Observational study: determinants for vegetable consumption among elementary school students in Indonesia

Lack of vegetable consumption among children

Our study found that vegetable consumption and other macronutrient intake was low among children participating in our study. Regarding vegetables, it showed that girls had better vegetable consumption compared to boys, this finding is in line with results from Puspitawati et al.²³ which stated that women tend to consume more vegetables. The national balanced diet guideline recommended a minimum of 250 g of vegetables per day. This amount can be converted to household size, one serving of vegetables is equal to one bowl of fresh vegetables or half a bowl of cooked vegetables. More than 80% of students in this study consumed far below this RDA.

Lack of vegetable consumption can be caused by various factors including the unavailability of vegetables at home²⁴ such as found in this study. However, the process can be two-fold, the lack of availability may be due to the lack of demand from children and the lack of demand might be caused by lack of creativity in preparing vegetables so that they are appealing to children. Vegetables are not naturally appetizing to children, thus the use of spices and herbs are needed to increase vegetable intake in children.²⁵ Studies have found that the absence of parental support for fruit and vegetable consumption, especially from mothers as educators as well as food providers, is a risk factor for a lack of consumption among children.^26,27 While a review on experimental research showed that the change in eating habits resulting from providing more fruits and vegetables to children has been proven to influence their long-term eating behavior.²⁸

Contento stated that consumption behavior is the choice of food and other actions related to food and nutrition that people do to achieve the desired effect of their own choices.²⁹ Furthermore, the food selection process involves six categories, namely taste, habits, health, diet, rules, and filling food. The choice category becomes an individual’s consideration in choosing the food to be consumed.³⁰ In addition, life experiences have a major influence on food choices which include ideals, personal factors, resources, social contexts, and food contexts. These influences inform the development of personal systems for making food choices that combine value negotiation and behavioral strategies.³¹ While in children, there are four things that influence their food choices: (1) main factors including hunger level, preferences (based on taste, familiarity, experience), time pressure and priorities (children tend to choose fast food when they have limited time), ability to prepare food, and desired impact; (2) secondary factors such as peers, media, supermarkets and schools; (3) action, which are the actions taken by parents in influencing children’s food choices; (4) time, children’s activities will form a pattern of food selection over time which is influenced by the past (experience) and future plans.¹⁹ The challenge from mental exercise can also influence food choice in children, a study found that children choose healthier foods to a greater degree when they have to do mathematical exercises than when they do not.³² Hence, food selection is clearly the end result of a decision-making process about the food that a person will consume.

Home and school environment influence

Findings regarding the influence of social environment found that interventions which focused on promoting a positive environment, by improving the availability and accessibility of healthier food as well as their taste preference toward these healthier choices, was seen as an effective approach.³³ The Voices for Healthy Kids, a multi-sectoral collaboration promoting food, environment, physical activity, and a healthy weight for all children and adolescents in the United States of America, proved that multi-sectoral collaboration involving many groups and stakeholders is key in responding to increasing prevalence of obesity in children and adolescents.³⁴ Availability and accessibility, fruit and vegetable preference, and taste have been the most consistent determinants for consumption.³⁵ Therefore, this study suggests that mothers should not to give up and should always provide vegetables at home, because children’s food preferences and desire to try new foods are influenced by the people around them.³⁶

A study showed that children whose mothers work are less likely to have breakfast than children with non-working mothers.³⁷ There are developmental differences between the perceptions of children and adolescents about the factors that influence food choices. In adolescents, parental control begins to decrease and adolescents have more independence in their food choices compared to children.³⁸ Therefore, to improve diets, especially vegetable intake, it is very important to gather input from children themselves regarding the factors that are thought to influence their food choices.

Our result showed that the availability of vegetables at home tripled the odds for having better vegetable consumption. Studies have shown that experiences in early life and the family have a prominent role in encouraging healthy eating patterns that will last throughout a person’s life. Parental eating habits and feeding strategies are the most dominant determinants of children’s eating behavior and food choices.³⁹ Thus, it is imperative for parents, as the closest environment for children, to always monitor children’s eating habits to avoid nutritional problems such as malnutrition, obesity, diabetes, and other diseases due to deficiency or excess nutrition. Mothers play the main role in providing and managing food in the family, mothers are most dominantly responsible for feeding children⁴⁰ and other family members. In particular, parents play the roles of health promoters, role models, and educators in children’s lives, influencing their cognition and eating choices. Food availability and the influence of parenting patterns have a strong relationship in the consumption of healthy and unhealthy foods in children.⁴¹

Children are more likely to eat foods that are readily available and they tend to eat more when larger portions are provided.⁴² Parents function as gatekeepers who can support and control healthy dietary behavior in children. Providing nutritional knowledge and parental support regarding the nutritional needs of children is important, for example through the provision of supplies to school and the management of nutritious and safe food for consumption at home.⁴³ It is suggested that parents create food choices through the purchase and preparation of food and indirectly influence children’s food choices by setting a number of rules, providing information, and shaping their behavior.¹⁹ Likewise, parents also play an important role in the formation of eating habits and preferences, for example the tendency to want to or be afraid to try new foods.⁴⁴ Previous eating experiences can be a major determinant of children’s eating development and acceptance of diverse foods. Following the law of supply and demand, parents often prepare only foods that their children like, which sometimes ignores the importance of nutritional diversity in food and offers fewer experiences of trying new foods. Thus, it is advised for parents to provide healthy food, and wherever possible accompany children and eat with family members, creating positive and enjoyable eating situations to help children develop healthy eating habits. Such an approach can be translated into a behavior change communication strategy through school-based nutrition programs where parents, especially mothers, are involved and provided not only with knowledge about the importance of a balanced diet for their children, but also to improve their ability to prepare healthy food that is affordable and appetizing for their children.

Nowadays many parents only provide energy-dense food which mostly comes from carbohydrates, then protein sources such as eggs and chicken because they are obtained at a low price, taste good, and are easy to manage and cook. Therefore, these foodstuffs are more widely chosen and consumed by children compared to foods with sufficient fiber including vegetables, fruit, and other protein sources such as fish (not preferred because processing starts from the cleaning process, has a fishy smell and contains bones). The practice of feeding children food that only contains carbohydrates and protein, if consumed continuously in excess, will have an impact on weight gain. To meet the challenge of providing children with healthy, balanced nutritious food choices, parents need exposure to information and knowledge about nutrition. The better a person’s nutritional knowledge, the more attention will be paid to the quality and quantity of food they consume.⁴⁵ The provision of early nutrition and food education in children plays an important role in shaping food choices, diet quality, and nutritional status.⁴⁶ The provision of early nutrition and food education in children plays an important role in shaping food choices, diet quality, and nutritional status. Therefore, it is important to involve parents, especially mothers, in children’s nutrition education activities. It is a good opportunity to organize nutrition education activities in schools because it targets students, parents, and also teachers who have an important role in shaping and determining children’s eating habits.

In addition to the food environment at home, school is the second most frequented environment for children, they spend approximately five to six hours with learning activities, playing, and exercising, so they need adequate food intake and healthy food environment at school to supply their need. The selection of healthy, safe, and nutrient-rich snacks at school, therefore, is also important. However, not all school canteens provide healthy and safe snacks. A Bogor District Health Office survey report on 2018, showed that almost 80% of the snacks sold in canteens and around schools in Bogor Regency did not meet the clean and hygienic requirements. Referring to our finding, that most children did not meet their macronutrient needs showed that food insecurity might still be an issue. The adverse impact of food insecurity in children can affect their academic development and skills as well as their nutritional status.⁴⁷ There is also a strong association between food safety and malnutrition, where children who eat unsafe foods are almost three times more likely to suffer from malnutrition than children who eat safe foods.⁴⁸

According to Brown et al. (2011)⁴⁹ schools are responsible for providing quality food for students. This must be included in the school education program, because school-age children are starting to develop their independence and distance themselves from parental supervision, especially in terms of choosing to eat at school. They can choose and make their own decisions regarding what snacks they consume during breaks, this highlighted the need for regulation of snacks in schools.⁵⁰ Our preliminary study in the eight schools involved in this study did not find any school policies regulating food safety and hygiene, we only found an oral appeal from government agencies to schools in their efforts to minimize children’s consumption of unhealthy food and drinks. While globally, the movement for malnutrition and obesity prevention in children should also cover not only hygiene but also sugar contents. However, it requires hard work and better enforcement. A study found that in some cases, the sale of energy drinks is prohibited in schools which is supported by local authorities, but children perceive that schools allow energy drinks to be brought and consumed during class. This proves the lack of enforcement of the existing rules in schools regarding snacks that are safe for consumption by children.⁵¹

Strengths and limitations

The study identifies the determinants of vegetable consumption among elementary school students by gathering information directly from them. It also involved a large number of participants within the same age range from various schools in the study area. The use of validated tools by trained enumerators also helped to improve the data quality. However, the study was conducted at a subnational level thus it limits the generalizability to other settings. Additionally, we did not record respondent’s food consumption data for more days (for example three or seven days of food recall), due to considerations of elementary school children’s memory, so it was limited to only 24 hours of food recall. We also did not include teachers and parents in the study to validate our findings since they also have an important role in the growth and development of elementary school children. Hence, for future research, in addition to increasing the scale of the study, we suggest including mothers and teachers to triangulate results.

Underlying data

Figshare: determinants for vegetable consumption among elementary school students in Indonesia. 10.6084/m9.figshare.20410704

The project contains the following underlying data:

Reporting guidelines

Figshare: STROBE checklist for observational study: determinants for vegetable consumption among elementary school students in Indonesia. https://doi.org/10.6084/m9.figshare.20410704

Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication).