan PJ, Rex J. New Moves: A school-based obesity prevention program for adolescent girls. Prev Med. 2003 Jul; 37(1): 41-51. 

Olvera N, Bush JA, Sharma SV, Knox BB, Scherer RL, Butte NF. BOUNCE: A community-based mother-daughter healthy lifestyle intervention for low-income Latino families. Obesity (Silver Spring). 2010 Feb;18 Suppl 1: S102-S104.

Parmer SM, Salisbury-Glennon J, Shannon D, Struempler B. School gardens: an experiential learning approach for a nutrition education program to increase fruit and vegetable knowledge, preference, and consumption among second-grade students. J Nutr Educ Behav. 2009 May-Jun; 41 (3): 212-217.

Prell HC, Berg MC, Jonsson LM, Lissner L. A school-based intervention to promote dietary change. J Adolesc Health. 2005 Jun; 36(6): 529.

Reinaerts E, Crutzen R, Candel M, De Vries NK, De Nooijer J. Increasing fruit and vegetable intake among children: Comparing long-term effects of a free distribution and a multi-component program. Health Educ Res. 2008; 23 (6): 987-996.

Sahota P, Rudolf MCJ, Dixey R, Hill AJ, Barth JH, Cade J. Randomised controlled trial of primary school based intervention to reduce risk factors for obesity. BMJ 2001; 323: 1-5.