Content uploaded by Asle Holthe
Author content
All content in this area was uploaded by Asle Holthe on Apr 09, 2018
Content may be subject to copyright.
https://doi.org/10.1177/1403494818756702
© Author(s) 2018
Reprints and permissions: sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/1403494818756702
journals.sagepub.com/home/sjp
Scandinavian Journal of Public Health, 1–10
Introduction
Vegetable consumption is an important factor in reduc-
ing the risk of non-communicable diseases (NCDs)
such as type-2 diabetes, cardiovascular diseases
and cancer [1]. The inadequate intake of vegetables is
a public health problem and can be a contributive
factor to increased morbidity [2]. According to the
Organization for Economic Co-operation and
Development (OECD), only 63% of the European
population ate vegetables daily in 2008, and availability
was the major determinant of consumption [2]. This
highlights the importance of improved access to vege-
tables in the different daily contexts for both children
and adults. Early prevention of NCDs is important and
emphasized by health authorities at all levels [3–5].
The national recommendation for adults in Norway is
250 g of vegetables per day [6]. Among Norwegian
two- and four-year-olds, the intake is roughly 50–70 g
daily [7,8].
Is the environment in kindergarten associated with the vegetables
served and eaten? The BRA Study
ANNE HIMBERG-SUNDET1, ANNE LENE KRISTIANSEN1, MONA BJELLAND1,
THOMAS MOSER2, ASLE HOLTHE3, LENE F. ANDERSEN1 & NANNA LIEN1
1Department of Nutrition, Faculty of Medicine, University of Oslo, Oslo, Norway, 2Department of Educational Science,
Faculty of Humanities, Sports and Educational Science, University College of Southeast Norway, Horten, Norway, and
3Faculty of Education, Western Norway University of Applied Science, Bergen, Norway
Abstract
Aim: The aim of the present study was to explore the associations between the economic, political, sociocultural and physical
environments in kindergartens, along with the frequency and variety of vegetables served, and the amount of vegetables eaten.
Method: The BRA Study collected data through two paper-based questionnaires answered by the kindergarten leader and
pedagogical leader of each selected kindergarten, and a five-day vegetable diary from kindergartens (n = 73) in Vestfold and
Buskerud Counties, Norway. The questionnaires assessed environmental factors, and the frequency and variety of vegetables
served. The non-parametric Mann–Whitney U and Kruskal–Wallis tests were used to explore the associations between
factors in the kindergarten environments and vegetables served and eaten. Results: Kindergartens that included expenditures
for food and beverages in the parental fees served a larger variety of vegetables (p = 0.046). A higher frequency of served
vegetables (p = 0.014) and a larger amount (p = 0.027) of vegetables eaten were found in kindergartens where parents paid
a monthly fee of 251 NOK or more. Similarly, the amount of vegetables eaten was higher (p = 0.017) in kindergartens
where the employees paid a monthly fee to eat at work. Furthermore, a larger amount (p = 0.046) of vegetables was eaten
in kindergartens that had written guidelines for food and beverages that were offered. Conclusions: This study indicates
that the economic environment in a kindergarten seems to be positively associated with the vegetables served
and eaten there. This is of high relevance for public health policy as vegetable consumption is an important
factor in reducing the risk of non-communicable diseases.
Keywords: Kindergarten, vegetables, preschool children, BRA Study, environment, Norway, political, economic, sociocultural,
physical
Correspondence: Anne Himberg-Sundet, Department of Nutrition, Faculty of Medicine, University of Oslo, PO Box 1046 Blindern, Oslo N-0316, Norway.
E-mail: Anne.Himberg-Sundet@medisin.uio.no
Date received 7 July 2017; reviewed 18 December 2017; accepted 28 December 2017
756702SJP0010.1177/1403494818756702The BRA StudyHimberg-Sundet et al.
research-article2018
ORIGINAL ARTICLE
2 Himberg-Sundet et al.
Obesity-related behaviors such as dietary intake
seem to carry over from childhood into adulthood
[9]. Children learn by observing others and their sur-
roundings, they are constantly developing and adapt-
ing, and the people and environment that surround
them will have influence on their development [10].
Food preferences appear to be more modifiable dur-
ing early childhood [11]; hence, targeting children’s
dietary habits during this period is important.
Norwegian kindergartens are institutions for all chil-
dren in the age group 1–5 years. The kindergartens
are regulated by law and have a framework plan for
the content and tasks [10]. Formal education is
required in order to be employed as a pedagogical or
kindergarten leader. In general, kindergartens are
open from approximately 7:30 a.m. until 5:00 p.m.
from Monday through Friday. Meals are either
brought from home (lunch box), provided by the kin-
dergarten or else a combination. There are normative
national guidelines for food and meals served in kin-
dergarten, which specify that the kindergarten should
serve or provide for at least two meals a day that are in
line with national dietary guidelines [12]. According
to the guidelines for food and meals, the kindergarten
has a responsibility to contribute to teaching children
healthy dietary habits [10]. National dietary surveys
in Norwegian kindergartens conducted in 2005 and
2011 [13,14] reported low availability of vegetables in
the kindergartens. However, with a 91% attendance
rate [15] kindergartens have the potential to reach
many children and their families.
According to the analysis grid for environments
linked to obesity (ANGELO) framework, factors
within the kindergarten environment can be charac-
terized as economic (i.e. resources related to buying
vegetables), political (i.e. guidelines and rules related
to vegetables), sociocultural (i.e. values and behavior
related to vegetables) and physical (i.e. factors that can
hinder or enable the availability of vegetables) [16].
With regard to economic resources, a review including
observational and intervention studies focusing on
children aged 4–8 years and using the ANGELO
framework, found no results of studies assessing eco-
nomic factors [17]. As for the political factors, policy
recommendations and written guidelines are not nec-
essarily sufficient to ensure adequate nutrition in the
child care settings [18]. However, Norwegian kinder-
garten leaders have previously reported that the two
most important factors to secure healthy meals in kin-
dergarten are to follow the national dietary guidelines
and include them in their annual plans [12,14].
Finally, regarding the sociocultural and physical fac-
tors, a previous study has found positive associations
between the sociocultural and physical environments
and the mealtime setting in child care services in the
Netherlands [19]. In addition, a review conducted by
Holley etal. [20] found a positive effect of repeated
exposure to increase vegetable intake in children aged
2–5 years, while for social factors the results were con-
tradictory. A small Norwegian qualitative case study
found that the physical environment was of great
importance for the quality of the food and meals
served by the kindergartens [21].
The aim of the present study was to explore the
associations between economic, political, sociocul-
tural and physical environmental factors in kinder-
gartens, and the frequency and variety of vegetables
served, as well as the amount of vegetables eaten.
Method
Study design and subjects
Baseline data from the BRA Study (Barnehage (kin-
dergarten), gRønnsaker (vegetables) and fAmilie (fam-
ily)) are used in the present study. The BRA Study is a
cluster randomized controlled intervention study with
an overall aim to improve vegetable intake among pre-
school children (3–5 years at baseline) through chang-
ing the food environment and dietary practices in the
kindergarten and at home. More specifically, the aim
is to increase the daily frequency of vegetable intake,
the variety of vegetables eaten over a month and the
daily amount of vegetables consumed. The target
group for the BRA Study is preschool children born in
2010 and 2011, attending public or private kindergar-
tens in the counties of Vestfold and Buskerud, Norway.
In fall and winter 2014/2015, all 479 public and pri-
vate kindergartens in these two counties were invited
by letter to participate in the study, of which 73 kin-
dergartens accepted (15.2% response rate). Within
the 73 kindergartens, departments with children born
in 2010 or 2011 were eligible for the study and 135
departments agreed to participate (Figure 1).
Figure 1. Flow chart of participants.
The BRA Study 3
Data were collected using several instruments: 1)
a paper-based questionnaire (Questionnaire A)
assessing frequency and variety of vegetables served
was answered by pedagogical leaders in 115 of the
135 departments (86%); 2) a paper-based question-
naire (Questionnaire B) assessing the kindergarten
environment was filled in by the kindergarten lead-
ers, where 69 of 73 leaders responded (95%); and 3)
the amount of vegetables eaten was assessed using a
five-day vegetable diary completed by employees in
122 of the 135 departments (90%) (Figure 1). Few
instruments have focused solely on factors affecting
vegetables served and the frequency and variety of
vegetables served to preschool children, and no
instrument was identified suiting the purpose of this
study. Therefore, modified items from statements
and questions used in the last national dietary survey
in kindergartens [14] and the last dietary sur vey
among Norwegian two-year-olds [7] were included
in the BRA questionnaires. The questions are not
tested for reliability or validity.
Data collection
(1) Vegetables served and eaten: Questionnaire A
and five-day vegetable diary
Questionnaire A was piloted among 11 pedagogical
leaders. Small adjustments were made after feedback.
In March 2015, Questionnaire A was mailed to all
the participating kindergartens (n = 73) and returned
in a pre-paid envelope. One mailed reminder was
sent with the questionnaire enclosed.
Frequency of served vegetables for lunch and the
afternoon meal was assessed through two separate
questions: “How often does your department offer
vegetables for lunch/the afternoon meal?”. The
response alternatives were on a seven-point scale
ranging from “five days a week” to “never”. The vari-
ety of vegetables served for lunch and afternoon meal
was assessed through two separate questions: “How
often does your department offer these vegetables for
lunch/afternoon meal?”. A total of 12 vegetable alter-
natives were given with the same response categories
as mentioned above.
For the five-day vegetable diary, all kindergartens
were given a digital kitchen scale (capacity = 5 kg,
graduation = 1 g). One employee from each depart-
ment received face-to-face instruction on how to
measure and report the amount of vegetables eaten
in the five-day vegetable diary. The employees were
asked to weigh the vegetables before each meal and to
weigh the leftovers after the meal, and to report the
number of children and employees eating at each meal.
They were encouraged to report five consecutive days
in order to assess a typical week. Data from the lunch
and the afternoon meals are presented as amount of
vegetables consumed per person per day. A protocol
was developed on how to interpret missing data.
The two main types of missing data were the num-
ber of children and employee eating, and whether
the vegetables were “ready-to-eat” or not. If the dia-
ries had data from 50% of the meals regarding num-
ber of children and employee eating, then a mean
number was calculated to replace missing data.
Diaries with data of less than 50% were registered
as missing. Diaries with missing data for “Are the
vegetables ready-to-eat?” were assumed to be
“ready-to-eat”.
(2) Factors in the kindergarten environment:
Questionnaire B
Questionnaire B was piloted with two kindergarten
leaders. Only minor revisions were made after the
pilot test. Most of the questions were from the last
national dietary survey in Norwegian kindergartens
[14]. In this paper, questions describing four aspects
of the kindergarten environment were used: the eco-
nomic, political, sociocultural and physical environ-
ments. In all questions where a five-point Likert scale
was used, the scale is collapsed into three categories:
“agree, neither, disagree” or “small, neither, large”,
and two of “small/neither, large”. The economic
environment was assessed through five questions as
shown in Table III, the political environment through
four questions as shown in Table IV, while the socio-
cultural environment was evaluated through two
questions shown in Table VI. In Table VI the factor
that covers “to what degree different mealtime peda-
gogics are emphasized in the training of new employ-
ees” is based on eight items summed from one to
eight and thereafter grouped into “low” (0–3), “aver-
age” (4–5) and “high” (6–8).
Statistical analysis
Statistical analyses were performed using the statis-
tical software package SPSS® Statistics Version
24.0. Data on frequency and variety (Questionnaire
A), in addition to data on amount of vegetables
served (five-day vegetable diary), were aggregated
to the kindergarten level as the data on the kinder-
garten environment were collected at an institutional
level and not at the department level (Questionnaire
B). The Shapiro–Wilk test was used to test for nor-
mality. Due to data not being normally distributed,
the non-parametric Mann–Whitney U and Kruskal–
Wallis tests were used to test for differences between
groups.
4 Himberg-Sundet et al.
Results
According to Statistics Norway, there were a total of
568 [15] kindergartens in Vestfold and Buskerud
Counties in 2014 (Table I), of which 41% were pub-
lic and 59% were private kindergartens. In the BRA
Study, 45% were public and 55% were private kin-
dergartens. Kindergartens in Vestfold and Buskerud
had a mean of 12.5 full-time equivalents, and a mean
of 4.1 employees with the formal education to work
as a pedagogical or kindergarten leader. In the kin-
dergartens in the BRA Study, the means were 13.9
full-time equivalents and 5.9 with formal education.
Furthermore, 47% of kindergartens in these counties
were registered as five-a-day fruit and vegetable kin-
dergartens compared with 41% of the BRA kinder-
gartens. Only full-time public and private
kindergartens were included due to these being the
most common child care institutions in Norway.
Therefore, the invitation to participate was sent to
479 of the 568 kindergartens.
The number of kindergartens providing data from
the pedagogical leader (Questionnaire A) and the
kindergarten leader (Questionnaire B) was 66, while
66 kindergartens had data from the kindergarten
leader (Questionnaire B) and the five-day vegetable
diary. The number of kindergartens with data from
all three sources (Questionnaire A, Questionnaire B
and five-day vegetable diary) was 63 (86% of the 73
kindergartens).
Vegetables served and eaten
The median variety of served vegetables was eight
per month, the median frequency of vegetables
served was 6.3 times per week and the median intake
of vegetables consumed per person per day was 36 g
(Table II). A higher frequency of vegetables served
was found in kindergartens where children consumed
30.1 g vegetables or more per day, compared to those
kindergartens where children consumed 30 g or less
per day (Table II).
Associations between the kindergarten
environment and vegetables served and eaten
In the economic environment, three out of nine fac-
tors were associated with the variety of vegetables
served, one out of nine factors was associated with
the frequency of vegetables served and three out of
nine factors were associated with the amount of veg-
etables eaten (Table III). Kindergartens with food
and beverages covered by a parental fee had a larger
variety of vegetables served per month. However, the
variety was also larger in the seven kindergartens that
did not ask for any additional payment from the par-
ents to cover food and beverage expenses. In kinder-
gartens where parents paid an additional amount of
>251 NOK to cover food supplies, a higher frequency
of vegetables served and a larger amount of vegeta-
bles consumed were observed. In kindergartens
where the leaders agreed that they could use the
budget as they wished, a larger amount of vegetables
consumed was observed compared to kindergartens
where leaders answered “neither” or “disagree”.
Those who answered “agree” or “neither” to the
same question had a larger variety of vegetables com-
pared to those who answered “disagree”. In the kin-
dergartens where the employees paid a monthly fee
for food and beverages, a larger amount of vegetables
was consumed (Table III).
For the political environment, one out of six fac-
tors was associated with the frequency of vegetables
served, and one out of six factors was associated
with the amount of vegetables eaten (Table IV). In
kindergartens that had written guidelines for food
and beverages offered, the children consumed a
larger amount of vegetables. However, kindergar-
tens with “written guidelines for food and beverages
brought from home” had lower frequency of vegeta-
bles served. For the physical environment, one out
of 10 factors was associated with the frequency of
vegetables served. Frequency of served vegetables
was highest among those who “agreed” to the state-
ment, “I do not buy vegetables because they are too
expensive”, compared to those that “disagreed” or
answered “neither” (Table V). No significant asso-
ciations were found with the sociocultural environ-
ment (Table VI).
Discussion
This study indicates that more factors within the eco-
nomic environment were important for the vegeta-
bles served and eaten in the kindergartens than
factors in the political, physical and sociocultural
environments.
The economic environment
The Norwegian government has established a maxi-
mum parental fee, independent of whether the kin-
dergarten is under public or private ownership [23].
However, most kindergartens ask for additional pay-
ment to cover expenses for food and beverages [14].
This was also shown for 59 out of 66 kindergartens in
our study. In line with previous research [14], our
results showed that having a larger food budget or
perceiving to have budgetary freedom contributed to
kindergartens buying and serving more vegetables.
The BRA Study 5
Table I. Descriptive data of the kindergartens in the BRA Study and the kindergarten population in Vestfold and Buskerud counties.
Kindergartens in the BRA Study
(N = 69)c
Kindergartens in Vestfold and
Buskerud counties
(N = 568)a
Number of kindergartens (percent) Number of kindergartens (percent)
Public kindergartens 31 (44.9) 235 (41.4)
Private kindergartens 38 (55.1) 333 (58.6)
Five-a-day-kindergartensb28 (41.1) 266 (46.8)
Mean + SD Mean
Full-time equivalent 13.9 + 6.4 12.5
Full-time equivalent educated as kindergarten
teacher
5.9 + 3.1 4.1
aStatistics Norway (2014), includes all kindergartens in Vestfold and Buskerud, including those that did not meet the criteria.
b Five-a-day kindergartens is a concept created by the Norwegian Fruit and Vegetable Marketing eBoard and provides supporting material
to the kindergartens for the promotion of fruit and vegetable consumption.
cBased on answers from the kindergarten leader.
SD: standard deviation.
Table II. The dependent variables: variation, frequency and amount of vegetables served in the kindergartens in the BRA Study (n = 66).
Median (percentiles)aNormality testb
p-value
Variation per month 8 (6.5;10) .098
Frequency per week 6.3 (5;8) .005
Amount per person per day (g) 36.4 (25.6;48.9) .045
Amount per person per day (g)
< 30 g 30.1–59 g 60 g >
N23 33 7
Variation median (percentiles)a8 (5.5;9.5) 7.8 (6.7;10) 10 (7.7;10.5)
p-value .352
Frequency median (percentiles)a5 (2.3;7.1) 6.8 (6;8) 6.8 (5.5;7)
p-value .021
aTukey’s hinges.
bShapiro–Wilk test.
cStatistics Norway (2014), includes all kindergartens in Vestfold and Buskerud, including those that did not meet the criteria [22].
d Five-a-day kindergartens is a concept created by the Norwegian Fruit and Vegetable Marketing eBoard and provides supporting material
to the kindergartens for the promotion of fruit and vegetable consumption.
eBased on answers from the kindergarten leader.
fChildren are attending kindergarten five days a week – frequency given in the table is for times per week.
Kindergartens with more than NOK 251 in addi-
tional payments had a larger frequency of vegetables
served and a higher amount of vegetables eaten com-
pared to those with additional payment of less than
NOK 251. Unexpectedly, those kindergartens that
did not ask for such additional payment had a larger
variety in vegetables served compared to those that
did ask for additional payment. This may indicate
that it is not only the economic resources that matter
when buying and serving vegetables. Our results
showed that in 53 out of 62 kindergartens, the
employees paid a monthly fee for food and beverages,
and a larger amount of vegetables was eaten. The
higher amount of vegetables eaten may be explained
by adults eating with the children, thus contributing
to a larger average amount of vegetables eaten.
Another explanation might be the positive effect of
modelling [20], or by children eating more when the
staff eat together with them [19].
For the associations found in the economic envi-
ronment, one may conclude that increasing the addi-
tional payment for food might be a good strategy. On
the other hand, this strategy might increase social
inequalities by lower socioeconomic groups opting
for kindergartens with a lower additional payment for
food. Taking into consideration experience from other
6 Himberg-Sundet et al.
Table IV. Factors in the political food environment in the kindergarten, and vegetables served or eaten (n = 66).
NVariation Frequency Amount
Median
(percentiles)b
p-value Median
(percentiles)b
p-value NMedian
(percentiles)b
p-value
1) Written guidelines: food and
beverages brought from home
Yes 42 7.5 (6;10) .197a5.8 (4;7) 42 38.9 (24.3;51.6)
No 22 9 (7;11)
8
7.5 (6.3;8) .001a22 36.2 (29.5;46.3) .562a
Food and beverage that’s offered Yes 55 (6.5;10) 6 (5;8) 54 38.9 (27;51.6)
No 9 9 (7;9) .635a6.8 (6.3;7.8) .373a10 32.8 (9;40) .046a
Mealtime setting Yes 41 7.5 (6;9) 6 (4.3;8) 41 39.8 (29.4;51.6)
No 21 9 (7;11) .072a6.3 (5.5;7.8) .479a21 31.2 (24;41.8) .091a
2) Who has developed the
guidelines: the entire staff
group?
Yes 19 8 (6.6;10) 6 (5.5;7.5) 18 39.2 (30.8;51.3)
No 47 8 (6.3;10) .955a6.3 (4.6;7.9) .645a48 36.2 (23.9;49.9) .536a
3) Knowledge of national
guidelines
Yes 61 8 (6.5;10) 6.3 (5;8) 59 36.4 (25.6;48.4)
No 5 8 (7;11) .653a6 (5.5;7) .827a7 51.3 (41.3;72.1) .075a
4) To what degree are the national
guidelines used in developing
own guidelines?
Small 7 10 (9;11) 6 (5.3;6.6) 8 42 (25.6;72.1)
Neither 12 9 (6.8;9.5) 6.8 (4.8;9) 13 38.5 (36;51.3)
Large 44 7.7 (6;10) .259c6.2 (5;7.9) .576c41 36.5 (24.3;47.9) .568c
aAsymp. Sig. (two-tailed) Mann–Whitney U test.
bTukey’s hinges.
cAsymp. Sig. Kruskal–Wallis H test.
Note: < 4 missing within variation and frequency data; < 4 missing within the amount data.
Table III. Factors in the economic food environment in the kindergarten, and vegetables served or eaten (n = 66).
Variation Frequency Amount
NMedian
(percentiles)b
p-value Median
(percentiles)b
p-value NMedian
(percentiles)b
p-value
1) Food supplies are covered
through: maximum parents’ fees
Yes 11 10 (8;11.8) 5.3 (5;9) 12 36.2 (31;52)
No 55 7.7 (6;10) .046a6.3 (5;7.5) .945a54 36.8 (24.3;50.7) .690a
Additional parental payment to cover
expenses for food and beverages
Yes 59 7.8 (6;10) 6.2 (5;7.5) 58 36.8 (24;51.3)
No 7 10 (8.5;11.8) .045a6.3 (5.1;9) .552a8 36.2 (32.3;44.5) .651a
2) Additional parental payment
to cover expenses for food and
beverages
< 250 NOKd 29 8 (6;10) 5 (3.5;7) 30 27 (15;57.7)
> 251 NOKd 36 8 (7;10) .450a6.8 (6;8) .014a34 39.9 (31.8;50.7) .027a
3) Freedom within the food budget: I
can use the budget as I wish
Agree 29 9 (7;10) 7 (5.5;9) 30 45.2 (29.5;57.7)
Neither 12 9 (7;10.5) 5.8 (4.5;6.8) 11 41.8 (27.5;46.2)
Disagree 25 7 (5;9) .033c6.2 (4;7.3) .166c25 31.3 (15.2;37) .010c
There are rules for how I distribute
the budget
Agree 27 8 (6.8;10) 6 (5;7) 25 36.5 (24.5;47.9)
Neither 12 6.8 (6;7.9) 6.2 (2.5;7.1) 13 42.7 (24.3;46.3)
Disagree 26 9 (7;10) .248c7 (5;8) .291c27 36.4 (27.5;53.5) .759c
The budget covers the kind of food
we want to offer
Agree 36 8 (6;10) 6.1 (5;7.3) 35 41.8 (29.5;53.6)
Neither 5 10 (7;12) 5 (4;6.8) .668c5 39.8 (14.9;45.8)
Disagree 24 7.7 (6.8;10) .409c6.6 (3.3;8.5) 25 31.8 (23.7;42.7) .150c
I am free to use other budgets on
food
Agree 40 8.8 (6.6;10) 6.1 (5;8) 38 36.4 (24.1;51.6)
Neither 13 7.7 (6;9.6) 7.1(5;8) 13 33.4 (30.8;42.6)
Disagree 13 7 (6.5;10) .500c6 (5;6.8) .672c15 41.8 (27.1;55.8) .508c
4) Employees pay a monthly fee for
food and beverages
Yes 53 8 (7;10) 6.5 (5.3;8) 52 39.9 (30.3;51.5)
No 9 6 (5;9) .079a4 (2.5;7.3) .113a10 27 (9;30.8) .017a
5) Monthly fee for employees (food
and beverages)
< 250 NOKd 37 8.5 (7;10) 6.3 (5;8) 36 36.7 (25.5;48.5)
> 251 NOKd 13 7.5 (6.5;9) .375a7 (6;7.8) .527a13 40 (36.4;51.3) .287a
aAsymp. Sig. (two-tailed) Mann–Whitney U test.
bTukey’s hinges.
cAsymp. Sig. Kruskal–Wallis H test.
dNorwegian kroner.
Note: < 3 missing within the variation and frequency data; < 4 missing within the amount data.
The BRA Study 7
Nordic countries, the Finnish kindergarten setting is
quite unique [24] with both nutrition-specific guide-
lines and all meals included in the maximum parental
fee [25]. Still, research points to low vegetable intake
among children in kindergartens in Finland [24,26].
These findings can imply that vegetable consumption
may also be affected by factors other than the econ-
omy [24,25]. Freedom when setting up the food
budget was also associated with a larger variety of veg-
etables served and a larger amount of vegetables
eaten. An explanation for this might be that the kin-
dergarten leaders participating in this study are more
personally interested in providing healthy food and
this budgetary freedom enables them to act upon it.
The political environment
In the present study, having written guidelines for
meals served in the kindergartens was positively asso-
ciated with vegetable consumption. This is in line
with the national survey, where more fresh vegetables
were served in kindergartens with written guidelines
for the mealtime setting [14]. However, a review
conducted in 2011 found that four out of 11 studies
explored guidelines and recommendations related
to the environment affecting nutrition and food
served in child care settings [18]. Moreover, two of
these found an insufficient intake of vegetables and
only one of the four found an adequate serving of
fruit and vegetables, despite having food-specific
recommendations, policies or written guidelines to
follow [18]. We also found associations indicating a
higher frequency of vegetables served in kindergar-
tens without written guidelines for food and bever-
ages brought from home. This might be explained
by a lack of need for such guidelines in kindergar-
tens that serve a higher frequency of meals and,
thus, also vegetables. This hypothesis was tested,
and we found that kindergartens serving meals more
frequently, compared to those kindergartens with
food brought from home, also served vegetables
more frequently (data not shown).
Table V. Factors in the physical food environment in the kindergarten, and vegetables served and eaten (n = 66).
NVariation Frequency Amount
Median
(percentiles)b
p-value Median
(percentiles)b
p-value NMedian
(percentiles)b
p-value
1) Barriers for using vegetables:
I do not buy vegetables because
they are too expensive
Agree 16 8.5 (7.3;10) 7.3 (6.7;9) 17 31.8 (23.7;41.8)
Neither 13 7 (6;8) 5 (3;6) 14 43.1 (27.1;49)
Disagree 37 8.5 (6;10) .335c6.2 (5;7.8) .008c35 36.4 (27.4;53.2) .404c
I do not buy vegetables because
they do not look fresh
Agree 10 8 (6.7;10) 6 (5.5;9) 11 44.7 (33.2;48.5)
Neither 15 7.8 (7;9.3) 7.1 (6.7;8) 15 36.7 (28.3;48.6)
Disagree 41 8 (6;10) .979c6 (4;7.3) .070c40 34.7 (24.2;51.2) .819c
I do not buy vegetables because
they are hard to keep fresh
Agree 17 7 (7;10) 6 (5.5;7.3) 18 36.2 (26.9;44.7)
Neither 10 7.4 (6;9) 6.2 (5;7.3) 11 29.5 (19.3;44.9)
Disagree 39 8.5 (6.3;10) .821c6.3 (5;8) .961c37 39.3 (29.4;54.9) .219c
I do not use vegetables because
they are too time consuming to
use in my daily cooking
Agree 7 6 (5.5;8.5) 6.2 (4.3;8) 7 25.7 (26;42.9)
Neither 5 8 (5.5;10) 7.3 (5.5;7.8) 5 31.8 (17.3;49)
Disagree 54 8.3 (7;10) .465c6.2 (5;8) .895c54 37.6 (27;51.3) .799c
I do not use vegetables because
they are difficult to include in
my daily cooking
Agree 3 11 (9.5;11.5) 7.8 (6.9;8.9) 3 31.3 (21.2;40)
Neither 3 5.5 (5.3;6.8) 2.5 (1.5;6.3) 3 27 (22.2;38.1)
Disagree 60 8 (6.5;10) .093c6.2 (5;7.6) .341c60 36.8 (27;51.3) .658c
2) How many staff have the
primary responsibility to:
Determine the food and
beverage offer
1 person: 9 8.5 (7;10.5) 6 (5;9) 17 33.4 (27;51.3)
> 1 person: 47 7.8 (6;10) .235 6.3 (5;7.3) .383 49 36.7 (24.3;48.8) .753
Plan the food and beverage
offer
1 person: 8.5 (6.3;10.5) 6.3 (4.6;8.5) 18 30.4 (24.1;54.8)
> 1 person: 47 8 (6.5;10) .555 6.2 (5;7.5) .681 48 37.8 (27.5;49.9) .481
Order food and beverages 1 person: 15 10 (7.2;11.3) 5.3 (5;6.8) 13 29.4 (16.3;45.8)
> 1 person: 51 7.7 (6;9.8) .090 6.4 (5.1;8) .263 53 37 (27.9;50.7) .249
Prepare the food 1 person: 43 8 (6;10) 6 (4.1;7.9) 43 33.4 (23.9;44.2)
> 1 person: 23 8.5 (7.2;10) .341 6.4 (5.8;7.6) .462 23 44.7 (31;51.5) .091
3) Dedicated kitchen staff Yes 11 10 (7.7;11.3) 5.3 (5;7) 9 31.8 (29.5;54.8)
No 55 7.8 (6;10) .078a6.3 (5;8) .262a57 36.7 (26.9;48.8) .661a
aAsymp. Sig. (two-tailed) Mann–Whitney U test.
bTukey’s hinges.
cAsymp. Sig. Kruskal–Wallis H test.
Note: 0 missing within variation and frequency data; 0 missing within the amount data.
8 Himberg-Sundet et al.
The physical environment
Previous studies have shown that availability is posi-
tively associated with children’s consumption of veg-
etables [20,25,27]. This study assessed the physical
environment through barriers for serving vegetables
in kindergarten, and, unexpectedly, those that agreed
to the statement “I do not buy vegetables because
they are too expensive” had the highest frequency of
serving vegetables. A potential explanation might be
that the Norwegian population is more concerned
about eating healthily than the associated costs.
However, the costs are also an important factor [28].
A Norwegian case study found that the physical struc-
tures, such as who is organizing and planning the
meals, were important factors for the food and meals
provided by the kindergarten [21], but in our study
we did not find an association with the number of
people involved in various parts of this process. The
physical environment was assessed through three
questions, as shown in Table V. The item pool used to
assess barriers was composed of modified versions of
statements used in an American study among par-
ents of preschool children [29]. For the question
regarding “How many have the primary responsibil-
ity to…” in Table V, the number of persons for each
task was collapsed into “one person” or “more than
one person”. In this study, the physical environment
has not measured the availability of vegetables, but
rather the barriers to serving vegetables and how
many employees are responsible for planning and
organizing the food.
The sociocultural environment
Contrary to previous research [19,20,27], we did not
find any significant associations between the socio-
cultural environment and vegetables served and
eaten. In this study, data were collected at a higher
institutional level compared to previous studies
[19,20,27]. Moreover, different methodologies when
assessing this environment may also have contrib-
uted to such discrepancies. In the present study we
assessed this environment by questionnaires, but
others have assessed this environment through, for
example, direct observations [19]. In addition, previ-
ous environmental studies have measured other fac-
tors in this environment, such as staff behavior,
supervision practice and food serving style [19],
nutrition education and support for healthy eating
[30], and parenting styles and practices [27].
Strengths and weaknesses of the study
This study was conducted in an understudied age
group and context. Furthermore, the sample of kin-
dergartens represented in this study was almost the
same share of public, private and five-a-day kinder-
gartens as the total kindergarten population in the
Table VI. Factors in the sociocultural food environment in the kindergarten, and vegetables served and eaten (n = 66).
Variation Frequency Amount
NMedian
(percentiles)b
p-value Median
(percentiles)b
p-value NMedian
(percentiles)b
p-value
1) To what degree do new
employees learn how to
interact with the children
in mealtime situations?
Low: 14 8 (6.5;9.6) 6 (4;7.3) 17 36.4 (26.9;44.7)
Average: 15 7.7 (6;8.8) 6.3 (5.3;7) 15 36.7 (28.3;53.7)
High: 34 8.8 (6.7;11) .287c6.4 (5;8) .813c34 37.5 (24.3;51.3) .777c
2) To what degree do you
think…
you need to improve the
practical part regarding
meals, food and beverages
in your kindergarten?
Small/neither:
48
8 (6.8;10) 6.3 (5;7.9) 49 36.5 (27;51.6)
Large: 18 7.3 (5.5;10) .386a6.1 (4;8) .708a17 36.7 (20.5;42.7) .281a
you are competent to guide
the employees in what a
healthy diet for children is?
Small/neither:
25
8 (7;10) 6 (4.3;8) 26 36.5 (26.9;47.9)
Large: 41 8 (6;10) .952a6.3 (5;7.3) .638a40 36.7 (25.3;54.9) .646a
it’s important for you to
guide the employees in
what a healthy diet for
children is?
Small/neither:
13
8 (6.5;9) 6 (4;8) 12 33.6 (20.8;36.8)
Large: 53 8 (6.6;10) .871a6.3 (5;7.3) .872a54 39.6 (27;51.6) .130a
aAsymp. Sig. (two-tailed) Mann–Whitney U test.
bTukey’s hinges.
cAsymp. Sig. Kruskal–Wallis H test.
Note: < 3 missing within variation and frequency data; < 1 missing within the amount data.
The BRA Study 9
two participating counties. Information about vege-
table consumption and the environment was col-
lected with three instruments and answered by staff
working at different levels in the kindergarten, giving
a more holistic dataset.
However, the sample of kindergartens presented in
this study might have had a greater interest in food
and nutrition or been more engaged in projects and/
or research participation. The measurement instru-
ments were piloted, but not tested for reliability and
validity. The amount of vegetables eaten was collected
by a five-day vegetable diary, which could be filled in
by anyone working in the department. This could
have impacted the consistency of how the data were
reported. Additionally, the amount of vegetables
weighed after the meal did not include vegetables that
were left on the children’s plates or that had fallen
onto the floor. This might have contributed to an
overestimation of the amount of vegetables eaten.
Moreover, when adults eat the vegetables served, they
potentially eat larger portions compared to the chil-
dren, which contributes to a higher amount of vegeta-
bles eaten in total. The questionnaires used were
primarily based on items used in the last national
dietary survey in kindergartens [14], ensuring com-
parability across studies in Norway. However, since
the ANGELO framework was not applied in develop-
ing the questionnaire, limited aspects of each environ-
ment were covered.
Conclusion
This study indicates that the economic environment
in kindergartens seems to be positively associated with
the vegetables served and eaten in those kindergar-
tens. Also, the political environment seems to be
important for the servings and intake of vegetables in
kindergartens. This is of high relevance for public
health policy as vegetable consumption is an impor-
tant factor in reducing the risk of NCDs. The lack of
associations within the sociocultural and physical
environments may be explained by factors being
assessed at a more distal level of the organization.
Furthermore, studies of how environmental factors
interact or are mediated by one another may also be
necessary in order to better understand their influence
on the variety, frequency and intake of vegetables.
Acknowledgements
We would like to thank all the participants who took
part in this study and the research team members.
Declaration of conflicting interests
The author(s) declared no potential conflicts of
interest with respect to the research, authorship, and/
or publication of this article.
Funding
The authors disclosed receipt of the following finan-
cial support for the research, authorship, and/or
publication of this article: This work was supported
by the Norwegian Research Council (228452/H10),
with supplementary funds from the Throne Holst
Nutrition Research Foundation, University of Oslo,
Norway.
References
[1] World Health Organization. Global status report on noncomu-
nicable diseases 2014: “attaining the nine global noncomunicable
diseases targets; a shared responsibility”. Geneva: World Health
Organization, Geneva 2014.
[2] OECD. Determinants of health. In: Health at a glance:
Europe 2012, pp. 49–64, OECD Publishing, 49–64, OECD
Publishing. 2012.
[3] European Commision. Green paper, “Promoting healthy diets
and physical activity: a European dimension for the prevention of
overweight, obesity and chronic disease”. Brussels: Commision of
the European Communities, 2005, http://ec.europa.eu/health/
ph_determinants/life_style/nutrition/documents/nutrition_gp_
en.pdf.
[4] Norwegian Ministries. The Norwegian Action Plan on
Nutrition (2007–2011): recipe for a healthier diet. Oslo:
Norwegian Ministries, 2007.
[5] World Health Organization. 2008–2013 Action plan for the
global strategy for the prevention and control of noncommunicable
diseases. Geneva: WHO, 2008.
[6] Norwegian Directorate of Health. Norwegian recommenda-
tions on diet, nutrition and physical activity [in Norwegian].
Oslo: Norwegian Directorate of Health, 2014.
[7] Kristiansen AL, Lande B and Andersen LF. Småbarnskost
2007 – dietary habits among 2-year-old children in Norway [in
Norwegian]. Oslo: University of Oslo, 2009.
[8] Hansen LB, Myhre JB and Andersen LF. UNGKOST 3 –
dietary habits among 4-year-olds [in Norwegian]. Oslo: University
of Oslo, 2016, https://www.fhi.no/globalassets/dokumenterfiler/
rapporter/rapport-ungkost-3-landsomfattende-kostholdsun-
dersokelse-blant-4-aringer-i-norge-2016.pdf.
[9] Craigie AM, Lake AA, Kelly SA, etal. Tracking of obesity-
related behaviours from childhood to adulthood: a system-
atic review. Maturitas 2011;70:266–84.
[10] Norwegian Ministry of Education and Research. Guide-
lines for the kindergartens content and tasks [in Norwegian].
Oslo: Norwegian Ministry of Education And Research,
2011.
[11] Birch LL. Development of food preferences. Annu Rev Nutr
1999;19:41–62.
[12] Norwegian Directorate of Health. Guidelines for food and
meals in the kindergarten. Oslo: Norwegian Directorate of
Health, 2007.
[13] Norwegian Directorate of Health and social affair. Food and
meals in the kindergarten – survey among kindergarten lead-
ers and pedagogical leaders. Oslo: Norwegian Directorate of
Health, 2005.
[14] Norwegian Directorate of Health. Meals, physical activity
and environmental health care in kindergartens 2012. Report
no. IS-0345. Oslo: Norwegian Directorate of Health,
2012.
[15] Statistics Norway. Kindergartens, 2016: nal numbers. Oslo:
Statistics Norway, 2016.
[16] Swinburn B, Egger G and Raza F. Dissecting obesogenic
environments: the development and application of a frame-
work for identifying and prioritizing environmental inter-
ventions for obesity. Prev Med 1999;29:563–70.
[17] Johnson BJ, Hendrie GA and Golley RK. Reducing dis-
cretionary food and beverage intake in early childhood: a
10 Himberg-Sundet et al.
systematic review within an ecological framework. Public
Health Nutr 2015;19:1684–95.
[18] Larson N, Ward DS, Neelon SB, et al. What role can
child-care settings play in obesity prevention? A review of
the evidence and call for research efforts. J Am Diet Assoc
2011;111:1343–62.
[19] Gubbels JS, Kremers SP, Stafleu A, et al. Child-care envi-
ronment and dietary intake of 2- and 3-year-old children. J
Hum Nutr Diet 2010;23:97–101.
[20] Holley CE, Farrow C and Haycraft E. A systematic review
of methods for increasing vegetable consumption in early
childhood. Curr Nutr Rep 2017;6:157–70.
[21] Aadland EK, Holthe A, Wergedahl H, etal. Physical factors
impact on the food and meal offer in the kindergarten – a
case study. Nordic Early Childhood Education Research Jour-
nal 2014;8:1–17.
[22] Statistics Norway. Kindergartens, 2016: nal numbers. Oslo:
Statistics Norway, 2014.
[23] The Norwegian Directorate for Education and Training.
Parental fee. Oslo: Norwegian Directorate for Education and
Training, 2017.
[24] Dahl T and Jensberg H. Diet in schools and kindergartens
and the significance for health and learning – an overview.
Norden 2011; 534, http://norden.diva-portal.org/smash/get/
diva2:700700/FULLTEXT01.pdf.
[25] Ray C, Määttä S, Lehto R, etal. Inuencing factors of children’s
fruit, vegetable and sugar-enriched food intake in a Finnish preschool
setting – preschool personnel’s perceptions. Appetite, Elsevier, 2016.
[26] Erkkola M, Kronberg-Kippila C, Kyttala P, et al. Sucrose
in the diet of 3-year-old Finnish children: sources, deter-
minants and impact on food and nutrient intake. Br J Nutr
2009;101:1209–17.
[27] Brug J, Kremers SP, Lenthe F, etal. Environmental determi-
nants of healthy eating: in need of theory and evidence. Proc
Nutr Soc 2008;67:307–16.
[28] Norwegian Directorate of Health. Utviklingen i Norsk kosthold
[Development in the Norwegian diet 2016]. Oslo: Norwegian
Directorate of Health, 2016.
[29] Baranowski T, Beltran A, Chen T-A, et al. Psychometric
assessment of scales for a Model of Goal Directed Vegetable
Parenting Practices (MGDVPP). Int J Behav Nutr Phys Act
2013;10:110.
[30] Ammerman AS, Ward DS, Benjamin SE, et al. An inter-
vention to promote healthy weight: Nutrition and Physi-
cal Activity Self-Assessment for Child Care (NAP SACC)
theory and design. Prev Chronic Dis 2007;4:A67.
