Improving fruit/vegetable behaviors as a social determinant of health among children: A systematic review

Katherine Taelman; Frank Snyder; Najat Yahia

doi:10.29333/ejgm/17391

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Katherine Taelman ¹ ^* , Frank Snyder ² , Najat Yahia ²

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¹ University of Michigan, Ann Arbor, MI, USA² Central Michigan University, Mount Pleasant, MI, USA^* Corresponding Author

Abstract

The national school lunch program (NSLP) supports nutrition, a social determinant of health, by improving children’s access to healthy meals, yet many still fall short of recommended fruit and vegetable (F/V) intake. This systematic review examines 21 school-based interventions (2018-2025) in NSLP-participating schools aimed at improving F/V behaviors (i.e., consumption, selection, and waste). Using behavioral economics and Kahneman’s system 1 (intuition-based) and system 2 (knowledge-based) thinking systems to organize results, 18 interventions (86%) improved at least one F/V behavior. System 1 interventions (n = 12) were most effective, improving all F/V behaviors regardless of setting or duration. System 2 interventions (n = 4) had mixed results, with one worsening F/V behavior. Mixed interventions (n = 5) showed variable outcomes. System 1 interventions that improve appeal of F/V and cafeteria food environments can improve F/V behaviors in children. These interventions did not require classroom time, large investments from school districts, and may save money and reduce waste.

Keywords

social determinants
health equity
lunch
behavioral economics
children
school
nutrition

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This is an open access article distributed under the Creative Commons Attribution License which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Article Type: Review Article

ELECTRON J GEN MED, Volume 22, Issue 6, December 2025, Article No: em697

https://doi.org/10.29333/ejgm/17391

Publication date: 09 Nov 2025

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References

USDA. Child nutrition programs: National school lunch program. United States Department of Agriculture; 2025. Available at: https://www.ers.usda.gov/topics/food-nutrition-assistance/child-nutrition-programs/national-school-lunch-program/ (Accessed: 29 July 2025).
USDA. Dietary guidelines for Americas, 2020-2025. United States Department of Agriculture; 2020. Available at: https://www.dietaryguidelines.gov/sites/default/files/2021-03/Dietary_Guidelines_for_Americans-2020-2025.pdf (Accessed: 29 July 2025).
Machado SS, Burton M, Loy W, et al. Promoting school lunch fruit and vegetable intake through role modeling: A pilot study. AIMS Public Health. 2020;7(1):10-9. https://doi.org/10.3934/publichealth.2020002 PMid:32258185 PMCid:PMC7109527
Palmer S, Metcalfe JJ, Ellison B, et al. The efficacy and cost-effectiveness of replacing whole apples with sliced in the national school lunch program. Int J Environ Res Public Health. 2021;18(24):13157. https://doi.org/10.3390/ijerph182413157 PMid:34948766 PMCid:PMC8701969
Sharma S, Marshall A, Chow J, et al. Impact of a pilot school-based nutrition intervention on fruit and vegetable waste at school lunches. J Nutr Educ Behav. 2019;51(10):1202-1210.e1. https://doi.org/10.1016/j.jneb.2019.08.002 PMid:31522894
Smathers C, Graffagnino C. Offering self-serve sliced apples in bulk increases students’ consumption and decreases apple waste in elementary school cafeterias. Sch Nutr Assoc. 2020;44. Available at: https://schoolnutrition.org/journal/spring-2020-offering-self-serve-sliced-apples-in-bulk-increases-students-consumption-and-decreases-apple-waste-in-elementary-school-cafeterias/ (Accessed: 29 July 2025).
Hamdi N, Ellison B, McCaffrey J, Metcalfe JJ, Hoffman A, Haywood P, et al. Implementation of a multi-component school lunch environmental change intervention to improve child fruit and vegetable intake: A mixed-methods study. Int J Environ Res Public Health. 2020;17:3971. https://doi.org/10.3390/ijerph17113971 PMid:32503325 PMCid:PMC7312556
Bean MK, Sova A, Thornton LM, Raynor HA, Williams A, Stewart MD, et al. Salad bars and fruit and vegetable intake in Title I elementary schools. Health Behav Policy Rev. 2020;7:461-72. https://doi.org/10.14485/HBPR.7.5.8 PMid:34277884 PMCid:PMC8284595
Xiao Y, Mann JJ, Chow JC-C, Brown TT, Snowden LR, Yip PS-F, et al. Patterns of social determinants of health and child mental health, cognition, and physical health. JAMA Pediatr. 2023;177:1294-305. https://doi.org/10.1001/jamapediatrics.2023.4218 PMid:37843837 PMCid:PMC10580157
Huang K-Y, Cheng S, Theise R. School contexts as social determinants of child health: Current practices and implications for future public health practice. Public Health Rep. 2013;128:21-8. https://doi.org/10.1177/00333549131286S304 PMid:24179275 PMCid:PMC3945445
United States Department of Agriculture. National School Lunch Program fact sheet. Food Nutr. Serv. 2019. Available at: https://www.fns.usda.gov/nslp/nslp-fact-sheet (Accessed: 29 July 2025).
Bean MK, Spalding BB, Theriault E, Dransfield K-B, Sova A, Stewart MD. Salad bars increased selection and decreased consumption of fruits and vegetables 1 month after installation in Title I elementary schools: A plate waste study. J Nutr Educ Behav. 2018;50:589-97. https://doi.org/10.1016/j.jneb.2018.01.017 PMid:29550173 PMCid:PMC5995641
Hopkins LC, Gunther C. A historical review of changes in nutrition standards of USDA child meal programs relative to research findings on the nutritional adequacy of program meals and the diet and nutritional health of participants: Implications for future research and the summer food service program. Nutrients. 2015;7:10145-67. https://doi.org/10.3390/nu7125523 PMid:26690207 PMCid:PMC4690075
Schwartz MB, Henderson KE, Read M, Danna N, Ickovics JR. New school meal regulations increase fruit consumption and do not increase total plate waste. Child Obes. 2015;11:242-7. https://doi.org/10.1089/chi.2015.0019 PMid:25734372 PMCid:PMC4484709
Mansfield JL, Savaiano DA. Effect of school wellness policies and the Healthy, Hunger-Free Kids Act on food-consumption behaviors of students, 2006-2016: A systematic review. Nutr Rev. 2017;75:533-52. https://doi.org/10.1093/nutrit/nux020 PMid:28838082
Vernarelli JA, O’Brien B. A vote for school lunches: School lunches provide superior nutrient quality than lunches obtained from other sources in a nationally representative sample of U.S. children. Nutrients. 2017;9:924. https://doi.org/10.3390/nu9090924 PMid:28837090 PMCid:PMC5622684
Whitman A, De Lew N, Chappel, A, Aysola V, Zuckerman R, Sommers B. Addressing social determinants of health: Examples of successful evidence-based strategies and current federal efforts]. ASPE Office of Health Policy; 2022 Apr. Report No.: HP-2022-12. Available at: https://aspe.hhs.gov/sites/default/files/documents/e2b650cd64cf84aae8ff0fae7474af82/SDOH-Evidence-Review.pdf (Accessed: 29 July 2025).
Burg X, Metcalfe JJ, Ellison B, Prescott MP. Effects of longer seated lunch time on food consumption and waste in elementary and middle school-age children: A randomized clinical trial. JAMA Netw Open. 2021;4:e2114148. https://doi.org/10.1001/jamanetworkopen.2021.14148 PMid:34156451 PMCid:PMC8220493
United States Department of Agriculture. Offer versus serve: Guidance for the National School Lunch Program and the School Breakfast Program. 2015. Available at: https://fns-prod.azureedge.us/sites/default/files/cn/SP41-2015av2.pdf (Accessed: 29 July 2025).
Patel KJ, Strait KM, Hildebrand DA, Amaya LL, Joyce JM. Variability in dietary quality of elementary school lunch menus with changes in National School Lunch Program nutrition standards. Curr Dev Nutr. 2020;4:nzaa138. https://doi.org/10.1093/cdn/nzaa138 PMid:32939439 PMCid:PMC7485789
Chandran A, Burjak M, Petimar J, Hamra G, Melough MM, Dunlop AL, et al. Changes in body mass index among school-aged youths following implementation of the Healthy, Hunger-Free Kids Act of 2010. JAMA Pediatr. 2023. https://doi.org/10.1001/jamapediatrics.2022.5828 PMid:36780186 PMCid:PMC9926355
Hales C, Akinbami L, Wei, R, Ogden C. Evaluation of alternative body mass index (BMI) metrics to monitor weight status in children and adolescents with extremely high BMI using CDC BMI-for-age growth charts. CDC Stacks. 2022;197. https://doi.org/10.15620/cdc:121711
Cohen JFW, Hecht AA, Hager ER, Turner L, Burkholder K, Schwartz MB. Strategies to improve school meal consumption: A systematic review. Nutrients. 2021;13: 3520. https://doi.org/10.3390/nu13103520 PMid:34684521 PMCid:PMC8538164
Gordon K, Dynan L, Siegel R. Healthier choices in school cafeterias: A systematic review of cafeteria interventions. J Pediatr. 2018;203:273-279.e2. https://doi.org/10.1016/j.jpeds.2018.07.031 PMid:30213461
Merlo C, Smarsh BL, Xiao X. School nutrition environment and services: Policies and practices that promote healthy eating among K-12 students. J Sch Health. 2023;93:762-77. https://doi.org/10.1111/josh.13365 PMid:37670594 PMCid:PMC10502941
Metcalfe JJ, Ellison B, Hamdi N, Richardson R, Prescott MP. A systematic review of school meal nudge interventions to improve youth food behaviors. Int J Behav Nutr Phys Act. 2020;17:77. https://doi.org/10.1186/s12966-020-00983-y PMid:32560731 PMCid:PMC7304192
Mumby S, Leineweber M, Andrade J. The impact the Smarter Lunchroom Movement Strategies have on school children’s healthy food selection and consumption: A systematic review. Sch Nutr Assoc. 2018;42. Available at: https://schoolnutrition.org/journal/fall-2018-the-impact-the-smarter-lunchroom-movement-strategies-have-on-school-childrens-healthy-food-selection-and-consumption-a-systematic-review/ (Accessed: 29 July 2025).
Oke S, Tan M. Techniques for advertising healthy food in school settings to increase fruit and vegetable consumption. Inq J Health Care Organ Provis Financ. 2022;59:00469580221100165. https://doi.org/10.1177/00469580221100165 PMid:35511550 PMCid:PMC9081710
Prescott MP, Cleary R, Bonanno A, Costanigro M, Jablonski BBR, Long AB. Farm to school activities and student outcomes: A systematic review. Adv Nutr. 2020;11:357-74. https://doi.org/10.1093/advances/nmz094 PMid:32173754 PMCid:PMC7442359
Kahneman D. Thinking, fast and slow. New York: Farrar, Straus and Giroux; 2011.
Quinn EL, Johnson DB, Podrabsky M, Saelens BE, Bignell W, Krieger J. Effects of a Behavioral Economics Intervention on Food Choice and Food Consumption in Middle-School and High-School Cafeterias. Prev Chronic Dis. 2018;15:E91. https://doi.org/10.5888/pcd15.170377 PMid:29981258 PMCid:PMC6040595
Byker CJ, Farris AR, Marcenelle M, Davis GC, Serrano EL. Food Waste in a School Nutrition Program After Implementation of New Lunch Program Guidelines. J Nutr Educ Behav. 2014;46:406-11. https://doi.org/10.1016/j.jneb.2014.03.009 PMid:24857599
Askelson NM, Brady P, Ryan G, Scheidel C, Delger P, Nguyen P, et al. Implementation and outcome evaluation of a team nutrition intervention: Increasing knowledge, attitudes, and preferences. Health Educ Res. 2021;36:75-86. https://doi.org/10.1093/her/cyaa036 PMid:33221862
Schachtner-Appel A, Song H. A mindful and sustainable eating intervention to improve attitudes related to mindfulness, sustainability, and fruit and vegetable consumption in elementary schools. J Hum Sci Ext. 2024;12. https://doi.org/10.55533/2325-5226.1447
Hernandez Sanchez MG, Bellini S, Christensen WF, Jefferies LK, LeCheminant JD, Patten EV, et al. The effects of potato presentation on vegetable intake in school-aged children: A cross-over study. Nutrients. 2023;15:4496. https://doi.org/10.3390/nu15214496 PMid:37960149 PMCid:PMC10650674
Siebert E, Lee S-Y, Philips C, Prescott MP. Mixed methods study investigating adolescent acceptance and implementation outcomes of serving spicy vegetables in school lunch. Curr Dev Nutr. 2024;8:104425. https://doi.org/10.1016/j.cdnut.2024.104425 PMid:39224143 PMCid:PMC11367512
PRISMA. PRISMA 2020 flow diagram. PRISMA Flow Diagr. Available at: https://www.prisma-statement.org/prisma-2020-flow-diagram (Accessed: 29 July 2025).
National Heart, Lung, and Blood Institute. Study quality assessment tools: NHLBI, NIH. Study Qual. Assess. Tools. 2021. Available at: https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools (Accessed: 29 July 2025).
Bean MK, Mazzeo SE, de Jonge L, Thornton L, Raynor H, Mendoza A, et al. Impact of school salad bars on fruit and vegetable selection, intake, and waste in mid-atlantic elementary schools. Int J Behav Nutr Phys Act. 2025;22:15. https://doi.org/10.1186/s12966-025-01713-y PMid:39910590 PMCid:PMC11800604
Chiero JD, Mobley AR. Evaluation of a farm-to-school intervention to improve locally grown vegetable choices of low-income, primary school students. J Sch Health. 2021;91:410-7. https://doi.org/10.1111/josh.13019 PMid:33768581
Cohen JFW, Richardson S, Rimm EB. Impact of Chef-Enhanced meals, and the removal of flavored milk on school meal selection and consumption. J Acad Nutr Diet. 2019;119:1511-5. https://doi.org/10.1016/j.jand.2019.04.003 PMid:31153957 PMCid:PMC6710101
Elnakib SA, Quick V, Mendez M, Downs S, Wackowski OA, Robson MG. Food waste in schools: A pre-/post-test study design examining the impact of a food service training intervention to reduce food waste. Int J Environ Res Public Health. 2021;18:6389. https://doi.org/10.3390/ijerph18126389 PMid:34204829 PMCid:PMC8296214
Epstein-Solfield A, Arango C, Ogan D, Stendell-Hollis N. The effects of a nutrition education intervention on third- and fifth-grade students’ fruit and vegetable knowledge, preference and consumption. Sch Nutr Assoc. 2018;42. Available at: https://schoolnutrition.org/journal/spring-2018-the-effects-of-a-nutrition-education-intervention-on-third-and-fifth-grade-students-fruit-and-vegetable-knowledge-preference-and-consumption/ (Accessed: 29 July 2025).
Koch PA, Wolf RL, Trent RJ, Ang IYH, Dallefeld M, Tipton E, et al. Wellness in the schools: A lunch intervention increases fruit and vegetable consumption. Nutrients. 2021;13:3085. https://doi.org/10.3390/nu13093085 PMid:34578962 PMCid:PMC8466064
Larson JN, Brusseau TA, Wengreen H, Fairclough SJ, Newton MM, Hannon JC. Fit “n” Cool Kids: The effects of character modeling and goal setting on children’s physical activity and fruit and vegetable consumption. Clin Med Insights Pediatr. 2018;12:1179556518784296. https://doi.org/10.1177/1179556518784296 PMid:30046261 PMCid:PMC6055244
Prescott MP, Burg X, Metcalfe JJ, Lipka AE, Herritt C, Cunningham-Sabo L. Healthy Planet, Healthy Youth: A food systems education and promotion intervention to improve adolescent diet quality and reduce food waste. Nutrients. 2019;11:1869. https://doi.org/10.3390/nu11081869 PMid:31405231 PMCid:PMC6723537
Rajbhandari-Thapa J, Vandellen M, Just D, Panda S. Fun facts about fruits and vegetables can improve consumption. Sch Nutr Assoc. 2020;44. Available at: https://schoolnutrition.org/journal/fall-2022-fun-facts-about-fruits-and-vegetables-can-improve-consumption/ (Accessed: 29 July 2025).
Richardson AS, Nugroho A, Dubowitz T, Schultz D, Martin CK. Students’ consumption of high and low nutrition foods and reduced plate waste by schools’ wellness-related policies and garden program participation. J Hum Nutr Diet Off J Br Diet Assoc. 2023;36:864-74. https://doi.org/10.1111/jhn.13167 PMid:36890709 PMCid:PMC10853945
Serebrennikov D, Katare B, Kirkham L, Schmitt S. Effect of classroom intervention on student food selection and plate waste: Evidence from a randomized control trial. PLOS ONE. 2020;15:e0226181. https://doi.org/10.1371/journal.pone.0226181 PMid:31918437 PMCid:PMC6952251
Thapa J, Lyford C. Nudges to increase fruits and vegetables consumption: Results from a field experiment. Sch Nutr Assoc. 2018;42. Available at: https://schoolnutrition.org/journal/spring-2018-nudges-to-increase-fruits-and-vegetables-consumption-results-from-a-field-experiment/ (Accessed: 29 July 2025).
Wells NM, Todd LE, Henderson CR, Myers BM, Barale K, Gaolach B, et al. The effects of school gardens on fruit and vegetable consumption at school: A randomized controlled trial with low-income elementary schools in four U.S. states. Prev Med Rep. 2023;31:102053. https://doi.org/10.1016/j.pmedr.2022.102053 PMid:36471768 PMCid:PMC9719027
Wengreen HJ, Joyner D, Kimball SS, Schwartz S, Madden GJ. A randomized controlled trial evaluating the FIT Game’s efficacy in increasing fruit and vegetable consumption. Nutrients. 2021;13:2646. https://doi.org/10.3390/nu13082646 PMid:34444805 PMCid:PMC8399486
American Psychological Association. Education and socioeconomic status. 2017. Available at: https://www.apa.org/pi/ses/resources/publications/education (Accessed: 29 July 2025).
Bardin S, Washburn L, Gearan E. Disparities in the healthfulness of school food environments and the nutritional quality of school lunches. Nutrients. 2020;12:2375. https://doi.org/10.3390/nu12082375 PMid:32784416 PMCid:PMC7468741
Chen EK, Reid MC, Parker SJ, Pillemer K. Tailoring Evidence-Based Interventions for New Populations: A Method for Program Adaptation Through Community Engagement. Eval Health Prof. 2013;36:73-92. https://doi.org/10.1177/0163278712442536 PMid:22523308 PMCid:PMC3553290
Matela H, Yadav SS, Menon K. Robust implementation of school food policy is needed to improve nutritional outcomes of children in European and Western Pacific countries: A systematic review. Nutrition. 2024;122:112373. https://doi.org/10.1016/j.nut.2024.112373 PMid:38428219
Robinson TN. Chapter 25 - Stealth Interventions for Obesity Prevention and Control: Motivating Behavior Change. In: Dubé L, Bechara A, Dagher A, Drewnowski A, Lebel J, James P, et al., editors. Obes Prev. San Diego: Academic Press; 2010. p. 319-27. https://doi.org/10.1016/B978-0-12-374387-9.00025-8
Flay BR, Snyder FJ, Petraitis J. The theory of triadic influence. Emerg Theor Health Promot Pract Res 2nd Ed. Hoboken, NJ, US: Jossey-Bass/Wiley; 2009. p. 451-510.

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Vancouver

Taelman K, Snyder F, Yahia N. Improving fruit/vegetable behaviors as a social determinant of health among children: A systematic review. ELECTRON J GEN MED. 2025;22(6):em697. https://doi.org/10.29333/ejgm/17391

APA

Taelman, K., Snyder, F., & Yahia, N. (2025). Improving fruit/vegetable behaviors as a social determinant of health among children: A systematic review. Electronic Journal of General Medicine, 22(6), em697. https://doi.org/10.29333/ejgm/17391

AMA

Taelman K, Snyder F, Yahia N. Improving fruit/vegetable behaviors as a social determinant of health among children: A systematic review. ELECTRON J GEN MED. 2025;22(6), em697. https://doi.org/10.29333/ejgm/17391

Chicago

Taelman, Katherine, Frank Snyder, and Najat Yahia. "Improving fruit/vegetable behaviors as a social determinant of health among children: A systematic review". Electronic Journal of General Medicine 2025 22 no. 6 (2025): em697. https://doi.org/10.29333/ejgm/17391

Harvard

Taelman, K., Snyder, F., and Yahia, N. (2025). Improving fruit/vegetable behaviors as a social determinant of health among children: A systematic review. Electronic Journal of General Medicine, 22(6), em697. https://doi.org/10.29333/ejgm/17391

MLA

Taelman, Katherine et al. "Improving fruit/vegetable behaviors as a social determinant of health among children: A systematic review". Electronic Journal of General Medicine, vol. 22, no. 6, 2025, em697. https://doi.org/10.29333/ejgm/17391