title: Enhancing nutritional environments through access to fruit and vegetables in schools and homes among children and youth: a systematic review.
abstract: BACKGROUND
  Low fruit and vegetable (FV) consumption is one of the top 10 global risk factors for mortality, and is related to increased risk for cancer, cardiovascular disease and diabetes. Many environmental, sociodemographic and personal factors affect FV consumption. The purpose of this review is to examine the effects of interventions delivered in the home, school and other nutritional environments designed to increase FV availability for five to 18-year olds.
  
  
  METHODS
  The search included: 19 electronic bibliographic databases; grey literature databases; reference lists of key articles; targeted Internet searching of key organization websites; hand searching of key journals and conference proceedings; and consultation with experts for additional references. Articles were included if: in English, French and Spanish; from high-, middle-, and low-income countries; delivered to anyone who could bring about change in FV environment for 5 to 18 year olds; with randomized and non-randomized study designs that provided before-after comparisons, with or without a control group. Primary outcomes of interest were measures of FV availability.
  
  
  RESULTS
  The search strategy retrieved nearly 23,000 citations and resulted in 23 unique studies. Interventions were primarily policy interventions at the regional or state level, a number of curriculum type interventions in schools and community groups and a garden intervention. The majority of studies were done in high-income countries.The diversity of interventions, populations, outcomes and outcome measurements precluded meta-analysis. The most promising strategies for improving the FV environment for children are through local school food service policies. Access to FV was successfully improved in four of the six studies that evaluated school-based policies, with the other two studies finding no effect. Broader state or federally mandated policies or educational programs for food service providers and decision makers had mixed or small impact. Similarly family interventions had no or small impact on home accessibility, with smaller impact on consumption.
  
  
  CONCLUSIONS
  The studies have high risk of bias but more rigorous studies are difficult to impossible to conduct in naturalistic settings and in policy implementation and evaluation. However, there are promising strategies to improve the FV environment, particularly through school food service policies.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Ganann
authors.affiliation: Effective Public Health Practice Project, McMaster University, Room HSC 3 N25, 1280 Main Street West, Hamilton, Ontario L8S 4 K1, Canada. fitzd@mcmaster.ca.
authors.forename: Donna
authors.initials: D
authors.lastname: Fitzpatrick-Lewis
authors.forename: Donna
authors.initials: D
authors.lastname: Ciliska
authors.forename: Leslea J
authors.initials: LJ
authors.lastname: Peirson
authors.forename: Rachel L
authors.initials: RL
authors.lastname: Warren
authors.forename: Paul
authors.initials: P
authors.lastname: Fieldhouse
authors.forename: Mario F
authors.initials: MF
authors.lastname: Delgado-Noguera
authors.forename: Sera
authors.initials: S
authors.lastname: Tort
authors.forename: Steven P
authors.initials: SP
authors.lastname: Hams
authors.forename: Maria José
authors.initials: MJ
authors.lastname: Martinez-Zapata
authors.forename: Luke
authors.initials: L
authors.lastname: Wolfenden
mesh_terms: D000293:Adolescent; D002648:Child; D002664:Child Nutritional Physiological Phenomena; D002675:Child, Preschool; D005260:Female; D005638:Fruit; D006291:Health Policy / Q000331:legislation & jurisprudence*; D006801:Humans; D008297:Male; D012574:Schools; D013334:Students / Q000523:psychology*; D014675:Vegetables