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Table 2 Effects of interventions strategies synthesised by included systematic reviews on measures of fruit and vegetable intake or purchase

From: Consolidating evidence on the effectiveness of interventions promoting fruit and vegetable consumption: an umbrella review

Author, year of publication Intervention strategy NOURISHING policy domain and policy area Primary study quality assessment Findings Effect Summary
School based intervention strategies
    Micha et al., 2018 [55] Providing (for free or at reduced cost) or increasing the availability (e.g. in cafeterias) of F&V Domain: Food environment (FE)
Policy area: Economic tools to address affordability and purchase incentives
Five studies had an overall quality score of five; five studies had a score of four; five studies had a score of three; and four studies had a score of two. a Fruit: Increased intake by 0.27 servings/day (95%CI 0.17, 0.36; p = 0.000; I2 78.3%; n = 15 primary studies)
Vegetables: Increased intake (marginally) by 0.04 servings/day (95%CI 0.01, 0.08; p = 0.221; I2 23.4%; n = 11 primary studies)
Combined: Increased F&V intake by 0.28 servings/day (95%CI: 0.17, 0.4; p = <.001; I2 90.2%; n = 16 primary studies)
Y
    Micha et al., 2018 [55] Food standard policies Domain: FE
Policy area: Offer healthy food and set standards in public institutions and other specific settings
Three studies had an overall quality score of two; one study had a score of three; and one study had a score of four.a Fruit: increased by 0.76 servings/day (95%CI: 0.37, 1.16; p = NR; I2 NR; n = 2 primary studies)
Vegetable: Non-significant trend toward increased intake of 0.30 servings/day (95%CI: −0.001, 0.59; p = NR; I2 NR; n = 2 primary studies)
Combined: nonsignificant trends toward increased intake of F&V intake of 0.12 servings/day (95%CI: − 0.08, 0.31; p = NR; I2 NR; n = 5 primary studies)
Y
    Rochira et al., 2020 [57] School Gardens Domain: Behaviour Change Communication (BCC)
Policy area: Give nutrition education and skills
Of the 15 studies assessed using the Cochrane Tool for Quality Assessment 3 were assessed as good quality while 12 scored fair quality. b,o
Of the 17 observational studies rated using the STROBE tool, 4 scored intermediate quality and 13 scored good quality. b, o
“The selected articles demonstrate that children increased F&V daily/weekly intake” (n = 20 primary studies) Y
    Silveria et al., 2011 [58] Circular/ nutrition education Domain: BCC
Policy area: Give nutrition education and skills
Of the 16 primary studies that measured fruit and/or vegetable consumption, four were rated as “quality level A”, nine were “quality level B”, and three were “quality level C”. c “Of the 12 studies that adopted at least two of the three most common components (activities in the classroom, parental development and school feeding policy), 10 presented results that confirm the effectiveness of nutritional education intervention strategies in schools for increased consumption of F&V among children and adolescents.” Y
    Champion et al., 2019 [46] School eHealth Domain: BCC
Policy area: Give nutrition education and skills
The quality of evidence for screen time and fruit and vegetable outcomes immediately after the intervention was deemed to be moderate. c eHealth school-based multiple health behaviour change intervention strategies led to a small but significant increase in fruit and vegetable intake immediately after the intervention (Standardised mean difference (SMD) = 0.11; 95%CI: 0.03, 0.19; p = 0.007; I2 42% n = 7 primary studies). Effects on F&V intake were not sustained at follow-up (SMD 0.07; 95%CI: − 0.01, 0.15; p = 0.07; I2 52% n = 6 primary studies) ?
    Langford et al., 2014 [54] Health Promoting schools Domain: FE, BCC
Policy area:
FE: Offer healthy food and set standards in public institutions and other specific settings
BCC: Give nutrition education and skills
GRADE assessment for 23 nutrition trials was ‘Low’. d, o Nutrition only intervention strategies were effective on average at increasing reported F&V intake among students (SMD 0.15; 95%CI: 0.02, 0.29; p = NR; I2 = 83%; n = 9 primary studies). Y
    DeCosta et al., 2017 [22] Cooking lessons/classes (i.e. not solely school-based) Domain: BCC
Policy area: Give nutrition education and skills
No formal quality assessment. “Evidence suggests that cooking classes may positively change intake and preference for vegetables and that the effect might be mediated by tasting new F&V. However, based on the little evidence currently available, no conclusions regarding best practise can be made. Additionally, long-term effects have not been investigated.” (n = 6 primary studies) ?
Childcare based intervention strategies
    Hodder et al., 2020 [23] Child feeding intervention strategies delivered by childcare providers Domain: BCC
Policy area: Give nutrition education and skills
GRADE for child feeding intervention strategies was ‘Low’.d, o Child feeding intervention strategies for childcare providers improved fruit and/or vegetable intake of children:
SMD 0.63 (95%CI 0.23, 1.03; p = 0.002; I2 81%; n = 8 primary studies)
Y
    Hodder et al., 2020 [23] Parent nutrition education intervention strategies delivered in childcare Domain: BCC
Policy area: Give nutrition education and skills
GRADE for parent nutrition education intervention strategies was ‘Very Low’.d, o Parent nutrition education did not significantly improve child fruit and/or vegetable intake: SMD 0.43 (95%CI −0.27, 1.13; p = 0.23; I2 84%; n = 2 primary studies) ?
    Hodder et al., 2020 [23] Multicomponent interventions Policy domain: BCC
Policy area: Give nutrition education and skills
GRADE for multi-component interventions was ‘Moderate’.d, o Multi-component interventions delivered in childcare did not significantly improve child fruit and/or vegetable intake: SMD 0.21 (95%CI − 0.07, 0.49; p = 0.15; I2 78%; n = 5 primary studies) ?
Parent and family home-based intervention strategies
    Hodder et al., 2020 [23] Nutrition education Domain: BCC
Policy area: Give nutrition education and skills
GRADE for parent nutrition education interventions was ‘Very Low’.d, o Parent nutrition education interventions delivered at home did not improve child F&V intake: SMD = 0.07 (95%CI −0.14, 0.27; p = 0.52; I2 68%; n = 5 primary studies) ?
    Hodder et al., 2020 [23] Child feeding intervention strategies Domain: BCC
Policy area: Give nutrition education and skills
GRADE for child feeding intervention strategies was ‘Low’.d, o Child feeding intervention strategies targeting parents significantly improved child F&V intake: SMD = 0.46 (95%CI: 0.13, 0.79; p = 0.007; I2 68%; n = 4 primary studies) Y
Workplace-based intervention strategies
    Hendren et al., 2017 [50] Cafeteria intervention strategies Domain: FE, BCC
Policy area:
FE: Standards in other specific locations; Nutrition label standards and regulations on the use of claims and implied claims on food; Use economic tools to address food affordability and purchase incentives BCC: Inform people about food and nutrition through public awareness
Of the 14 primary studies reporting significant results, five were rated as high-quality, six as moderate-quality, and three as low-quality.k “There appears to be a moderately strong association toward a positive impact of cafeteria intervention strategies to increase fruit and/or vegetable consumption. Of the 18 studies in the review, 13 reported a statistically significant increase, one reported a significant decrease, three reported mixed results, and one did not assess a change in consumption.”
Six studies assessed long-term follow-up and reported mixed results
Y
    Feltner et al., 2016 [48] Total Worker Health (TWH) program (“target e protection from work-related safety and health hazards with prevention efforts) Domain: BCC, FE
Policy area:
BCC: Give nutrition education and skills FE: Offer healthy food and set standards in public institutions and other specific settings
All three RCTs that measured changes in fruit and vegetable intake, were rated as have a low strength of evidence.n “Three RCTs (all from the same research team) … measured changes in fruit and vegetable intake among US manufacturing or construction workers who were randomly assigned to a multicomponent integrated intervention or no intervention. Evidence from these three RCTs supported the effectiveness of TWH intervention strategies compared with no intervention for improving fruit and vegetable consumption over 26 to 104 weeks.” Y
Primary care intervention strategies
    Patnode et al., 2017 [56] Counselling - individual or group; via in-person, telephone, web-based, text message, and/or print mailing Domain: BCC
Policy area: Nutrition advice and counselling in healthcare settings
Of the 26 primary studies reporting fruit and vegetable intake, three were rated as ‘good’ quality and the remaining 23 were rated as ‘fair’ quality.e “… Between-group differences in the mean change of fruit and vegetable intake ranged from −0.2 servings/day (favouring the control group) to 2.2 servings/day (favouring the intervention group) at 6 months to 1 year of follow up. All six trials that focused dietary messages exclusively on increased fruit and vegetable intake found statistically significantly greater benefit among intervention versus control participants” (n = 26 primary studies) Y
Community-based individual and group based programs
    Hendrie et al., 2017 [51] After school community-based nutrition education and skill based programs for children and/or families Domain: BCC
Policy area: Give nutrition education and skills
Three studies were rated as weak quality and one was rated as moderate quality.i, o Of the four primary studies assessing children’s vegetable intake, two studies assessed longer-term effectiveness (6 months) on children’s vegetable intake. One of two trials of after school programs were effective in the longer-term (6 months) ?
eHealth intervention strategies
    Rodriguez et al., 2019 [26] Any eHealth intervention (i.e. includes the use technology to deliver and enhance health services and information) Domain: BCC
Policy area: Give nutrition education and skills
Most primary studies were assessed as being fair quality (n = 12), five as good quality, and two as poor quality.f Overall e-Health intervention strategies improved fruit and/or vegetable intake: SMD/Hedge’s g = 0.26 (SE 0.05; 95%CI 0.17, 0.35; p < 0.001; I2 NR; n = 19 primary studies) Y
    Rodriguez et al., 2019 [26] Computer-based intervention strategies Domain: BCC
Policy area: Give nutrition education and skills
Most primary studies were assessed as being fair quality (n = 12), five as good quality, and two as poor quality.f Computer-based intervention strategies improved fruit and/or vegetable intake: SMD = 0. 44 (SE 0.08; 95%CI NR; p < 0.001; I2 NR; n = 3 primary studies) Y
    Rodriguez et al., 2019 [26] SMS intervention strategies Domain: BCC
Policy area: Give nutrition education and skills
Most primary studies were assessed as being fair quality (n = 12), five as good quality, and two as poor quality.f SMS intervention strategies improved fruit and/or vegetable intake: SMD/Hedge’s g = 0.41 (SE 0.10; 95%CI 0.21, 0.61; p < 0.01; I2 NR; n = 3 primary studies) Y
    Rodriguez et al., 2019 [26] Internet-based intervention strategies Domain: BCC
Policy area: Give nutrition education and skills
Most primary studies were assessed as being fair quality (n = 12), five as good quality, and two as poor quality.f Internet-based intervention strategies improved fruit and/or vegetable intake: SMD/Hedge’s g 0.19 (SE 0.05; 95%CI 0.09, 0.29; p < .001; I2 42; n = 9 primary studies) Y
    Rodriguez et al., 2019 [26] CD-ROM, intervention strategies Domain: BCC
Policy area: Give nutrition education and skills
Most primary studies were assessed as being fair quality (n = 12), five as good quality, and two as poor quality.f CD-ROM intervention strategies did not significantly improve F&V intake: SMD/Hedge’s g 0.09 (SE 0.10; 95%CI NR; p > .05; I2 NR; n = 2 primary studies) ?
    Rodriguez et al., 2019 [26] Mobile apps, intervention strategies Domain: BCC
Policy area: Give nutrition education and skills
Most primary studies were assessed as being fair quality (n = 12), five as good quality, and two as poor quality.f Mobile-based (app) intervention strategies did not significantly improve F&V intake: SMD/Hedge’s g 0.13 (SE 0.15; 95%CI NR; p > .05; I2 NR; n = 1 primary study) ?
    Rodriguez et al., 2019 [26] Video game intervention strategies Domain: BCC
Policy area: Give nutrition education and skills
Most primary studies were assessed as being fair quality (n = 12), five as good quality, and two as poor quality.f Video game intervention strategies did not significantly improve F&V intake: SMD/Hedge’s g 0.08 (SE 0.23; 95%CI NR; p > .05; I2 NR; n = 1 primary studies) ?
Mass media campaigns
    Afshin et al., 2015 [43] Media Domain: BCC
Policy area:
Inform people about food and nutrition through public awareness
No formal quality assessment. “Several studies suggest potential effectiveness of mass media campaigns as a stand-alone intervention. These have shown temporal improvements in consumption of specific dietary factors, especially increased F&V …” (n = 5 primary studies) Y
Choice architecture
    DeCosta et al., 2017 [22] Choice Architecture strategies in school food service, tuck shops and vending machines Domain: BCC
Policy area: Public awareness, mass media and informational campaigns and social marketing on healthy eating
No formal quality assessment. “In school settings, choice architecture and nudging have been shown to positively increase selection and overall consumption of fruits and vegetables in the short term. However, evidence for long-term benefits is sparse.” (n = 7 primary studies) ?
    Carter et al., 2018 [45] Information based cues Domain: BCC
Policy area: Inform people about food and nutrition through public awareness
Of the three primary studies undertaken in supermarkets, two were assessed as high risk of bias and the remaining study at unclear risk.c, o “In relation to supermarkets, two of the three included studies observed significant increase in sales of fruit and vegetables.” (n = 3 primary studies) ?
New food retail opportunities
    Hsiao et al., 2019 [53] Mobile Produce markets (MPM) Domain: Food system
Policy area: Harness supply chain and actions across sectors to ensure coherence with health
All four primary studies assessing fruit and/or vegetable intake received a quality score of two. j Positive associations were observed for all five studies that assessed the relationship between Mobile Produce Markets (MPM) use and fruit and/or vegetable intake. “Overall, intervention primary studies (n = 4) found consistent increases in reported vegetable intake and in combined reported fruit and vegetable intakes during the study periods among MPM users, with greater changes observed in vegetable intake.” Y
    Hollis-Hansen et al., 2019 [52] Farmers markets Domain: Food System (FS)
Policy area: Harness supply chain and actions across sectors to ensure coherence with health
No formal quality assessment. “Two of five primary studies of new farmers markets reported improvements in F&V intake ranging from −0.70 to + 0.70 cups/day and Cohen’s d effect sizes ranging from 0.15 to 0.38. “
“The remaining three primary studies report findings graphically or with frequencies, and these suggest improvements in F&V consumption although insufficient data are available to draw a conclusion.”
?
    Hollis-Hansen et al., 2019 [52] Retail supermarkets Domain: FS
Policy area: Harness supply chain and actions across sectors to ensure coherence with health
No formal quality assessment. “None of the four retail supermarket primary studies reported a positive impact on F&V consumption. Two of the primary studies reported statistically significant inverse findings that suggest the introduction of a new retail supermarket may have decreased F&V consumption, with a third study also reporting an inverse finding that was not statistically significant.” X
Agricultural intervention strategies
    Girard et al., 2012 [49] Household food production Policy domain: Food system
Policy area: Community food production (directly mapped to home-based gardening strategies)
GRADE for the five primary studies assessing fruit and vegetable intake was low to very low.d “In general home gardening strategies both with and without animal production improved … the consumption of vitamin A (VA)-rich fruits and vegetables. Findings for VA-rich foods were consistent regardless of whether the home gardening strategy included an animal production component.” (n = 5 primary studies) Y
Food pricing intervention strategies
    Afshin et al., 2017 [44] Subsidy Domain: FE
Policy area: Use economic tools to address food affordability and purchase incentives
Used CDC Community Guide grading system: ‘Strong Evidence, Strongly Recommended grade’.g, P A 10% price decrease increased consumption of fruits and vegetables by 14% (95%CI: 11 to 17%). (n = 9 primary studies) Y
    Cornelson et al., 2015 [47] Tax/price increase Domain: FE
Policy area: Use economic tools to address food affordability and purchase incentives
Of the 24 primary studies with fruit and vegetable outcomes, 41.2% were classified as ‘replicable’.h Low income countries
−10% increase in the price of F&V = decrease in F&V 7.2%; p < .001
− 10% increase in the price of meat = increase in F&V 0.05%; p = not significant (NS)
− 10% increase in the price of Fish = decrease in F&V 0.14%; p = NS
− 10% increase in the price of Dairy = decrease in F&V 0.01%; p = NS
− 10% increase in the price of Cereals = increase in F&V.65%; p < .10
− 10% increase in the price of Fats & oils = decrease in FV 0.14%; p = NS
− 10% increase in the price of sweets = increase in F&V 1.12%; p < .001
Middle income countries
− 10% increase in the price of F&V = decrease in F&V 6.5%; p < .001
− 10% increase in the price of meat = decrease in F&V 0.26%; p = NS
− 10% increase in the price of Fish = decrease in F&V 0.79%; p < 0.05
− 10% increase in the price of dairy = decrease in F&V 0.58%; p < 0.05
− 10% increase in the price of cereals = increase in F&V 0.07%; p = NS
− 10% increase in the price of fats & oils = decrease in F&V 0.39%; p = NS
− 10% increase in the price of sweets = increase in F&V 0.34%; p = NS
High income countries
− 10% increase in the price of F&V = decrease in F&V 5.3%; p < .001
− 10% increase in the price of meat = increase in F&V 0.02%; p = NS
− 10% increase in the price of Fish = increase in F&V 0.10%; p = NS
− 10% increase in the price of dairy = decrease in F&V 0.30%; p < .001
− 10% increase in the price of cereals = increase in F&V 0.48%; p = NS
− 10% increase in the price of fats & oils = decrease in F&V 0.33%; p = NS
− 10% increase in the price of sweets = increase in F&V 0.60; p < .001
Y/X
  1. aTool not reported. Scores from 0 to 3 were considered lower quality and 4 to 5 higher quality
  2. bCochrane Tool for Quality Assessment and the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE)
  3. cA modified version of the Quality Assessment Tool for Quantitative Studies, developed by the Effective Public Health Practice Project (EPHPP) and GRADE. Primary studies were categorized as: A, high quality (EPHPP ≥4 and GRADE ≥ 3); B, regular quality (EPHPP ≥4 and GRADE = 2); or C, low quality (EPHPP ≤3 or GRADE ≤ 1)
  4. dCochrane tool for assessing risk of bias and GRADE
  5. eCochrane tool for assessing risk of bias
  6. fUSPSTF design-specific criteria. Each primary study was assigned a rating of “good” “fair” or “poor” based on the methodological quality
  7. gCochrane tool for assessing risk of bias. Agency for Healthcare Research and Quality Standards used to categorize primary study quality as good, fair, or poor
  8. hTool not reported. Quality assessment based on 5 criteria. Strength of evidence graded using Center for Disease Control and Prevention Community Guide
  9. iTool not reported. Quality assessment based on whether the description was sufficient for replication of the study
  10. jEffective Public Health Practice Project (EPHPP) quality assessment tool
  11. kMixed Methods Appraisal Tool (MMAT) version 2011. An overall quality score based on number of criteria met (0–4)
  12. lA quality and bias assessment tool created with scores presented by quartile (25th quartile = low quality; 25th–75th = moderate quality; 75th = high quality)
  13. mPrimary study quality was independently assessed by two authors according to the Jadad Score. Studies were scored according to the presence of three key methodological features of clinical trials, specifically randomisation, masking, and accountability of all participants, including withdrawals
  14. nStrength of evidence rated as high, moderate, low, or insufficient according to the AHRQ Methods Guide for Effectiveness and Comparative Effectiveness Reviews
  15. oThe quality assessment refers to assessments undertaken on all included primary studies and may not represent the studies included in the fruit and vegetable outcome reported
  16. PGraded the strength evidence also using tools from i) American Heart Association; ii) U.S. Preventive Services Task Force; iii) Centers for Disease Control and Prevention Community Guide. Reported
  17. Y Overall judged as likely to have a positive effect on measures of fruit and/or vegetable intake based on assessment of statistical significance of point estimates in meta-analyses, or summary statements for narrative reviews
  18. X Overall judged as likely to have a negative impact on measures of fruit and/or vegetable intake based on assessment of statistical significance of point estimates in meta-analyses, or summary statements for narrative reviews
  19. ? Overall the effects of the intervention strategies are uncertain