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'Food Dudes': Increasing Children's Fruit and Vegetable Consumption C. Fergus Lowe, PhD and Pauline J Horne, PhD Corresponding Author: Suggested citation: Lowe, Fergus and Horne, Pauline. Food Dudes: Increasing children's fruit and vegetable consumption. Cases in Public Health Communication & Marketing. 2009; 3:161-185. Available from: www.casesjournal.org/volume3. AbstractThe UK has one of the lowest fruit and vegetable intakes in Europe, and Britain now has one of the worst heart disease records in the world. Other diet-related health problems such as obesity are also on the increase. Children, in particular, are reluctant to eat fruit and vegetables, and it is the aim of the present Government to increase children's consumption of these foods. The Food Dudes Program is an initiative to encourage and maintain healthy eating habits in children. It is a school-based intervention designed for use in primary schools that:
The Program has two main phases: Phase 1 (16 days): Children are read a letter and/or watch a specially designed DVD episode starring the "Food Dudes", who provide influential role-models to imitate. Children are then given a portion of fruit and vegetable and those who eat both are given a small reward (e.g. juggling balls, pedometers). This encourages repeat tasting so that children begin to like these foods. Phase 2: Ongoing but less intensive support for eating of fruit and vegetables, using Classroom Wall Charts to record consumption levels which earn further rewards and Food Dudes certificates. Full evaluations demonstrate large and long-lasting increases in fruit and vegetable consumption in children from 2 to 11 years of age. The greatest increases are shown by those children who were, at the start, the poorest eaters of fruit and vegetables. Increases extend across a wide range of fruit and vegetable varieties. Based on these successes, Food Dudes is being rolled out in England, Ireland, Sicily and California. Project OverviewThe Food Dudes Healthy Eating Programme is a school-based intervention, designed to increase consumption of fruit and vegetables among children 4 - 11 years old. The program works by encouraging children to taste fruit and vegetables repeatedly, so that they are able to develop a liking for these foods. Small rewards are given each time the child tries fruits and vegetables, and in the process children come to re-categorize themselves as 'fruit and vegetable eaters' 1. Figure 1. Food Dudes website visual.  There are two main phases to the program: Phase 1 (16 days) Phase 2 Budget Results Overview 2 Full evaluations are available, demonstrating significant behavior changes, including:
Background and ContextThere is strong evidence that eating a diet rich in fresh fruit and vegetables is vital for health and well-being 3. However, in spite of health messages, the UK has one of the lowest fruit and vegetable intakes in Europe 4. The recommended '5 A DAY' guidelines in the UK advise eating at least 5 portions (totaling approximately 400g) of fruit and vegetables a day. However, current British consumption levels are estimated to average only 245g per person per day and, in some age and social groupings, the real figure is substantially lower i. Diet-related health problems are on the increase and current predictions indicate that by 2010 over a quarter of all adults will be clinically obese 5. Research suggests that children's food consumption patterns are established early in life 6. It is therefore clear that, to improve a nation's long term health, work has to start with children. The Food Dudes Healthy Eating Programme, originated in 1992 by the Food and Activity Research Unit at Bangor University in Wales, incorporates known psychological principles to help change children's eating habits. The program works by encouraging children to taste fruit and vegetables repeatedly, so that they are able to discover the intrinsically rewarding properties of these foods and to develop a liking for them. In the process, children come to view themselves as 'fruit and vegetable eaters' 7. The Food Dudes Healthy Eating Program has now attracted a great deal of interest from overseas and government agencies. 2005: The Irish Government, with support from the European Union and Industry, launched a pilot program in 150 primary schools across Ireland (view the Irish 'Food Dudes' website at: www.fooddudes.ie). 2006: In recognition of its success after one year, the program was awarded a World Health Organization Best Practice Award. It was chosen to receive this prestigious award from among 202 applications from 35 countries. 2007: Based on the pilot's success, the Irish Government made the Food Dudes Program available to every primary school in Ireland. It is being introduced to the country's 3,300 primary schools over 7 years, on a budget of 28 million euro ($36 million US). 2009 and beyond: England begins a roll-out in selected regions. Wolverhampton City Primary Care Trust (PCT) ii and The Worshipful Company of Fruiterers iii are supporting the first major roll-out of the Food Dudes program in England. In the course of a three-year project, the program will be extended to 20,000 primary school children in Wolverhampton as part of the Primary Care Trust's strategy to improve children's health. The total budget is £575,000 ($805,000 US). The program will also be introduced in London in 2009. This is supported by the Government's School Food Trust iv, the Department of Health (DoH) and other organizations. DoH will be conducting formal evaluation of the roll-out. Trials of the program in Italy (view the Italian 'Food Dudes' website at: http://www.fooddudes.it/doceboCms) and California also began in 2009. The Food Dudes Program is a key feature of an exciting new European Union initiative launched in 2009, in which 90 million euros ($116 million US) will be provided annually to promote the eating of fruit and vegetables in the 27 member states. i The English government's 5 A DAY program aims to increase fruit and vegetable consumption by: raising awareness of the health benefits; improving access to fruit and vegetables through targeted action. The 5 A DAY program has five strands which are underpinned by an evaluation and monitoring program: National School Fruit Scheme; Local 5 A DAY initiatives; National/local partners - Government Health Consumer Groups; Communications program including 5 A DAY logo; Work with industry - producers, caterers, retailers. Available at: http://www.dh.gov.uk/en/Publichealth/Healthimprovement/FiveADay/FiveADaygeneralinformation/DH_4069924. The Social Marketing Benchmark CriteriaBenchmark 1: Customer Orientation The Food Dudes Program began with behavioral psychology - a deep understanding of how children learn; how they emulate role models; how they respond to incentives; and how they acquire early taste patterns. Original Research Based on this academic research, a pilot intervention was designed and tested on a small scale. This trial was funded by the Economic and Social Research Council v and the multinational company Unilever. The study involved more than 450 children aged from 2-7 years old in homes, schools and nurseries. The program template included two key elements: video adventures that featured the Food Dude hero figures; and small rewards to encourage children to taste the new foods. All studies confirmed that the program brought about significant long-term increases in children's consumption of fruit and vegetables. For instance, in one of the home-based studies with 'fussy eaters' (aged 5-6 years), children's consumption of targeted fruit rose from 4% to 100%, and of targeted vegetables from 1% to 83%. Targeted fruit consumption was still at 100%, and vegetable consumption at 58%, when the children were observed again 6 months later 9. The Food Dudes Healthy Eating Program: pre-testing and development Following these initial successes, the BFARU developed a stand-alone package to enable primary schools to implement the program across all age groups. In all schools, children were presented with fruit and vegetables at lunchtime and fruit and/or vegetables at 'snack-time' (immediately prior to morning break). The Food Dudes Program was then introduced in a number of schools selected to receive the intervention. Following introduction of the intervention, all of these schools recorded significant increases in pupils' fruit and vegetable consumption 10. All new procedures and materials, including videos and educational materials, were pre-tested with children in primary schools in Harwell (Oxfordshire, England), Bangor (Gwynedd, Wales), Salford (Greater Manchester, England), Brixton and Stockwell (London, England). Benchmark 2: Insight A range of insights identified by behavioral psychology research were used in the development of the Food Dudes Program. The first insight was that children are motivated by praise, recognition, and rewards. This was borne out by the evidence that when rewards were omitted from the Food Dudes intervention its effectiveness was almost completely eliminated 11. Positive role models were also identified as having a powerful influence over children's learning and value systems. It was established that a child's likelihood of imitating behavior is increased if the role model is older than the child; if the role model is part of a group; and if there is a clear reward or benefit in being like the role model. This understanding was used in developing the Food Dude super heroes 12. Behavioral psychology accepts that language locks in specific behaviors, through the process of categorization. For example, if a parents say repeatedly of their child, 'Jenny hates tomatoes', Jenny, indeed, will come to categorize herself as a tomato-hater, saying of herself, 'I hate tomatoes'. The Food Dudes Programme works on the premise that you can change this learned conceptualization if you encourage a child to try new foods, and to re-categorize himself as a 'fruit and vegetable liker' 13. Figure 2. A Food Dude enjoying fruit.  Benchmark 3: Behavioral Goals The Food Dudes Program has a primary behavioral goal that accords with the UK Government's 5 A DAY guidelines to increase fruit and vegetable consumption among primary-aged children. In addition, it aims to maintain this behavior change in children's eating habits over the long-term, and to encourage parents and teachers to support children's acceptance of fruit and vegetables and their move towards healthier eating choices. In all schools, baselines are collected prior to the intervention, and the program is fully evaluated in terms of actual changed behavior (see 'Evaluation & Results'). Consumption data are also collected from control schools to demonstrate the impact of straight-forward fruit and vegetable provision without the 'Food Dudes' package of promotion and support. Benchmark 4: Segmentation The Food Dudes Program is two-tiered, working not just to influence children's healthy food choices, but also to equip teachers, parents and caregivers with the necessary resources for supporting this change. It thus has two discrete target audiences: Primary Target Audience:
Secondary Target Audience:
(see 'Methods Mix' for details of how interventions are tailored to each audience) Benchmark 5: Exchange The Food Dudes exchange element works on two levels: For children However, there are a range of barriers that traditionally prevent children from attaining their recommended five portions a day. These include: lack of support for healthy eating at home or in schools; lack of positive role models; negative role models 15; and the low profile of fruit and vegetables, compared to less nutritious, heavily marketed alternatives that are high in sugars and fats. The Food Dudes Program aims to overcome these barriers by creating a positive environment (at home and school), in which children are encouraged to try new foods and develop a taste for them. In addition, it offers specific benefits that give children clear incentives to adopt the program: Viewing the adventures of the Food Dudes on DVD is a fun experience for them to share with friends; the small Food Dudes prizes they win reward their healthy eating and make participation in the program appealing; as they come to see themselves as ‘fruit and vegetable eaters' they come to take pride in their new identity; they gain kudos and self-confidence from being able to succeed on the program. Problems sometimes found with rewards schemes 16 are avoided in the Food Dudes program. Initially rewards are used to encourage children to taste new foods. Children's liking for the foods increases each time they taste them and it is their enjoyment of the taste of the foods that maintains consumption in the longer-term when the tangible rewards are phased out. For parents and teachers However, the benefits of the Program speak for themselves, and evaluation demonstrates that teachers and parents come to support it strongly because the children are perceived to enjoy it and because it works. During evaluation of the Ireland program, 96% of parents and 99.1% of teachers reported that children were enjoying participating. In addition, 99% of parents and 99% of teachers thought that the health of children in Ireland would benefit from the introduction of the Food Dudes Program in all primary schools 17. The home pack also encourages changes at home, including changes to parents' own diets: 88% of parents reported consuming one or more portions of fruit and vegetables themselves on a daily basis as a result of the Program 18. As an added incentive for schools, the program offers a fun experience for the whole school to become involved in, supporting the idea of 'health-promoting schools' and strengthening the school community by involving parents, caregivers and volunteers. It also has the potential to offer behavioral improvements among children: 31% of teachers felt that children's classroom behavior had improved since the introduction of the program 19. (See 'Evaluation and Results' for full details) Benchmark 6: Competition 'Food Dudes' developers recognize that brand allegiance is a strong driver of behavior. Heavily branded 'junk foods' are all around, and children are inevitably attracted by what they appear to offer. In industrialized countries, food advertising accounts for around half of all advertising broadcast during children's TV viewing times. Three-quarters of such food advertisements promote high-calorie, low-nutrient foods 20. The Food Dudes Program thus had to create a product that could compete with the high sugar, fat and salt foods that are so heavily marketed to children. Figure 3. The Food Dude heroes.  This meant evolving a strong brand presence that would become as recognizable as the cartoon figures and imagery used to market mainstream food products to children. 'Food Dudes' now offers children an alternative brand - a fruit and vegetables brand - whose appeal is carefully built through the design and promotion of its product range. The 'Food Dudes' superhero cartoon characters represent this brand, and the video creates a fun identity for the program, which children can engage with, remember, and ask for. Furthermore, 'Food Dudes' recognizes that peer pressure is a strong influence in schools. However, rather than trying to circumvent this fact, the program uses peer pressure in its favour - turning it around to get the whole school (and especially older children) on board, and making it 'cool' to eat fruit and vegetables. Initial results show that, by developing children's taste for fruit and vegetables, their learned preference for sugary, sweet snacks can also be overcome. In pilot trials in primary schools, fruit consumption of 5-6 year olds more than doubled from 28% to 59% over six months, while vegetable consumption increased from 8% to 32% 21. This was true even when popular sweet and savoury snacks were presented alongside the fruit and vegetables 22, demonstrating the ability of fruit and vegetables to hold their own against strong food competitors, if positive taste patterns can be established. A further source of 'good' competition is represented by the other initiatives also aiming to increase fruit and vegetable consumption among children. The main example of such is the Department of Health's School Fruit and Vegetable program, which is part of the UK Government's 5 A DAY program to increase fruit and vegetable consumption. Under the program, all 4-6 year old children in Local Education Authority-maintained infant, primary and special schools are entitled to a free piece of fruit or serving of vegetable each school day 23. In order not to duplicate with this 'competitor', 'Food Dudes' is working closely with the Department of Health to ensure close coordination is achieved. In particular, the new roll-out in Wolverhampton is being evaluated by the Department of Health. In fact both programs are entirely complementary. While the School Fruit and Vegetable Scheme is concerned with the supply of fruit and vegetables, the focus of the Food Dudes Program is to increase demand, which, of course, enhances the effectiveness of supply-based programs. Benchmark 7: Methods Mix 'Food Dudes' has a strong methods mix, including 'Food Dudes' DVDs, letters, rewards, and Home Packs - each described below. The program runs in three phases as follows: Preparation Phase 1 (16 days) This introduction provides opportunities for children to sample fruit and vegetables, and, in the process, to develop a liking for them. Phase 1 procedures can either take place during the school's snack time or lunch time break. Every day during this phase, children are read a letter and/or watch a specially designed DVD episode (lasting 6 minutes) starring the Food Dudes. The Food Dudes are young superheroes who are involved in saving the 'Life Force' from the 'Junk Punks', who plot to take away the energy of the world by depriving it of fruit and vegetables. The children watch the Dudes getting the better of the Punks in a series of video adventures. They see the Dudes eating and enjoying a range of fruit and vegetables while praising their health-giving properties and taste, and the children see that these eating choices are part and parcel of the Dudes' winning strategy. The short letters that accompany these DVDs are read out by teachers to their class and they provide a key means of communication between the Food Dudes and the children. They also provide important information about prizes and the benefits of eating a healthy diet, as well as giving encouragement and praise for the children's eating efforts. The purpose of the 'Food Dudes' hero figures is to provide influential role-models for children to imitate. At the same time, children are also given small rewards if they succeed in eating the pieces of fruit and vegetable they are given. Acting together, the Food Dudes and their rewards provide the children with the incentives to follow the Food Dudes' healthy eating advice and this, in turn, ensures that they get enough repeated tastes of the foods to begin liking them for their own intrinsic qualities. Children are also provided with a 'Food Dudes' Home Pack, to encourage them to eat more fruit and vegetables at home through the involvement of parents and a system of self-monitoring. Phase 2 This phase lasts for up to a year and the aim is for the school to move towards a self-sustaining system of intrinsically rewarding fruit and vegetable consumption, which will ensure that a culture of healthy eating is maintained over time. In Phase 2 the program continues to support successful eating of fruit and vegetables, but with less intensity than during Phase 1. Classroom wall charts are used to record consumption levels of these foods and, as the children achieve more advanced goals, they earn further rewards and Food Dudes' certificates. Phase 3 Education Support Materials Benchmark 8: Theory The Food Dudes Healthy Eating Programme is based on a comprehensive theoretical foundation. For a full review of the social and cultural learning theory that underpins it, see Lowe, C.F., Dowey, A.J & Horne, P.J. (1998) Changing what children eat. In A. Murcott (Ed.) The Nation's Diet: The Social Science of Food Choice. London. Longman, pp. 57-80. In brief, two fundamental theories were used in development of the program: Reinforcement Theory 24 Reinforcement theory concentrates on the relationship between the operant behavior and the associated consequences. In the case of 'Food Dudes', the operant behavior involves eating a piece of fruit or vegetable, and the consequence is the receipt of a tangible reward or verbal encouragement. Using rewards and praise in this way, the Food Dudes Program positively reinforces the operant behavior. As a consequence, the children are encouraged to taste different fruits and vegetables over and over again. Taste Acquisition Theory 25 The Food Dudes Healthy Eating Programme facilitates a process of repeat tastings that enables children to discover the intrinsically rewarding properties of fruits and vegetables. In other words, the children grow to like these foods for their own particular flavours, textures and other sensual properties, rather than for any other external rewards. At this point the program's outcomes become long term and sustainable: children have learned to enjoy fruit and vegetables for their own sake. Figure 4. Food Dudes reinforcement theory model.  Evaluation and ResultsThe Food Dudes Healthy Eating Programme has been developed and extensively tested with thousands of children aged 2-11 in home, nursery and primary school contexts in England (Oxford, Manchester and London), Wales and Ireland, and it has been shown, in every such study, to be highly successful in encouraging children to eat fruit and vegetables 26. In taking the program forward in Wolverhampton, England, the Department of Health has also agreed with the School Food Trust vi to undertake and fund a full evaluation of the impact of the project on the diets of the children who participate. An intensive evaluation, comparing different methodologies, will also be conducted in the Bedford schools. Robust evaluation has always been an integral part of the program. Much of the research carried out by the Bangor Food and Activity Research Unit (BFARU) used observational measures of each child's individual consumption of fruit and vegetables before, during and after the program had been introduced. This was time-consuming, but yielded an objective, quantitative measure of the Program's effectiveness. Simpler measures suitable for a large number of schools have now been developed for roll-out alongside the program. These take the form of questionnaires or food diaries. In addition, BFARU are developing a 1-day diary (the "DIET-24: 24hour dietary intake evaluation tool") that may be used in large-scale evaluations of the Food Dudes Program to assess food intake both by children and parents. BFARU has also developed short questionnaires for parents, teachers and in-school co-ordinators to assess the perceived impact of the Program. Formative evaluation, through interviews or focus groups, is another means of determining the acceptability of the Program to its target audience. As the program is rolled out, Food Dudes Project Managers monitor progress in each school to ensure that class teachers are adhering to procedures. Teachers or other school staff (e.g. teaching assistants) are asked to record the number of children in their classes eating fruit and vegetables before the Program, and during Phases 1 and 2. A Class Record Card is provided for each class in every school for this purpose. The in-school co-ordinator is then asked to collate the results from all classes onto the Whole School Record Card, which, when completed, is returned to the Food Dudes Project Managers. This information enables the Project Managers to determine the overall effects of the program in each school, and it provides useful material in support of the evaluation. Baseline measures of fruit and vegetable consumption should be taken for a four-day period just prior to the start of Phase 1. These same measurements should be taken again at the end of Phase 1 and at a follow-up period, into Phase 2 and beyond, in order to assess immediate and longer-term effects of the Food Dudes Program. ResultsEvaluation to date indicates that the Food Dudes Healthy Eating Programme brings about substantial increases in pupils' consumption of fruit and vegetables. Key evaluation findings from three major evaluations 27 include:
Results from Year One of the Irish rollout (implemented in 46 schools, September 2005 - June 2006), were obtained via questionnaires to parents and teachers in participating schools. These questionnaires were analyzed independently by University College Dublin. Questionnaires were returned from 44 of the 46 schools; from 3,833 (51%) parents; and from 218 (73%) teachers 34. These results confirmed those obtained from earlier studies as follows: Analysis of the teacher questionnaires showed
Analysis of the parents' questionnaires showed
Roll OutBased on these successes, Food Dudes is being rolled out in Europe and beyond. In Ireland the program is being introduced into all primary schools. To-date 1103 schools and 162,000 children have participated. In England, the program is going into all primary schools in Wolverhampton over the next 3 years, beginning this January. So far twelve schools have been involved and the evaluation findings are being analyzed. This project will also be evaluated separately by the DoH. A similar project has begun in Bedfordshire, with nine schools participating so far and, again, evaluation data are being analysed. The project has also been launched in Sicily this year, with six schools participating so far. Initial results are being analysed. A pilot project is underway in California (a collaboration between researchers at UC Davis and California State University, Stanislaus). Lessons LearnedResults indicate that this is a program that can now be introduced into all primary schools internationally, to produce large and long-lasting changes in the diets of children in both school and home contexts. The Food Dudes Healthy Eating Programme has wide-ranging impacts on the diets of boys and girls alike across the economic spectrum, including those who, for reasons related to family income, suffer social exclusion from improvements in the nation's conditions of life. The program has an important role to play in redressing one of the prime sources of health inequality in contemporary society. The Fit Food Dudes Programme: Initial research findings suggest that an intervention modeled closely on the Food Dudes Programme is effective in increasing physical activity in primary school children. This project has been funded by the Wales Office of Research and Development for Health and Social Care. A lunch-based version of the Food Dudes Programme has been recommended for the future since it was found to be:
It is crucial to ensure that sufficient funding is in place before embarking on any plans to implement the Program. The key costs associated with setting up and running the 'Food Dudes' program are as follows: Food Dudes materials: (i.e., DVDs, rewards, letters, parents pack, wall charts) for Phases 1 and 2. All materials need to be printed and delivered to schools in a ready-to-use format. Project management: there needs to be funding for designated Food Dudes Project Managers based in host countries who will facilitate and ensure correct implementation of the Program in those countries' schools. Fruit and vegetable provision: on each of the 16 days of Phase 1, as well as on all days during baseline (at least 4 days), all children need to be provided with a piece of fruit and a portion of vegetables at school. In some countries, these foods may already be available to children in school as part of national provision programs. In these cases, the Food Dudes Program may be used to complement these existing programs by boosting consumption of the foods and reinforcing the healthy eating ethos within schools. In countries where fruit and vegetables are not provided to all children, a merit of the Food Dudes Program is that the foods need only be provided for 16-20 days. Training and support: from the Bangor Food and Activity Research Unit. References
Author InformationDr Pauline J Horne (BSc, MPhil Biochem, BA, PhD Psychol) Professor C. Fergus Lowe (BA, PhD, CPsychol, FBPsS) |
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