Accompanying the Primary Grocery Shopper Is Positively Related to Requests for Purchase of Fruits & Vegetables in Third & Fourth Grade Students

Consumption of fruits and vegetables is important for growth and development yet intake remains below recommended levels in children in the US. The purpose of this study was to determine whether children accompanying the primary grocery shopper impacts requests for fruit and vegetables and if those children requesting fruits and vegetables like to consume them on a daily basis. A cross-sectional survey design of matched pairs of thirdand fourth-grade students and their parents/guardians in an urban Midwest school district was utilized. Thirdand fourth-grade participants who asked for fruits and vegetables were more likely to accompany the primary grocery shopper and more prone to liking these key foods as part of their regular diet. Grocery shoppers should consider taking children along when food shopping, emphasizing strategies to find a variety of fruits and vegetables.


Introduction
Fruits and vegetables are important sources of nutrients in childhood as well as adulthood and are an essential part of a well-planned diet.Healthy dietary intake (including meeting recommendations for fruit and vegetable intake) is important for growth and development including maintaining a healthy weight and preventing obesity, overweight, and subsequent chronic diseases [1].Health behaviors, including dietary intake, during the years of growth and development can influence health in adulthood, since poor dietary habits in childhood often continue into adulthood [2] [3].
Fruit and vegetable intake remains below recommended levels in children and adults in the United States [4]- [8].The current Dietary Guidelines for Americans recommend 1.5 cups of fruit and 2.5 cups of vegetables per day for an 1800 calorie food pattern intended for children 9 to 13 years of age [9].Less than 25% of children between the ages of 9 and 12 years consume recommended servings of fruits and vegetables each day [10].
Parental knowledge of recommendations related to fruit and vegetable intake, promotion of healthy foods by parents or caregivers (such as fruits and vegetables), and parents' health attitudes and food involvement positively influence children's eating patterns [11]- [14].In addition, the types of foods parents procure for consumption at home are influenced by parental nutritional knowledge and health attitudes [15] [16] and availability of fruits and vegetables at home enables higher consumption [17]- [20].
There are multiple influences on dietary behavior and food choices including biological (taste, hunger, and satiety), social-affective context (social conditioning, parenting practices), intra-and inter-personal determinants (beliefs, attitudes, family relationships), social and environmental factors (availability, accessibility), and economic considerations (price, education, and income) [19] [21]- [23].These factors, including the person-related determinant of child food preferences, affect food purchasing patterns of parents of school-age children [21] [24].Because parents are the gatekeepers for food availability in the home, determining factors that may increase parental purchasing intentions of fruits and vegetables can provide valuable information for nutrition educators [25].
Parents, or caregivers, who fill the role of primary grocery shopper, determine the foods available at home and ultimately, what to purchase.Therefore, the purchasing decisions of the primary grocery shopper will influence the availability of fruits and vegetables for consumption.This study utilized social-cognitive theory to determine whether children accompanying the primary grocery shopper will impact requests for fruit and vegetables and if those children requesting purchase of fruits and vegetables like to consume fruits and vegetables on a daily basis.Researchers hypothesized those children who asked the primary grocery shopper to purchase fruits and vegetables would be with parents/guardians more often in the grocery store.Researchers also hypothesized that children who asked for more fruits and vegetables would like to eat fruits and vegetables every day.

Sample
Participants in the study included third and fourth-grade students enrolled at Midwest elementary schools and their parent/guardians.Participants were recruited from four randomly selected schools of eight in a US Midwest school district.Random selection of schools was completed via cluster sampling [26].Of 475 distributed surveys, 233 (49%) were returned by matched pairs of parent/guardians and students during spring, 2009.Missing data for either children or parent/guardian responses resulted in the elimination of an additional seven surveys.There were 226 paired surveys included in the analysis.Sample size minimum was not calculated prior to distribution of the surveys.

Procedure
A previously validated questionnaire (using intra-class correlation coefficients, Cronbach's α, and Spearman correlations) for examining the factors that influence intake of fruits and vegetables from the child's perspective [27] was adapted and pilot-tested before finalization for the study.This survey was provided for child participants.The 10-item student survey included five questions pertaining to fruit and five identical questions specific to vegetables.Student consumption and availability for fruits or vegetables was assessed using a 5-point scale from strongly agree to strongly disagree and yes/no questions, and likelihood of parental purchase of fruit or vegetables was assessed using a scale from always to never.The parent survey was developed after a literature review of identified factors that influence food choices [15] [28]- [32].The 8-item parent survey included demographic questions, frequency of children accompanying parents in the grocery store on a 5-point scale from always to never, and rank-order regarding factors that determine purchasing decisions.The developed parent survey is presented in Table 1.Both student survey and parent survey were pilot tested and modified prior to finalization for the study.Pilot testing included eight 3 rd and 4 th grade students and ten parents of students, all with similar background as participants, from another school in the district not participating in the study.The pilot school was located in the same district and had similar demographics to participating schools.Survey packets, which included the child survey, parent survey, and consent forms, were distributed by classroom teachers.Students returned the completed surveys to the school, along with the signed parental permission and child assent forms.While participation in the study was voluntary, stickers were provided to students who returned the survey packet to school (whether completed or incomplete).The university Institutional Review Board and the school district approved the study protocol.All participants provided written informed consent and child assent as required for IRB approval.

Statistical Analysis
Demographic information was summarized using descriptive statistics.In order to normalize the distribution of the data related to accompanying the primary grocery shopper, this question was re-scaled through collapsing from five-point categories (always, usually, sometimes, rarely, and never) to two-point scale (always/usually and sometimes/rarely/never). Correlation analysis was performed between children who asked their parents to buy fruits and vegetables and whether children accompanied parents for grocery shopping (based on the two-point scale).Since there were two groups, independent sample t-test analysis was used to compare children who asked or did not ask their parents to buy fruits and vegetables and their preference for liking to eat fruits and vegetables every day.Data for correlational and t-test analysis was assessed for normality using histogram analysis.Differences in demographic variables were not included in the analysis.Statistical analyses were carried out using SPSS 21.0 (IBM SPSS Statistics for Windows, Version 21.0.Armonk, NY: IBM Corp, 2012).The statistical significance was defined as p < 0.05.
Frequency data for children accompanying the primary grocery shopper indicated respondents had children with them in the grocery store "always" "usually" (36%), "sometimes" (45%), "rarely" (7%), and "never" (1%).Frequency data for grocery store shopping is presented in the Figure 1.Descriptive statistics showed more children asked for fruits (85%) than vegetables (67%) and that the number of children who generally liked to eat fruits at home (on a scale of 1 to 5 with 1 being strongly agree) was higher than the number who liked to eat vegetables (M = 1.97 and M = 2.20, respectively).
Correlation analysis indicated a significant positive relationship between children who asked for fruits and whether they were with parents in the grocery store always/usually or sometimes/rarely/never (r = 0.175, p < 0.01) as well as those who requested vegetables (r = 0.150, p < 0.05).In addition, children who asked for fruits were significantly positively related to children who asked for vegetables (r = 0.601, p < 0.01).Correlation analysis is displayed in Table 3.
Children who asked or did not ask their parents to buy fruits and vegetables were compared on their preference for liking to eat fruits and vegetables every day.Children who asked for fruit from the person who does the grocery shopping were more likely to like fruit on a daily basis (on a scale of 1 to 5 with 1 being strongly

Discussion
Since fruit and vegetable intake remains below recommended levels in both children and adults, it is critical that nutrition professionals identify factors that influence parental purchase of fruits and vegetables.Purchase of fruits and vegetables is the first step in getting fruits and vegetables into the home.Understanding this process will help educators to develop programs that will promote behavior change such as increasing fruit and vegetable consumption.In order to develop programs that promote behavior change such as increased consumption of fruits and vegetables, understanding influencing factors on dietary behaviors is critical [21] [33].This research revealed that third and fourth-grade student participants accompanying the primary grocery shopper was positively correlated with requests to purchase fruits and vegetables.This finding was consistent with the researcher's hypothesis and provides valuable insight for nutrition education efforts that include a focus on consumer shopping habits.Children's requests may influence grocery store purchases, and this study revealed that third and fourth-grade student participants being present in the grocery store environment with the primary grocery shopper was significantly correlated with child requests for fruits and vegetables.Increased purchasing of fruits and vegetables promotes availability for consumption in the home.Home food availability of fruits and vegetables is associated with improved intake in children and adolescents [17]- [20].
Accompanying the primary grocery shopper may pose other dietary challenges such as the increased likelihood of children's requests for sweets and snacks instead of fruits and vegetables [24] and the challenge of trying to restrain child requests rather than fulfill child desires [34].In addition, children may be more likely to be influenced by advertising techniques often used in food purchasing environments including cartoon characters on food packaging [35].However, previous research has shown that children are interested in the grocery store environment (particularly the produce section) and that the grocery store can be a potential learning opportunity for children [24].Additionally, young children may influence the food purchasing, preparation, and consumption of healthy foods such as fruits and vegetables if those foods are encouraged or sampled in a childcare or school environment [14] [36].For nutrition educators, including methods for promoting healthy food intake and education using the food purchasing environment as well as encouragement of fruit and vegetable intake in formal childcare and school settings may be beneficial for dietary behavior outcomes [37].
The findings of the current study also indicated that third and fourth-grade student participants who requested the purchase of fruits and vegetables also liked to eat fruits and vegetables every day.Whether this was due to parental intake of fruits and vegetables, parent education levels, food involvement, or exposure to fruits and vegetables at school or home was not determined from this study.However, previous studies have linked intake of fruits and vegetables (amount and variety) with parents who have high levels of food involvement (the level of importance of food in a person's life), knowledge of fruit and vegetable recommendations, promotion of healthy foods, and health attitudes [11]- [14].In addition, those parents who prioritize natural or whole, nutrient-dense, high-fiber, low calorie foods have children with higher intake of nutrient-dense foods such as fruits and vegetables [38].This provides insight for nutrition educators to plan education and programming to include a focus on parental knowledge, food involvement, and promotion techniques for use with children.

Limitations
Limitations to this study included limited racial/ethnic diversity in the study sample since 90% of participants were White.However, this racial/ethnic percentage is similar to the demographics of the city's population.In addition, participants included only third-and fourth-grade students and parent/guardians resulting in less variation due to physical and cognitive development of the child participants.Future studies may include students from a variety of grade levels and additional qualitative and quantitative questions for parents regarding why the child accompanied the parent to the grocery store and the impact of children's food preferences on food purchasing patterns.

Conclusion
Overall, the findings of the study indicate third and fourth-grade student participants accompanying the primary grocery shopper to the food purchasing environment is positively related to whether they ask for fruits and vegetables to be purchased.Parent/guardians who are the primary grocery shopper may be influenced by children accompanying them when it comes to fruit and vegetable purchases.In addition, it appears that third and fourth-grade student participants who are requesting the purchase of fruits and vegetables are more apt to eat them on a daily basis.Including children in the food purchasing environment may have a positive influence on fruit and vegetable procurement and should be considered in nutrition education efforts.Healthcare and school professionals should encourage families to consider taking children along when food shopping, emphasizing strategies to find a variety of fresh, frozen, and canned fruits and vegetables.

Table 1 .
Parent/guardian questionnaire.1)How many of your children are currently enrolled in 3 rd and 4 th grade?If you have had packages of fruits or vegetables with the picture of a cartoon character like Sponge Bob or Dora the Explorer on it at home, has your child/children eaten more of the fruits and vegetables from these packages?
Yes NoWe don't have packages at home with cartoon characters 8) What determines your purchasing decision when it comes to fruits and vegetables?(Please rank them in order, 1 meaning the

Table 2 .
Demographic characteristics of parent/guardians of third-and fourth-grade students (n = 226).
* Some college is defined as schooling beyond a high school diploma but less than a 2 or 4-year college degree.

Table 3 .
Correlation analysis among third and fourth-grade students.Frequency of accompanying the primary grocery shopper in third-and fourth-grade students (n = 226).agree) than children who did not ask (M = 1.87 and M = 2.66, respectively; t (224) = −4.38,p < 0.01).Children who asked for vegetables were also more likely to like vegetables on a daily basis than the group of children who did not ask (M = 1.88 and M = 2.91, respectively; t (224) = −7.23,p < 0.01).
* Correlation is significant at the 0.05 level; ** correlation is significant at the 0.01 level.Figure 1.