text:
Previous induced abortions and the risk of very preterm delivery: results of the EPIPAGE study
Dr C. Moreau, INSERM U569, Hôpital de Bicêtre, 82 avenue du Général Leclerc, 94276 Le Kremlin Bicêtre Cedex, France.
Objectives To evaluate the risk of very preterm birth (22–32 weeks of gestation) associated with previous induced abortion according to the complications leading to very preterm delivery in singletons.
Design Multicentre, case-control study (the French EPIPAGE study).
Setting Regionally defined population of births in France.
Sample The sample consisted of 1943 very preterm live-born singletons (<33 weeks of gestation), 276 moderate preterm live-born singletons (33–34 weeks) and 618 unmatched full-term controls (39–40 weeks).
Methods Data from the EPIPAGE study were analysed using polytomous logistic regression models to control for social and demographic characteristics, lifestyle habits during pregnancy and obstetric history. The main mechanisms of preterm delivery were classified as gestational hypertension, antepartum haemorrhage, fetal growth restriction, premature rupture of membranes, idiopathic preterm labor and other causes.
Main outcome measures Odds ratios for very preterm birth by gestational age and by pregnancy complications leading to preterm delivery associated with a history of induced abortion.
Results Women with a history of induced abortion were at higher risk of very preterm delivery than those with no such history (OR + 1.5, 95% CI 1.1–2.0); the risk was even higher for extremely preterm deliveries (<28 weeks). The association between previous induced abortion and very preterm delivery varied according to the main complications leading to very preterm delivery. A history of induced abortion was associated with an increased risk of premature rupture of the membranes, antepartum haemorrhage (not in association with hypertension) and idiopathic spontaneous preterm labour that occur at very small gestational ages (<28 weeks). Conversely, no association was found between induced abortion and very preterm delivery due to hypertension.
Conclusion Previous induced abortion was associated with an increased risk of very preterm delivery. The strength of the association increased with decreasing gestational age.
Induced abortion is a relatively common event in France, occurring in 15 out of every 1000 women aged 15 to 44 years per year. This rate has been stable over time and is comparable to that from other European countries.1 There is some concern about the consequences of induced abortion on subsequent childbearing because induced abortion generally occurs at the beginning or middle of a woman's reproductive life. In France, 60% of women who have an induced abortion are younger than 30 years old.2 Therefore, many women probably intend to have a child after one or several induced abortions.
There has been much debate about the impact of induced abortion on subsequent pregnancy outcome as results of earlier studies were inconsistent and failed to draw clear conclusions regarding the obstetric risks following induced abortion.3–5 More recent studies have tended to show an excess risk of preterm delivery associated with induced abortion, with adjusted odds ratios between 1.3 and 2. These studies also suggested that the risk increases with the number of previous abortions.6–9
When analysing the risk factors for preterm delivery, it is important to differentiate the risk according to gestational age. This issue is a major public health concern as infants born before 33 weeks of gestation have a higher risk of morbidity and mortality than more mature babies. In addition, risk factors for very and moderately preterm births have been found to be similar, but the strength of the associations is different, especially for obstetric history.10 However, information concerning the impact of induced abortion on the risk of subsequent very preterm births remains limited. In a study conducted in Australia, Lumley8 found the risk to be higher for extremely preterm delivery (<28 weeks of gestation) than for more mature delivery (≥28 weeks). However, given the infrequency of very preterm delivery, only a few studies have focussed on this particular issue.7,8
The mechanisms by which induced abortions affect the outcome of subsequent pregnancies have rarely been explored. The role of infection and cervical trauma following surgically induced abortion has been discussed.3,11 Several studies have indirectly addressed this question by distinguishing between the risk of spontaneous preterm delivery after induced abortion, expected to be related to infectious mechanisms, and the risk of indicated preterm delivery after induced abortion, which is more often related to vascular complications during pregnancy.7,12,13 However, as suggested by Ancel et al.,14 the distinction between spontaneous and induced delivery only very partially reflects the underlying infectious or vascular complications responsible for preterm delivery.
The present study had two main objectives. The first was to quantify the risk of very preterm birth associated with previous induced abortion in a large population-based case–control study conducted in France in 1997. The second was to investigate differences in the risk of very preterm delivery according to the main pregnancy complications leading to the delivery, with the hypothesis that induced abortion could increase the risk of a subsequent very preterm birth due to infectious11,14–16 or mechanical processes,14,17 but not the risk of very preterm delivery due to vascular causes, especially hypertension.18
This study was undertaken using data from the EPIPAGE study, designed to explore very preterm births, their risk factors and their consequences. Recruitment took place in 1997 in all maternity wards in nine French regions, covering about one-third of all births in France.19 Cases were defined as all births, including stillbirths and late terminations of pregnancies for medical reasons, occurring between 22 and 32 completed weeks of gestation.
Two other groups were also selected in the same regions:
- 1A reference group of infants born alive at 39 or 40 weeks of gestation. Infants born during a one-week period were selected with the following criteria: one live birth at 39–40 weeks out of four was randomly selected from all maternity units in university hospitals and all maternity units with at least 2000 births per year; for all other maternity units, one maternity out of four was randomly selected, and all live births at 39 or 40 weeks from these selected maternities were included.
- 2A group of infants (stillbirths and live births) born at 33 and 34 completed weeks of gestation was used to estimate the variation of risks around 32 completed weeks of gestation. All eligible infants of this group born during a two-month period were included.
Gestational age at delivery was defined as the number of completed weeks of amenorrhea, based on the date of the last menstrual period, confirmed by ultrasonography in almost all cases.19
Women were enrolled during their postpartum stay in the hospital. Information was obtained partly from the medical records and partly by interviewing the mothers during their hospital stay. Data extracted from the medical records included information on maternal age, reproductive and medical history, care and complications of the current pregnancy, delivery and infant's health. The interviews of the mothers provided information on social and demographic characteristics, lifestyle and smoking habits before and during pregnancy.
This study was limited to pregnancies resulting in single births, alive at the beginning of the labour; 717 late terminations and 529 fetal deaths before labour were excluded. The initial sample included 3056 women (<33 weeks: n+ 2103; 33–34 weeks: n+ 294; 39–40 weeks: n+ 659). Women were excluded if one of the key pieces of information from the medical record was missing: 46 with missing information on previous induced abortions, eight with missing information on maternal age, two with missing information on parity and 167 with missing information on outcome of previous pregnancies. Thus, this study included 2837 women (<33 weeks: n+ 1943; 33–34 weeks: n+ 276; 39–40 weeks: n+ 618), of whom 405 (14.3%) had had at least one previous induced abortion.
We first compared the social demographic and obstetric characteristics of the women in the three groups: very preterm births (<33 weeks), moderately preterm births (33–34 weeks) and reference group (39–40 weeks of gestation). The following characteristics, known as risk factors for preterm or very preterm births,10,12,13,20,21 were examined: maternal age, parity and history of preterm delivery, marital status, level of education, employment during pregnancy, smoking habits during pregnancy, weight before pregnancy. Parity and history of preterm delivery were taken into account in a single variable defined in three categories: nulliparous, multiparous with no history of preterm delivery, multiparous with a history of preterm delivery. We looked for associations between previous induced abortion and very preterm delivery, and tested the possibility that the risk of preterm delivery increased with the number of previous induced abortions. Interaction between a history of preterm delivery and induced abortion was examined and the analysis was also performed after excluding women with a history of preterm delivery. We explored the differences in risk of preterm delivery associated with previous induced abortion according to the length of gestation, categorised in three groups as follows: 22–27 weeks, 28–32 weeks, 33–34 weeks. Finally, we estimated the risk of very preterm delivery related to previous induced abortions according to the main complications leading to preterm delivery. For this analysis, we defined six subgroups of women according to the main complication leading to very preterm delivery. Women were assigned to either one of these six categories, designed to be mutually exclusive, according to the following hierarchic order:
- 1hypertension or HELLP syndrome
- 2antepartum haemorrhage, including placenta praevia, placental abruption and blood loss before delivery without any other complication
- 3intrauterine fetal growth restriction without hypertension, placenta praevia or placental abruption
- 4PROM defined as premature spontaneous rupture of the membranes at least 12 hours before the onset of labour without placenta praevia, placental abruption, hypertension or fetal growth restriction
- 5idiopathic spontaneous preterm labour, defined as the onset of labour without hypertension, placenta praevia, placental abruption, fetal growth restriction or PROM
- 6all other cases
The analysis was carried out using univariate and multivariate logistic regression models providing unadjusted and adjusted estimates of the odds ratios of very preterm delivery according to the history of previous induced abortion. Polytomous regression models were used to estimate the odds ratios of very preterm birth by gestational age and by pregnancy complication leading to preterm delivery, with 95% confidence intervals. In all models, the reference group consisted of women whose current pregnancy ended at 39 or 40 weeks of gestation. Multivariate models included the following risk factors for preterm delivery20: maternal age, parity and history of preterm delivery, marital status, level of education, employment during pregnancy, weight before pregnancy and smoking during pregnancy. For several reasons, mainly linked to early neonatal deaths and region of inclusion, some of the women did not complete the interview, thus resulting in missing information on marital status, level of education, employment during pregnancy, smoking during pregnancy and weight before pregnancy. To limit the selection bias and to avoid excluding these women from the analysis, missing data were taken into account in the analysis by creating an ‘unknown’ category for each of these variables.
Statistical analyses were performed using the Stata software.22 The study received the approval of the CNIL (Commission Nationale de l'Informatique et des Libertés).
The social and demographic characteristics and the obstetric history of the women in the three groups are presented in Table 1. Mothers of preterm infants (very preterm or moderately preterm) were younger, had a lower educational level, and were more likely to live alone, to be unemployed and to smoke at the time of the current pregnancy than were mothers in the reference group. They were also more frequently nulliparous and were more likely to report a previous preterm delivery.
Table 1. Characteristics of mothers of very preterm, moderate preterm and control neonates. Values are presented as n (%),a unless otherwise indicated.
|<25 years||540 (27.8)||69 (25.0)||121 (19.6)|
|25–34 years||1098 (56.5)||164 (59.4)||418 (67.6)|
|≥35 years||305 (15.7)||43 (15.6)||79 (12.8)|
|% missing informationb||0.0||0.0||0.0|
|Parity = 0||1002 (51.6)||141 (51.1)||281 (45.5)|
|Parity > 0 with no previous preterm birth||575 (29.6)||86 (31.2)||310 (50.2)|
|Parity > 0 with a history of preterm birth||366 (18.8)||49 (17.7)||27 (4.4)|
|% missing informationb||0.0||0.0||0.0|
|Married||878 (52.6)||101 (45.1)||339 (59.4)|
|Unmarried cohabiting||599 (35.9)||92 (41.1)||191 (33.5)|
|Single||191 (11.5)||31 (13.8)||41 (7.2)|
|% missing informationb||14.2||18.9||7.6|
|Level of education|
|Primary school||112 (7.3)||14 (6.7)||20 (3.6)|
|Secondary||701 (45.4)||97 (46.2)||229 (41.2)|
|High school||312 (20.2)||44 (21.0)||112 (20.1)|
|University||418 (27.1)||55 (26.2)||195 (35.1)|
|% missing informationb||20.6||23.9||10.0|
|Employment during pregnancy|
|Yes||892 (54.2)||136 (61.3)||367 (65.5)|
|No||754 (45.8)||86 (38.7)||193 (34.5)|
|% missing informationb||15.3||19.6||9.4|
|Weight before pregnancy|
|≥45 kg||1500 (92.0)||206 (94.1)||537 (94.7)|
|<45 kg||131 (8.0)||13 (5.9)||30 (5.3)|
|% missing informationb||16.1||20.7||8.3|
|Smoking during pregnancy|
|0 cigarette per day||1022 (64.3)||132 (62.6)||418 (76.0)|
|<10 cigarettes||269 (16.9)||45 (21.3)||71 (12.9)|
|≥10 cigarettes||298 (18.8)||34 (16.1)||61 (11.1)|
|% missing informationb||18.2||23.6||11.0|
Women with a history of induced abortion were at higher risk of very preterm delivery than those with no such history (OR + 1.6, 95% CI 1.2–2.1). Similar results were obtained when controlling for maternal characteristics (Table 2) and when the analysis was performed without adjusting for the history of preterm deliveries (OR + 1.5, 95% CI 1.1–2.0). The association remained unchanged after excluding women with a history of preterm delivery (OR + 1.5, 95% CI 1.1–2.1). The risk tended to increase with the number of past induced abortions (Table 2).
Table 2. Risk of very preterm delivery according to the number of previous induced abortions. Values are presented as n (%), unless otherwise indicated.
|0||1644 (84.6)||555 (89.8)||1|| ||1|| |
|≥1||299 (15.4)||63 (10.2)||1.6||1.2–2.1||1.5||1.1–2.0|
|1||238 (12.2)||56 (9.1)||1.4||1.1–1.9||1.3||1.0–1.8|
|>1||61 (3.1)||7 (1.1)||2.9||1.3–6.5||2.6||1.1–5.9|
The adjusted risk for preterm delivery associated with a history of induced abortion tended to be higher for extremely preterm deliveries (22–27 weeks of gestation) than for other very preterm deliveries (28–32 weeks of gestation); no difference in risk was observed between 28–32 weeks and 33–34 weeks of gestation (Table 3).
Table 3. Risk of very preterm delivery by length of gestation associated with previous induced abortions.
|Reference group (39–40 weeks)||618||10.2||1|| ||1.0|| |
The main complications leading to very preterm births differed according to gestational age (Table 4); PROM and idiopathic spontaneous preterm labour were more frequently observed among the extremely preterm births (22–27 weeks) than among less extreme preterm births (28–32 weeks). Conversely, hypertension and fetal growth restriction were more common among the group of infants born between 28 and 32 weeks than among infants born before 28 weeks. A history of induced abortion significantly increased the risk of very preterm delivery associated with premature rupture of the membranes (OR + 1.7) and placenta praevia (OR + 2.4), but the associations were strongest for extremely preterm delivery (22–27 weeks). The risk of idiopathic spontaneous preterm labour related to past induced abortion (OR + 1.8) was higher in the extremely preterm group than in the other groups. An association between past induced abortion and very preterm delivery related to fetal growth restriction was observed in the group of infants born between 28 and 32 weeks of gestation (OR + 1.7). Finally, no significant associations were found with maternal hypertension (OR + 1.1).
Table 4. Risk of very preterm delivery associated with induced abortion according to the aetiological context leading to delivery.
|Reference group (39–40 weeks)||618|| ||1|| ||618|| ||1|| ||618|| ||1|| |
|Hypertension and HELLP syndrome||77||17||1.4||0.6–2.9||418||28.1||1.0||0.7–1.6||495||25.5||1.1||0.7–1.7|
|Other haemorrhages||0||0.0|| || ||11||0.7||0.8||0.1–6.9||11||0.6||0.8||0.1–6.4|
|Isolated fetal growth restriction||11||2.4||0.6||0.1–5.9||124||8.3||1.7||1.0–3.0*||135||6.9||1.7||1.0–2.8*|
|Idiopathic spontaneous preterm labour||157||34.7||1.8||1.0–3.0*||303||20.3||1.0||0.7–1.6||460||23.7||1.3||0.9–1.9|
|Other||7||1.6|| || ||50||3.4||1.7||0.7–3.8||57||2.9||1.5||0.7–3.2|
We found that a history of induced abortion was associated with a higher risk of very preterm delivery, especially for very preterm births (22–32 weeks) following PROM or placenta praevia, and for extremely preterm births (22–27 weeks) after idiopathic spontaneous preterm labour. Conversely, induced abortion was not associated with an increased risk of very preterm delivery after hypertensive complications.
This study is one of the first to explore the risk of very preterm delivery (<33 weeks of gestation) associated with previous induced abortion. Furthermore, it is the first to study this relationship according to the pregnancy complications leading to very preterm delivery, an important issue that needs to be considered to improve our understanding of the mechanisms by which induced abortion can affect subsequent pregnancies. As the study was geographically defined, it was possible to recruit all very preterm deliveries that occurred in the nine regions included, thus limiting selection bias. Nevertheless, some methodological points need to be discussed.
As commonly reported in fertility surveys based on women's reports, it is likely that induced abortion was under-reported. The extent of under-reporting varies between 40% and 65% in the literature.23 However, in this study, data on previous induced abortion were taken from hospital records that were filled in prior to enrolment, which reduces the risk of differential recall according to gestational age. In a specific study addressing this question in relation to cancer, Tang et al.24 found no differential reporting of induced abortion between cancer cases and controls. In addition, under-reporting varies according to women's social and demographic background and is more common among older women and women living alone, with a low educational level.25–27 Thus, we would expect more under-reporting among cases than among controls, and consequently, an under-estimation of the association.
In the EPIPAGE study, the control group was defined as live births occurring at 39–40 weeks of gestation, instead of a larger definition of deliveries at term, usually defined as 37 to 41 weeks of gestation. Due to this definition, it is possible that women in the control group had a lower level of most risk factors for preterm deliveries than the general population, including a lower frequency of previous induced abortions. Therefore, the relationship between previous induced abortions and very preterm delivery might have been over-estimated. However, using data from the 1998 French national perinatal survey, we checked that the use of controls at 39–40 weeks of gestation rather than ≥37 weeks, only slightly over-estimated the association between induced abortion and very preterm delivery (Ancel, personal communication). In addition, our findings are consistent with other studies.6,7,28
Due to early neonatal deaths, severe complications and difficulties in organising data collection in some units, some women did not complete the postpartum interview, thus resulting in missing information concerning their social and demographic background. The proportion of missing values was higher among cases than controls, but was not linked to a history of induced abortion. Treating missing data of a variable as a category allowed us to include all women in the analysis, thus increasing statistical power. The impact of such an approach is difficult to evaluate. However, in our study, the confounding effect of the characteristics we took into account seems limited as crude and adjusted ORs were very similar. Also, we performed sensitivity analyses by systematically assigning women with missing data either to the highest level of risk (heavy smoker, single, non-active, low weight…) or, on the contrary, to the lowest level of risk: the adjusted OR remained unchanged (OR + 1.5).
The association observed between very preterm delivery and previous induced abortion raises the question of possible residual confounding. However, the main socio-demographic characteristics (level of education, employment, marital status) and lifestyle characteristics (smoking) known as risk factors of preterm delivery have been taken into account in the analysis. Other behavioural characteristics which may be more common among women with a history of induced abortion, such as high risk sexual habits, have been suggested to influence preterm delivery.29 However, studies addressing this question give inconsistent results, showing either no or only weak associations between sexual behaviour and prematurity.
In our analysis, we adjusted for previous preterm deliveries, known to be a major risk factor for a subsequent preterm delivery.20 However, as no information concerning the chronology of the previous pregnancies was available, some of the previous preterm deliveries may also have been linked to an induced abortion that occurred earlier in life, thus resulting in over-adjustment of our model. However, the same analysis without adjusting for previous preterm deliveries gave similar results. Also, the association remained significant after excluding women with a previous preterm delivery.
Our findings are consistent with recent results that gave adjusted odds ratios between 1.3 and 2.7,28 As described by Lumley in Australia,8 we found a tendency for a stronger association with extremely preterm deliveries (22–27 weeks of gestation) than with less extreme gestational ages (28–32 or 33–34 weeks of gestation). Pregnancy complications vary with gestational age, which may explain some of the differences observed. However, very few studies have explored the underlying mechanisms by which induced abortion increases the risk of subsequent preterm delivery (<37 weeks),28 and none have addressed this question concerning very preterm delivery (<33 weeks). Spontaneous preterm delivery, which is expected to be related to infectious mechanisms, and indicated preterm delivery, which is more frequently related to vascular complications, are sometimes preceded by the same pregnancy complications.28 In our study, delivery was induced in 50% of women with placenta praevia and 24% of women with other types of antepartum haemorrhage. Our results improve our understanding of the relationship between induced abortion and very preterm delivery as we tested the association among different subgroups of very preterm births, based on the main complications leading to preterm delivery. Previous studies have suggested that infectious diseases following induced abortion account for the increase in the risk of preterm delivery.15,30 Krohn et al.11 found that women who had previously undergone an induced abortion were at higher risk than other women of intra-amniotic infection, which is a risk factor for PROM.16 This association may result from the revival of latent local infectious processes caused by surgery at the time of the abortion,15 or reveal a mechanical adverse outcome caused by dilatation, leading to cervical incompetence31 with a possible risk of upper genital tract infections.
Cervical instrumentation has also been suggested to increase the risk of endometrial damage, in such a way as to impair trophoblastic invasion and migration, thus increasing the risk of placenta praevia, a major cause of antepartum haemorrhage.17,32 In accordance with our initial hypothesis that an infectious or a mechanical mechanism was involved, we found that induced abortion increased the risk of very preterm delivery due to PROM and placenta praevia and the risk of extremely preterm delivery (<28 weeks) due to idiopathic spontaneous preterm labour. Conversely, no association was found between induced abortion and very preterm delivery due to hypertension. These findings are consistent with the results of a recent multicentre case–control survey conducted in 10 European countries.28 They all suggest that induced abortion could produce cervical and uterine abnormalities, responsible for an increased risk of subsequent preterm delivery. As medical abortion is expected to reduce mechanical injuries, it would be interesting to assess if it also reduces the risk of subsequent preterm delivery. We also found an association between induced abortion and very preterm delivery after fetal growth restriction that was not described in the European study. This needs further investigation.
Our results show that a history of induced abortion increases the risk of very preterm births, particularly extremely preterm deliveries. Both infectious and mechanical mechanisms may be involved, as we found that past induced abortions were more specifically associated with a higher risk of very preterm delivery following PROM and placenta praevia.
The authors would like to thank all women who participated in this survey. The authors also thank all those who contributed to data collection. The study was financially supported by INSERM (National Institute of Health and Medical Research), Merck-Sharp, Dohme-Chibret, la Fondation de la Recherche Médicale (The Medical Research Foundation) and la Direction Génerale de la Santé du Ministère des Affaires Sociales (French Ministry of Health).
Appendix: Composition of the EPIPAGE Group.
INSERM U149: B Larroque (national coordinator), PY Ancel, B Blondel, G Bréart, M Dehan, M Garel, M Kaminski, F Maillard, C du Mazaubrun, P Missy, F Sehili, K Supernant.
ALSACE: M Durand, J Matis, J Messer, A Treisser (Hôpital de Hautepierre, Strasbourg).
FRANCHE-COMTE: A Burguet, L Abraham-Lerat, A Menget, P Roth, J-P Schaal, G Thiriez (CHU St Jacques, Besançon).
HAUTE-NORMANDIE: C Lévêque, S Marret, L Marpeau (Hôpital Charles Nicolle, Rouen).
LANGUEDOC-ROUSSILLON: P Boulot, J-C Picaud (Hôpital Arnaud de Villeneuve, Montpellier), A-M Donadio, B Ledésert (ORS Montpellier).
LORRAINE: M André, J Fresson, JM Hascoët, JL Boutroy, (Maternité Régionale, Nancy).
MIDI-PYRENEES: C Arnaud, S Bourdet-Loubère, H Grandjean (INSERM U558, Toulouse), M Rolland (Hôpital des Enfants, Toulouse).
NORD-PAS-DE-CALAIS: C Leignel, P Lequien, V Pierrat, F Puech, D Subtil, P Truffert (Hôpital Jeanne de Flandre, Lille).
PAYS-DE-LOIRE: G Boog, V Rouger-Bureau, J-C Rozé (Hôpital Mère-Enfant, Nantes).
PARIS-PETITE-COURONNE: PY Ancel, G Bréart, M Kaminski, C du Mazaubrun (INSERM U149, Paris), M Dehan, V Zupan (Hôpital Antoine Béclère, Clamart), M Vodovar, M Voyer (Institut de Puériculture, Paris).

domain: medical


text:
It is very easy to control flappy fly - just tap anywhere to go up and release your finder to go down. Once 'Kitty' fly, you can not stop playing!Just tap to fly more and more and more. This new mode will challenge your reflexes to the extreme as the rubber chickens fly in from all directions and the bouncing turd gradually picks up speed.
- Definitely never heard of it.
Avoid obstacles and share your best score!The best game of flap is Flappy Kitty. It's not enough to think one or two steps ahead. Be careful don't hit the obstacles.
Your Jelly Power 'value' is added to your score if you reach a new level ( e. Like free stuff? Game on. The game will end if you run out of Jelly Power.
12 Mission American Campaign.
How long will you survive?What's new in this version:- MORE COLORS!- Adds Twitter Sharing- Squashes Bugs
Starting your career as a rookie- you need to earn respect out there before you can challenge the best, work your way through an intense and engaging storyline to prove yourself top dog. " "Totally new concept that just blows my mind.=> Fun For all Age. Super fun and addictive flying game!!Can you help Slender Man avoid the obstacles?What's new in this version:Minor Updates People do not like to go to the dentist, but they like to be a dentist.
Get the easter surprise of your life time.

domain: game


text:
What a Boost... juice bar sales nearly triple in two years to hit £13m
The parent company of Boost Juice Bars UK, TD4 Brands, has said sales have nearly tripled over the past two years to more than £13million.
Richard and Dawn O’Sullivan set up the UK franchise of the international business in 2007, shortly after they sold bakery chain Millie’s Cookies, and first received funding from growth capital provider the Business Growth Fund in 2013.
Since then, the Manchester-based firm has increased the number of Boost bars from 10 to 32 and opened seven new sites in the past year, including in Cambridge, Reading, Southampton and Sheffield.
Backing: The firm has had more help from the Business Growth Fund
TD4 introduced milkshake bar The Shake Lab to Manchester’s Trafford Centre mall in December, and seven other locations are being targeted for a roll-out this year.
TD4 now has a team of 400 and up to eight more Boost bars are planned for the UK this year. BGF has increased its investment in TD4 to £4.9million to support the expansion.
BGF makes initial investments of £2million to £10million and can provide more funding to support further growth. Investment is typically in return for a minority equity stake. It is backed by five of the UK’s main banking groups – Barclays, HSBC, Lloyds, Royal Bank of Scotland and Standard Chartered.
Neil Inskip, of BGF, who sits on the TD4 board, said: ‘Richard and Dawn demonstrate incredible leadership, sound judgment and ambition for the growth of the business. That is something we are keen to support.’
Boost has a franchise network of 400 stores worldwide.
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domain: news


Huck! The Herald Angel
Be sure to grab this week’s angelic issue of Kidzone!
We check out Huck The Herald Angel, a new Christmas book illustrated by our very own Rod Allen. Oliver’s making tassel angels and Cheffy whips up some adorable angel meringues. We meet Champion Oliver, who donated his pocket money to help people in need this Christmas. We preview a special basketball game between the Sydney Kings and Melbourne United to be played on Christmas night in support of the Salvos. Plus, we check out the Kmart Wishing Tree Appeal, Myer’s Hugo Bear and Channel 7’s Christmas With The Salvos. And, of course, there’s the colouring comp and puzzles galore!


text:
The Gzhan stong Chen mo
Among the magnificently diverse syntheses of Indian Buddhist thought elaborated in Tibet, the understanding of gzhan stong (zhentong) or “extrinsic emptiness” as articulated through authors of the Jo nang tradition has come to inhabit a distinctive place within Tibetan Buddhist philosophical discourse. Exploring the history and literary heritage of gzhan stong philosophical thinking within the Jo nang tradition, we trace the sequential lineage (rings lugs) of the Jo nang pa, examining the distinctive gzhan stong view through a study and translation of the gzhi (ground) section of 'Dzam thang Mkhan po Ngag dbang Blo gros grags pa's (1920-75) seminal text titled, the “Gzhan stong Chen mo” or the “Great
Exposition on Extrinsic Emptiness.”
Part I presents the genesis of Jo nang gzhan stong thought. Situating the Jo nang within the history of Buddhism in India and Tibet, this section explores the lives of selected forefathers of the Jo nang pa and central figures in Tibet, as well as the life and works of Mkhan po Blo grags. Emphasis is placed on both the sūtra and tantra lineages of gzhan stong thought and attention is given to the specific lineage of the Kālacakra within the Jo nang.
Part II is on the exegesis of the Tibetan Buddhist genre of Jo nang gzhan stong literature. Here, we discuss Mahāyāna Buddhist hermeneutical schemas employed by the tradition to interpret what is of definitive (nges don) and provisional (drang don) meaning, as well as the core textual basis for sūtra gzhan stong.
Part III is an annotated translation of chapter I.A of the gzhi (ground) section of the Gzhan stong Chen mo. This part provides readers with the first English translation of a text explicitly on the gzhan stong view from a modern Jo nang author, and one of the few translations of a text from the Jo nang tradition. Here, Mkhan po Blo grags explains the abiding reality (gnas lugs) of the ground for reality, the principles that the ground relies upon, and how reality's basic ground is effulgently full of enlightened qualities while devoid of superficial phenomena.
|Sheehy, Michael. "The Gzhan stong Chen mo: A Study of Emptiness according to the Modern Tibetan Buddhist Jo nang Scholar 'Dzam thang Mkhan po Ngag dbang Blo gros Grags pa (1920-75)." PhD diss., California Institute of Integral Studies, 2007.

domain: library


Honiara : 26 February 2017
Letter to the Editor. Solomon Star and Island Sun Newspaper.
New statistics of traffic related offences revealed by the Inspector in charge of the Kumum Traffic Centre focus on the fact that the police arrested 180 drivers last year following the introduction of random breath testing procedures.
Inspector Surimalefo has said that to-date in 2017, a further 54 drivers were arrested after failing a RBT.
There are no statistics to show how these offending motorists have been dealt with by the courts, but clearly many drivers are abusing the road traffic laws and regulations and there must be a stop to such a disregard of the law.
I take the view that the decision of a drunk to drive betrays an attitude of ‘extreme indifference to the rights and lives of others’.
Moreover, any action that is done from an attitude of ‘extreme indifference to the rights and lives of others’ is morally wrong.
It can be argued that driving itself is a dangerous activity. Even when a driver is not intoxicated, he presents a threat to others.
Drivers that are found guilty of drinking and driving need to be effectively dealt with by the courts and steps taken, if permitted within the law, given penalties to try and prevent a re-occurrence of offending in the same way.
The way in which punishment can be imposed by a court varies from country to country but generally sees an offender given a hefty fine, a term of imprisonment, and suspension or cancellation of his or her driving licence.
It will be for the Solomon Islands courts to decide how those found guilty of drinking and driving are to be dealt with, but from the disturbing statistics revealed by Inspector Surimalefo, I believe drivers who have been found to have breached both their legal and moral responsibilities as drivers must face the consequences of their selfish, irresponsible and willful actions because by their very conduct they have endangered the safety and welfare of the public.


text:
Vol. VI—No. 13.
RALEIGH, N. C., MARCH 28, 1912.
One Dollar a Year.
The Parcels Post.
Do Our Congressmen Pepreseni us or the Express Company and
On the editorial page of the Statesville Land
mark of March 19th, appears the following:
“Merchants who are alarmed about the parcels
Post bill, which they not unnaturally think will
give an advantage to the mail order houses, may
calm their fears so far as the measure now before
Congress is concerned.” Writing to a constituent
who had expressed concern about the bill, Con
gressman Page of the Seventh District, says:
“The truth is, I think you have been misinform
ed enitrely as to the provisions of this bill and the
effect of the legislation proposed. The bill merely
Puts into operation the schedule of rates that is
effective between the United States and foreign
Countries by which merchandise can be transport
ed for twelve cents a pound and is limited to a
Package of twelve pounds.
“Now to show you that this can not possibly
hurt you by the mail order houses, you only have
to make a little calculation to show that it is twice
as high as present express charges. On the other
hand the bill provides that originating on the
I’ural free delivery routes, the rates shall be five
•^cnts a pound for the first pound, and two cents
a pound for each additional pound, w’hich will give
you and every other local merchant an opportun
ity to reach your customers in the country.
“The people who have been most zealous for the
Parcels post bill are not, it should be said, satis-
had with this measure. They want the mails to do
iPuch of the business now' done by the express
'Companies but at a much lower rate.”
I wonder if Congressman Page and other Con-
Si’essmen are equally as frank with their farmer
•Constituents who w'rite them and ask that they ad
vocate and vote for a general parcels post bill? It
‘ardly probable. The majority of representatives
ip Congress are non-committal on bills that they
‘ii'o opposed to, when writing constituents who fa-
the bills. They write courteous replies, deal-
Seneralities and promise to give the matter
be consideration when it comes up.”
Page’s letter to his merchant con-
^ ctuent is interesting in that it shows not only the
^Perations of the parcels post bill but the intenfe
ten would infer that there is no in-
Congress to give the people any
of from the robbery of the express companies.
rates provided in the bill “is twice as
isn’t express charges.” Fellow farmers,
Poopi^,^*^ outrage on a patient, long forbearing
Con ^ it not an insult to'our intelligence?
Psk not only give us a stone when w'e
^ouid ^ hut, presuming on our ignorance,
make us belie.ve it is bread,
lieent ^•^st not be molested. The intel-
mercantile class must be catered
the farmers w'ill be fed on garden seeds.
farm bulletins, long speeches and nice letters. 1
for one am getting tired of that kind of diet.
Why is it that the agricultural class, which is
the strongest numerically in the country, can not
secure legislation to relieve it from oppressive con
ditions that are unjust, if the needed legislation is
detrimental to any other class? Why should not
the strongest class dominate our law making bod
ies? One reason is that we permit other classes
to furnish the men who are to represent us in our
law making bodies, and too often these men are
not identified with our interests or in sympathy
with our condition. A majority of our National
Congress are men who are or have been corpora
tion attorneys. It is but natural that these men
should be more concerned about the interests of
the classes that they have been identified with.
But they will do our bidding if we make our de
mands in no uncertain tones and persist therein.
And here is where we have “fallen down” in the
past. We have never marshalled our full strength
and made a united, determined fight for any re
form legislation in the interest of our class.
Whenever w'e do this our demands will be grant
ed, or,—we will chose men who will represent our
interests rather than corporate interests.
Now why should we not have a general parcels
post such as Germany has, where an eleven pound
package can be sent across the empire for twelve
cents. All of the leading countries of the world
have such a parcels post, except the United States.
Our government is responsive to the interests of
Big Business rather than to the will of the people.
A parcels post like that of Germany would ben
efit both the city and country people. It would
uring producer and consumer of food products
closer together and lessen the cost of living.
The merchants are lighting the parcels post,
claiming that it would subject them to tne com
petition of the mail order houses. 1 do not believe
any local merchant’s business would be hurt by a
general parcels post. The rural classes do not buy
anything until they need it and then they want to
see it and feel of it” and try it on before paying
But usppose we admit for the sake of argument
that the mail order houses would become compet
itors of the local merchants. Can not the local bus
iness man compete with the city house five hun
dred to one thousand miles away? He evidently
thinks that he can not do it. Why? Isn’t it be
cause he is not satisfied with a reasonable profit?
Or is it because of the round-about expensive sys
tem of distribution that obtains in the commercial
world? A system whereby commodities are
handled by two or three agencies instead of one.
If this be true, why do not the merchants in their
organized capacity inaugurate a reform movement
that will change the present 'system and lead to
the adoption of an economical one? If they will
not do this, then where is the justice in requiring
nine-tenths of the people to pay tribute to one-
tenth in the form of unnecessarily high prices in
order to maintain an expensive method of doing
business? There are too many men engaged in mer
cantile pursuits. There is hardly a railroad town
in the State with a thousand or more population
that has not a greater number of merchants than
necessary. This does not lead to competitive un
derselling. The price of nearly all manufactured
products is fixed by monopoly or the trade on a
common level. Patronage is won by clever ad
vertising, a good display of wares, courteous
Why should the public be forced to maintain
express companies at a cost that is but little bet
ter than highway robbery? Why should not the
railroads do this work as they now carry the
heavy freight. Why not have passenger train
freight and freight train freight and both at just
and equitable rates. The average cost per ton for
delivering freight is less than one dollar. The
average cost per ton for delivering express is more
than thirty dollars per ton. And yet the repre
sentatives of the people (?) in Congress will do
nothing to relieve the situation.
A man prominent in State politics and well-
known throughout the State, told me a year or
more ago that one of the Congressmen from North
Carolina w'as drawning three salaries; one as rep
resentative of the people (?) in Congress, one as
attorney for a rail-road and one as attorney for
an express company. Do not ask me to name the
man. The gentleman did not volunteer to give his
name, and I did not ask him. If you want to
know whether it is the Congressman from your
district, write to , him.
In conclusion let me say, there is a community
interest that should unite all classes for the com
mon good. The church, the schools, morality' tem
perance, good roads, etc., all represent the prog
ress and life of any community. There should be
no division here.
“But in business matters there is some conflict
of interest between the different classes. The
seller wants to sell in the highest market; the
buyer wants to buy in the lowest market. The
money lender wants a high rate of interest; the
money borrower wants a low rate of interest.
But even here the different classes should get to
gether on an equitable basis that is fair to all.
We would thus eliminate as far as possible all
clashing and friction. Nothing is ever settled un
til it is settled right.
Candor compels me to say that little or no ef
fort has been made to harmonize class differences.
The merchants are organized and offering no con
cessions. Middle men continue to multiply, both
between the farmer and the consumer or manu
facturer and between the manufacturer and con
sumer. As a result, the farmers are going to put
into operation a plan of their own through the
medium of the Carolina Warehouse, Incorporated.
(Continued on page 9.)

domain: politics


West Norfolk villagers react to councillor's flooding comments saying it was 'their choice to live there'
Coastal residents have reacted to a West Norfolk councillor dismissing potential flooding issues as “their choice” to live there.
Ian Devereux, cabinet member for environment, was responding to questions regarding flooding in Snettisham amidst the council failing to declare a climate emergency.
Speaking at a full West Norfolk Council meeting last week, he said: “That was their choice. They chose to live there and develop their houses there in full knowledge of what was happening.”
More by this authorBen Hardy
This website and its associated newspaper are members of the Independent Press Standards Organisation (IPSO)


text:
After puppies come to our home, we usually need to conduct behavior training and good habits at home, some necessary aids need to be prepared, we can using them can help us to achieve the purpose with half the effort.
Dog Training Rattles
A rattle is a small device for anyone's hand. When your dog performs a good behavior, you can click the rattle to make a clicking sound.
Followed by giving your dog a treat to reward the behavior for happening. This process, known as rattle training, is a quick and easy way to do this.
Dog Harness/ Collar
Every dog needs a dog harness/collar.
Going out on a leash has been added to the regulations.
Also, the harness/collar plays an important role in dog training, and picking the correct and appropriate harness/collar will help you solve the problem of bursting into flushes while not hurting them.
A dog leash is another necessity for training a dog.
Having your dog learn and become comfortable with walking on a relaxed leash makes it more likely that your dog will get adequate exercise and mental stimulation.
These are the foundations for getting your dog to behave well.That's why we always emphasize that walks are the best behavioral adjustment for dogs.
When choosing a leash for training, avoid the kind of retractable leash.
When training your dog to burst the punch problem, Vanpardo's shock-absorbing leash can help you better, made of Flex-poly, connected with Shock absorbent Bungee and car seat belt buckle, to help you control your dog in a variety of environments.
Leaky Food Toys/Chew Toys
Some of the most common dog behavior problems, such as digging and destructive chewing, are actually effective ways for dogs to keep themselves from getting bored and relieve stress rather than being intentionally destructive as we would like.
Parents can fill a chew-resistant leaky toy with some treats or a little peanut butter, and your dog will happily ponder these toys and pull out the food.
Best of all, many toys are very chewable, and you can use them again and again to kill your dog's boredom.
As summer approaches, fill the toys with peanut butter and pop them in the freezer to make your own cold summer treats.
Dog Anxiety Wrap
If you have a dog that is easily frightened or has a phobia of thunderstorms and firecrackers, there is a calming aid that you will want to add to your dog training toolbox.
There are many products designed to help dogs cope with anxiety. The Anxiety Wrap is one such product. By wrapping the bandage around your dog through the Ttouch stress reduction method, it can help alleviate your dog's fears and anxiety.
There are also Dog Appeasement Pheromone (DAP) collars and sprays that have been designed to calm a fearful dog.
We strongly recommend the use of aids and proper training methods that will not only allow us to train our dogs with less effort, help them correct some wrong behavioral actions, but also prevent them from getting injured during the training.
For these reasons, Vanpardo will introduce better training tools to allow dogs to better complete the training.

domain: pet


text:
In this day and age, it’s quite a shocker to have more than five kids, but not in the situation of Michael Landon’s children. You see, the actor, who was best known for his role in “Little House on the Prairie,” married three times!
Michael Landon has charmed the audience for years. He had acted, directed, and worked as an executive producer, yet all of those things outshine his role as a father to his nine grown-up kids. Although he passed away at the age of 59 on July 1, 1991, his legacy still lives on to his nine children.
The first known child among Michale Landon’s known children is Mark. He was a child of Dodie Fraser from a previous marriage before Michael. Moreover, he’s the first adopted kid of the actor when he turned 12 years old. His biological mom and adopted dad got married on March 11, 1956. Mark followed Michael’s footsteps as he became an actor himself and took on different roles for films such as “Double Edge” in 1986, “Us” in 1991, and “Goodbye America” in 1997.
Josh and Jason
According to reports, Jason was not officially adopted by Dodie for some unknown reasons, but his name is still intact whenever people are talking about Michael Landon’s children. Josh was adopted by the family at the same time as Mark on February 11, 1960. The actor said in an interview that he didn’t want people calling Josh and Jason “adopted” because he hates that term on them. He treats them well and promised that he’s their father till death do them apart.
The first child of Michael Landon and Lynn Noe, the actor’s second wife. Like Mark, Leslie Ann became an actress and appeared in “Little House on the Prairie” with his father. She also had a role in “Father Murphy” in 1981 and three years later, “Little House: The Last Farewell.” She suffered from bulimia in her young adult years but had overcome the illness and even used her experience as fuel for a Ph.D. in psychology at the University of Southern California. After achieving the degree and title, she has become a family therapist.
He’s two years younger than Leslie Ann and was born to the same parents. Michael Jr., as he is known, became a director and producer with a popular filmography, “Jamaa” in 2011. He also made a television film called “When Calls The Heart” and made a series of the same story in 2014. Before making it big behind the cameras, Michael Graham acted on stage, appearing in “Little House on the Prairie,” “Superboy,” and “Bonanza: Under Attack.” He married his wife Sharee Gregory in December 1987 and bore three children named Ashley, Brittany, and Austin.
Born in December 1971, she became an actress and starred in the 1991 film “Michael Landon: Memories with Laughter and Love” and “Little House on the Prairie” too. However, she later switched careers and became a successful real estate sales agent in Malibu, California. She’s also a mother of two and quite active in social media.
Christopher is the youngest child of Michael Landon to Lynn Noe. He was born on February 27, 1975, and set his eyes on the entertainment industry. After graduating from Loyola Marymount University, he became a writer and producer. Christopher’s first works include Larry Clark’s “Another Day in Paradise” and “Blood and Chocolate.” But his biggest break happened when he wrote the script of “Disturbia.” This script was born when he moved from Los Angeles to Austin, Texas.
“Disturbia” was signed by Montecito Pictures, and Dreamworks brought it to the big screen, racking up almost $80 million domestically and staying at No. 1 for three weeks. With his success, Christopher thought it was time to come out of the closet and came out as gay when he was 24. His other works include the 2014 movie “Paranormal Activity: The Marked Ones,” 2015 “Scouts Guide to the Zombie Apocalypse” and 2019 “Happy Death Day.”
On August 29, 1983, the first baby of Michael Landon with his third wife, Cindy Clerico, was born. Their relationship broke up the former’s eighteen-year marriage to Lynn Noe. At the age of five, Jennifer got her first acting role in “Highway To Heaven” with her father. It looks like she also caught the acting bug and set on to study drama at NYU. She then made friends there, and one of them knows a manager in Lionsgate. Jennifer got introduced and got an acting job straight away.
Jennifer got a role in “As The World Turns” as Gwen Norbeck and also starred in “House M.D.” and “Animal Kingdom” in 2016. Her fondest memories with the late Michael Landon were when they went on a ski trip together.
Sean and Jennifer are advocates of Pancreatic cancer, and they help in the Pancreatic Cancer Action Network to raise research funds and create awareness. Currently, Sean Matthew is a successful real estate sales agent in Malibu, California. There is not much information online about him as he’s a private person, but people can still stalk his social media account through his mom and sisters.
Cheryl Ann Pontrelli
Cheryl was only nine years old when her mother married Michael Landon. The latter then took her in as his own and became the best step-father for her. Their closeness and unconditional love were evident when Cheryl changed her last name to that of Michael and wrote a book entitled “I Promised My Dad,” which honors the late actor.
Michael Landon’s children still honor to this day their late father. Although they are a lot, the sons and daughters of the late actor still make sure to commemorate him on his death anniversary.

domain: entertainment


text:
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It was surrounded by a stone wall and contained a population of two,000–three,000 folks and a massive stone tower. Around 6400 BC the Halaf tradition appeared in Syria and Northern Mesopotamia. The Halaf tradition was adjacent to the Ubaid culture (c. 6500 BC) of southern Mesopotamia, Hassuna culture check this site out (c. 6000 BC) of northeastern Mesopotamia and Samarra tradition (c. 5500 BC) of central Mesopotamia. In the late Thirties, the British established the Middle East Command, which was primarily based in Cairo, for its navy forces within the area.
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After that point, the term “Middle East” gained broader usage in Europe and the United States, with the Middle East Institute based in Washington, D.C. The time period “Middle East” may have originated within the 1850s in the British India Office. However, it turned extra widely known when American naval strategist Alfred Thayer Mahan used the term in 1902 to “designate the area between Arabia and India”. During this time the British and Russian Empires have been vying for affect in Central Asia, a rivalry which might turn out to be generally known as The Great Game.
The region served as the intellectual and economic heart of the Roman Empire and performed an exceptionally essential position because of its periphery on the Sassanid Empire. From the 4th century CE onwards, the Middle East turned the middle of the two major powers at the time, the Byzantine empire and the Sassanid Empire. The four caliphates that dominated the Middle East for more than 600 years had been the Rashidun Caliphate, the Umayyad caliphate, the Abbasid caliphate and the Fatimid caliphate. The Mongols, the Kingdom of Armenia, the Franks during the crusades, the Seljuks, the Safavids, the Mamluks, the Ottoman Empire, and the British Empire also dominated the region. Around 10,000 BC the first absolutely developed Neolithic cultures belonging to the part Pre-Pottery Neolithic A appeared in the Fertile Crescent. Around 10,seven-hundred–9400 BC a settlement was established in Tell Qaramel, 10 miles north of Aleppo. Around 9000 BC through the PPNA, one of many world’s first towns, Jericho, appeared within the Levant.
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The world’s earliest civilizations, Mesopotamia , historical Egypt and Kish in the Levant, all originated within the Fertile Crescent and Nile Valley areas of the traditional Near East. The Near East was first largely unified underneath the Neo Assyrian Empire, then the Achaemenid Empire followed later by the Macedonian Empire and after this to some extent by the Iranian empires , the Roman Empire and Byzantine Empire.
Mahan realized not only the strategic importance of the region, but additionally of its middle, the Persian Gulf. He labeled the realm surrounding the Persian Gulf as the Middle East, and mentioned that after Egypt’s Suez Canal, it was the most important passage for Britain to control so as to keep the Russians from advancing in direction of British India. Mahan first used the time period in his article “The Persian Gulf and International Relations”, printed in September 1902 within the National Review, a British journal. This portal is exclusive as long as it supplies an astonishingly wide variety of interaction instruments so you can take pleasure in the dialogue with Chinese females. An array of prime-notch pages makes this online dating web web site certainly one of this largest and famous in Asia.
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domain: geography


Jacob Jock is handcuffed after being sentenced to three days in jail for Contempt of Court.
Sarasota, Florida -- A Sarasota judge threw the book at a man who got out of jury duty by friending the defendant on Facebook, and then later bragging about his actions online.
Jacob Jock was convicted of Contempt of Court, a misdemeanor, and sentenced to three days in jail and was imposed all court costs.
Jock was admonished and kicked out of the courtroom back in December when it was learned he friended the defendant in a car accident case that he was serving the jury on.
He then went online afterwards and bragged about getting out of jury duty, which is what brought him back before the judge on Thursday.
"He went home and made a joke out of it and said, 'Ha, ha, ha, I got out of jury duty,'" said civil trial lawyer Damien Mallard, who served as the plaintiff's attorney in the case. "To my client, who had $48,000 in medical bills on the line, it was a very big deal to him."
"Freedom is not free," Judge Nancy Donnellan told Jock as he was sentenced Thursday. "It comes with responsibilities and duties, one of the most important of which is to serve as a juror when called."
The judge continued, "You were called, and you thumbed your nose at it."
This isn't the only recent incident where someone wound up in legal hot water for sabotaging his chances of serving on a jury. During jury selection of Casey Anthony's murder trial last year, one potential juror, Jonathan Green, violated the judge's direct order and spoke with reporters during a break.
More Info: Would-be Casey Anthony juror fined
Green fared a bit better than Jock did when he was brought before the judge; he was ruled in Contempt of Court but only fined $450.
Knowing what it would mean to serve in such a high profile trial, Green said of his punishment at the time, "I'm glad I don't have to serve on the jury. No regrets."
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text:
Fruit and Vegetable Consumption in EuropeLast Updated : 10 January 2012
Fruit and vegetables are important elements of a healthy, balanced diet, be it as part of a main meal or as a snack. They bring us vitamins, minerals and fibre, some energy (mainly in the form of sugar), as well as certain minor components - often referred to as phytochemicals or secondary plant products - which are potentially beneficial for our health. Epidemiological studies have shown that high intakes of fruit and vegetables are associated with a lower risk of chronic diseases; particularly, cardiovascular disease1-3, also type 2 diabetes4, and certain cancers i.e. of the mouth, pharynx, larynx, oesophageal, stomach and lungs5.
A majority of European citizens associate a healthy diet with fruit and vegetable consumption, and many of them believe that their diet is healthy6. But is this true? Do people in Europe actually get the amounts of fruit and vegetables recommended for good health? Aiming to answer this question, this review also looks deeper into what factors influence fruit and vegetable consumption in Europe, and what are the best intervention approaches to increase it. Lastly, we will have a glance at on-going European initiatives around fruit and vegetable consumption.
First of all, we need to understand which foods and drinks fall into the category of fruit and vegetables, how much we are recommended to have of these and why it might be difficult to obtain reliable and comparable data on fruit and vegetable consumption.
Definitions of fruit and vegetables
How are fruit and vegetables defined? It might seem like a simple question, but it is actually quite complicated to derive an all-embracing definition. Tomatoes and lettuce, apples and strawberries may be easy to identify as vegetables and fruits, respectively. But how about potatoes? And is fruit juice equal to fruit? Then there are pulses and nuts, which are also plant foods that may or may not be categorised in these food groups. This is important to keep in mind when performing dietary surveys in order to know what is actually being measured.
The definition of fruit and vegetables also varies between countries. Some countries (e.g. Austria, Belgium, Denmark, Iceland, Netherlands, Portugal, Spain and Sweden) have not included potatoes and starchy tubers, following the same principle as the World Health Organization (WHO), whereas the Norwegian recommendations, for example, include potatoes. Juice is sometimes excluded from the fruit and vegetable recommendations (e.g. Belgium, Spain), sometimes included with limitations (e.g. counts as maximum 1 portion (e.g. Denmark, the Netherlands and Sweden), and fully included in other countries (e.g. Iceland and Norway). Austria and Portugal do not provide any specification regarding juice.7
Varying definitions of which foods belong to fruit and vegetables present a barrier to comparing data from different studies. This is a major issue when trying to estimate fruit and vegetable consumption in Europe. Given that many national authorities regularly perform surveys of fruit and vegetable intake, standardising the survey methodology would vastly improve data comparability across different countries.
Measuring fruit and vegetable intake
There are different ways to measure food consumption. Food diaries and dietary recalls (i.e. interviews and questionnaires) are means to obtain information on what individuals eat. Household spend and average food supply based on national statistics may also be used to assess consumption.
Different methods take into account different aspects and the exactitude varies between them. Hence data obtained with different methods are not directly comparable. National Authorities have typically selected methods for their dietary surveys without international comparability in mind8.
The lack of comparable data on dietary intake will be tackled by the EU Menu, a pan-European dietary survey by the European Food Safety Authority (EFSA) that uses standardised data collection methods. The 5 year survey will start at the beginning of 20129.
Definitions of fruit and vegetables are not only important to obtain accurate and comparable data on consumption, but they are also crucial for intake recommendations and what their effect will be on population intakes.
WHO recommends eating ≥400 g per day of fruits and vegetables, not counting potatoes and other starchy tubers such as cassava10. In Europe, the recommendations vary between countries. In general, these are in line with the WHO recommendation, but some countries recommend higher amounts e.g. ≥600 g per day in Denmark7.
2. Fruit and vegetable consumption in Europe
What do food supply data say?
The Food and Agriculture Organization of the United Nations (FAO) provides data on food consumption based on agricultural data which indicates the food supply patterns at national level.
According to the FAO data, the vegetable supply (excluding potatoes and pulses) in Europe has increased over the last four decades. It also shows a north-south gradient; in Northern Europe the vegetable supply is lower than in Southern Europe. For example, in Finland the average supply is 195 g per person per day, which corresponds to 71 kg per person per year, whereas Greece has an average supply of 756 g per person per day (276 kg per person per year)11.
What do household food consumption data say?
National Authorities regularly collect data on food consumption at household level through household budget surveys. Efforts have been made to compile and modulate these data - from a number of European countries (collected at different time points) - to enable comparison.
Household data show that total vegetable consumption (excluding potatoes and pulses) varied from 284 g per day in Cyprus to 109 g per day in Norway. These countries had also the highest and lowest recorded intakes, respectively, of fresh vegetables. Interestingly, Cyprus had the lowest consumption (4 g per day) of processed vegetables (frozen, tinned, pickled, dried and in ready meals, but excluding potatoes). The consumption of processed vegetables was highest in Italy at 56 g per day12.
Based on household food data on fruit and vegetable consumption it has been suggested that household availability of fruit and vegetables is satisfactory in some Southern European countries and that in a number of countries the availability of fruits is higher than that of vegetables11.
What do dietary survey data say?
EFSA has compiled national food consumption data based on dietary surveys in order to assess food intake in Europe. Adjustments of the compiled data allow for a certain level of comparison13.
These data reveal that the mean vegetable intake (including pulses and nuts) in Europe is 220 g per day. Mean fruit intake is 166 g per day, implying that the average consumption of fruit and vegetables is 386 g per day. The data further show that the vegetable consumption is higher in the South than in the North of Europe and that the regions with the highest intake of fruits are those of Central and Eastern Europe followed by those in the South13.
Only in Poland, Germany, Italy and Austria the recommendation of consuming ≥400 g of fruit and vegetables per day was met. When fruit and vegetable juices were included, Hungary and Belgium also reached the recommended amount11. It is worth noting that the database only contains data from one Southern European country, namely Italy (Figure 1).
Figure 1 - Mean fruit & vegetable intake per country (in grams per day), excluding juices13
There is only limited data on European children’s fruit and vegetable consumption, but one study suggests that 6-24% of European children reach the WHO recommendation7. The average vegetable intake was estimated to be 86 g per day, the average fruit intake 141 g per day. When fruit and vegetables are combined, the highest intakes are seen in Austria and Portugal and the lowest in Iceland and Spain. The type of vegetables consumed differed according to the geographical location. In the North, consumption of raw vegetables was higher, while vegetable soups were the main sources of vegetables in the South.
Insufficient fruit and vegetable intakes in Europe
The WHO estimates that in more than half of the countries of the WHO European Region the consumption is lower than 400 g per day of fruit and vegetables, and in one third of the countries the average intake is less than 300 g per day (8). EFSA’s analysis based on national dietary surveys suggests that the recommended amount is reached only in 4 of the participating EU Member States11.
Disease burden related to low fruit and vegetable intakes
According to the estimates above, a majority of Europeans do not meet the WHO recommendations for fruit and vegetable intake. As eating recommended amounts of these foods helps to ensure health and prevent disease, poor intakes would be expected to negatively impact on health.
To get an idea of the magnitude of the problem, attempts have been made to estimate the contribution of low fruit and vegetable consumption to the burden of disease. The most recent analysis in the European Union (EU) dates from 1997. At the time, it was estimated that 8.3% of the burden of disease in the EU-15 could be attributed to inadequate nutrition, with low intakes of fruit and vegetables being the cause for 3.5% of the disease burden14. WHO has estimated that 2.4% of the burden of disease in the WHO European Region was attributable to low intakes of fruit and vegetables in 2004 (Table 1)15.
|Risk factor||Burden of disese (%)|
|1. Tobacco use||11.7|
|2. Alcohol use||11.4|
|3. High blood pressure||11.3|
|4. Overweight and obesity||7.8|
|5. High cholesterol||5.9|
|6. Physical inactivity||5.5|
|7. High blood glucose||4.8|
|8. Low F&V intake||2.4|
|9. Occupational risks||1.7|
|10. Illicit drug use||1.6|
Most of the benefit of consuming fruit and vegetables comes from a reduction in cardiovascular disease risk, but fruit and vegetables may also reduce the risk of certain cancers16.
WHO has estimated that insufficient intake of fruit and vegetables causes around 14% of gastrointestinal cancer deaths, about 11% of ischaemic heart disease deaths and about 9% of stroke deaths worldwide15.
As for dietary habits in general, a wide range of factors influence fruit and vegetable consumption; factors in our physical, social and cultural environment as well as personal factors, such as taste preferences, level of independence, and health consciousness. Many of these factors change throughout life.
Income and education
There are many studies supporting a relation between income level and fruit and vegetable intake; low-income groups tend to consume lower amounts of fruit and vegetables than higher income groups17. But why is that?
High costs may negatively impact on fruit and vegetable intake levels18. This does not only concern low income groups. Also people with higher incomes perceive price as a barrier to consumption of these foods. However, it tends to be more of a concern among those with smaller revenues19. Thus, affordability is likely to be only one of several factors mediating the effect of income level on fruit and vegetable consumption.
Better educated adults show higher vegetable consumption. Besides the financial aspect just mentioned – higher education generally means higher income – this could be related to greater knowledge and awareness of healthy eating habits in those with higher education levels. It is also likely that certain values, ideals and social influence linked to education and income levels influence our eating behaviours, including fruit and vegetable consumption20.
Gender and age
In general, girls and women consume larger amounts of fruit and vegetables than do boys and men17, 21-23. This seems to be the case also for pre-school children24, thus the gender difference already shows at an age when nutrition knowledge is unlikely to have any impact.
There is no simple answer to the question why females eat more fruit and vegetables than males. Social structures linked to the traditional roles of men and women in society could be one explanation22. It has also been suggested that girls like fruit and vegetables more than do boys and hence they eat more of them. Why that is, however, remains unclear21.
Age also appears to influence fruit and vegetable consumption. In children and adolescents, consumption tends to decrease with age23. In adults, the relation between age and intake is inversed, i.e. intake levels increase with age. Possible explanations include higher income and knowledge with age, and social habits and cues, e.g. what type of social activities people take part in, social eating habits and ideals related to food and the time devoted to cooking20.
Accessibility and availability
The availability of a variety of attractively displayed fruit and vegetables all year round positively affect fruit and vegetable consumption, particularly with higher socioeconomic status (19). Similarly, availability of and access to fruit and vegetables in the home is important for consumption in both children and adults19, 23, 25. On the other hand, lack of or limited supply of fruit and vegetables (e.g. little variety offered in canteens or local shops and poor quality) has been reported to be obstacles to consumption of such foods18.
Family factors and social support
Social support appears to enhance fruit and vegetable consumption26 and family factors influence fruit and vegetable intake in children, adolescents and adults.
In adults, particularly in men, being married positively impacts on the amounts of fruit and vegetables consumed19, 22. Women seem to have a positive influence on their husbands’ intake frequency, amounts and variety of the fruit and vegetables eaten19. In general, family factors seem to be stronger determinants in men than in women. This is thought to be related to their traditional roles in the household; women handle health-related issues and more commonly shop and prepare food than do men19, 22.
Children’s fruit and vegetable intake levels are related to how much their parents consume24. There is also a relationship between family rules and children’s vegetable intake. Pressure to eat fruit and vegetables does not have any positive effect on intake in children. However, consumption can be enhanced when parents are good role-models and encourage children to eat fruit and vegetables27. Family meal patterns, in particular shared family meals, also improve fruit and vegetable consumption in children23, 24. Home availability and other factors in the shared environment as well as genetic pre-disposition (inborn food preferences) could explain the link between parents’ and children’s intake levels24.
Dietary habits learnt in childhood seem to be predictive for intake levels in adulthood19. The earlier children are introduced to vegetables the more likely they are to have higher consumption levels at pre-school age24. People who eat a lot of fruit and vegetables in childhood remain good consumers28.
Food preference is one of the factors related to fruit and vegetable consumption23, 25. When starting to eat solid food the child may initially not seem to like certain foods, but repeated exposure may improve this. As many vegetables have a slightly bitter taste, the child may need to try them more often than other foods before accepting them.
Parents using pressure and rewards to make their children eat fruit and vegetables may not be very successful. Typically such strategies result in even stronger aversions. Giving children a variety of foods, tastes and textures, being patient and repeatedly serving foods they initially seem to dislike, being a role model, and encouragement are far better strategies29.
Although to a large extent developed during childhood30, food preferences change over time and may be modified also in adulthood. As for children, repeated exposure may reduce food neophobia, i.e. being reluctant to try new foods, in adults as well31.
To what extent nutritional knowledge and awareness of recommendations influence what we eat is widely discussed and explanations to why certain groups eat more healthily than others have been sought. Among the psychosocial factors, nutritional knowledge is one of the strongest predictors for fruit and vegetable consumption26. The lack of skills to prepare fruit and vegetables for consumption is another factor which could constitute an obstacle to purchase and consumption18.
There often seem to be gender differences in nutritional knowledge, with women being more knowledgeable than men. Men also tend to be less aware of dietary recommendations and the risks linked to unhealthy dietary habits32, whereas women are more likely to associate a healthy diet with eating more fruit and vegetables6.
Psychological factors, attitudes, beliefs and perceived barriers
Attitudes and beliefs towards fruit and vegetables have an impact on consumption levels26. There is evidence that self-efficacy (belief in one’s own ability to perform tasks, attain goals etc.) is a strong predictor for fruit and vegetable intake in adults23, 26. Self-esteem also positively impacts vegetable intake20 as does perceived healthiness of fruits and vegetables32.
The vast majority of the citizens in the EU consider what they eat good for their health, 20% even declare that their eating habits are very healthy. A majority of Europeans believe that it is easy to eat a healthy diet and that eating a healthy diet means eating more fruit and vegetables6. Considering what we know about Europeans’ dietary habits and their fruit and vegetable intake, this may appear surprising. However, it has been suggested that one important barrier to fruit and vegetable consumption is that people actually believe their diet is satisfactory17.
Lack of time and control over what they eat are the two main reasons Europeans give to explain the difficulty of eating a healthy diet6. Time constraints to eat fruit and vegetables represent a complex issue. For example, there are indications that fruit is often considered convenient food whereas vegetables are not. For Europeans, irregular working hours and a busy lifestyle are perceived as barriers to vegetable consumption. Low consumers of fruit and vegetables consider convenience factors, such as time available for preparation of food and shopping, availability of shops and simplicity of preparation and cooking, of higher importance for their intake than high consumers31.
Increasing vegetable intakes
In 2006, 1 in 5 Europeans reported having changed their diet over the last year. Of these more than half indicated that they had increased their fruit and vegetable intake. Weight management and health maintenance were the major reasons for diet changes. Increased fruit and vegetable intake was reported by fewer in the Mediterranean region than elsewhere. On the other hand, as many as 70% of the individuals in Denmark and Slovenia who had changed their diet reported having increased their consumption of these foods. People in countries with relatively high fruit and vegetable consumption could be more likely to consider their intake of fruit and vegetables as sufficient6.
4. Interventions – what is effective?
The factors influencing fruit and vegetable intake are numerous and linked to each other in complex ways. As a consequence, changing consumption patterns remains a challenge, particularly at population level. Different intervention programmes addressing low fruit and vegetable consumption have adopted different strategies, with variable success.
Dietary habits and preferences largely form during childhood and hence many initiatives for increasing fruit and vegetable consumption target children. The sad truth is that despite a large number of interventions and intense efforts, impact on consumption levels has been rather limited18. Some elements of success can be identified, though.
Most often the projects aimed at increasing fruit and vegetable consumption in children are school-based. Implementing programmes in schools ensures wide participation and gives the opportunity to combine different types of activities, such as traditional classroom-based learning, school gardening, cooking classes and feeding33.
For maximum effect, school-based interventions should consist of a number of different activities. The more intense and multi-faceted the intervention, the higher the increase in intakes34. Skill-building activities, like cooking classes, are more effective than passive learning approaches18, 33. Duration is also important, with programmes running at least one year being the most effective 33.
Distributing fruit and vegetables as well as involving parents, teachers and peers also improves the results of school-based interventions. Involving parents is of great importance since parental intakes, encouragement and home availability of fruit and vegetables are factors with strong influence on children’s consumption (35). Active encouragement by food-service personnel in school canteens, training and involvement of peer leaders and the use of cartoon characters are as well positive elements in fruit and vegetable intervention programmes for children. Making fruit and vegetable messages a part of existing school subjects may also help18, 33.
In fruit and vegetable interventions for adults the strategies with the greatest impact on intake have included some kind of face-to-face counselling. The problem is that individual approaches are very resource-demanding and therefore hardly applicable in population-wide interventions. Individually-tailored printed or computer-based information, may serve as a good alternative to face-to-face counselling as the messages can be adopted to individual needs, attitudes etc.
Adults are often targeted at the workplace. To be effective, such interventions must consist of a number of different strategies, which often makes them costly. Collaboration with the company managers as well as with other stakeholders is also necessary to make workplace interventions successful. It appears to be difficult to recruit and retain participants in such projects, which might be the reason why, so far, the success of worksite interventions has been limited. The time demands and efforts required from workers and managers are considered barriers to their success18. Another important strategy is to establish supportive structures that will sustain efforts in the long run. Involving workers in planning and running of the programme, addressing the existing barriers and integrating the workers’ broader social context by targeting also their families, neighbourhoods etc. are other means to achieve better outcome34.
There are also broader, community-based fruit and vegetable programmes. The effectiveness of these has often been difficult to assess18. However, some elements for the success of community-based interventions have been identified. As for school- and worksite-based programmes a multi-component strategy seems to be the way to go for increasing intakes of fruit and vegetables18, 36. Clear fruit and vegetable messages, involvement of the family and using a theoretical framework as the basis of the intervention have also been demonstrated to be advantageous. Flexibility and participation of the target population in the intervention design also promotes better outcome, and the duration of the programme is important36.
The average effect obtained by interventions aiming at increasing adults’ fruit and vegetable consumption is around half a serving more per day18.
5. Initiatives across Europe
National nutrition policies
Given the contribution of low fruit and vegetable consumption to the burden of disease, action at national level towards increasing fruit and vegetable consumption has become common.
Most Western and Nordic European countries address insufficient intakes in their national nutrition policies and include fruit and vegetable promotion as one of their objectives. Equally, in Southern European countries, despite having intake levels closer to the recommended amounts, fruit and vegetable goals are part of their nutrition policies8. One example of strategies implemented at national level to enhance fruit and vegetable intake of the general population is the 5-a-day campaign, which is run in a number of European countries. In Denmark, where fruit and vegetable intake is also rather low, there is a 6-a-day campaign11.
The EU School fruit scheme
Increasing fruit and vegetable consumption is one of the goals identified in the European Commission's White Paper on Nutrition from 200737, which among other things addresses childhood obesity in Europe. In the concluding remarks of the White Paper, it is stated that a 'School Fruit Scheme would be a step in the right direction'. This has become reality and an EU-wide scheme to provide fruit and vegetables to school children started in the school year 2009/201028.
The 'School Fruit Scheme” takes into account several of the aspects identified as factors of success in other school-based programmes: it is a long-term programme providing fruit and vegetables for free, encouraging children to make fruit and vegetable consumption part of their lifestyle. It is involving children, teachers and parents. Additionally it will involve partners from public health, education and agriculture sectors and its effectiveness will continuously be monitored to allow improvements of the strategies throughout the programme (28).
The “School Fruit Scheme' is partly financed by the European Commission, but participating countries have to contribute as well. The funds from the Commission are aimed at encouraging additional activities, within or in addition to existing programmes. Besides provision of fruit and vegetables, awareness-raising and educational activities will take place to teach children the importance of good eating habits28.
National initiatives promoting fruit and vegetable consumption
There are already national initiatives in place aiming at increasing fruit and vegetable consumption in children28. Examples of such programmes are:
- SchoolGruiten – The Netherlands (schoolgruiten.kennisnet.nl/)
- Frugtkvarter – Denmark
- 5 am Tag – Germany (www.5amtag.de/)
- 3x3 – Hungary (www.3x3.hu/)
- Fruitness – Italy
- 5 al dia – Spain (www.5aldia.com/)
- 5 a day – UK (www.nhs.uk/LiveWell/5ADAY/Pages/5ADAYhome.aspx)
- Un fruit pour la récré – France
- All day long – Belgium
- Food dudes – Ireland (www.fooddudes.ie/)
6. Fruit and vegetable consumption in Europe – summary
Despite various issues limiting the possibilities to assess fruit and vegetable intake on a European level, there are some consistent findings on consumption patterns in Europe:
- A majority of Europeans do not reach WHO recommendations on vegetables and fruit consumption (≥ 400 g per day).
- Consumption varies, with higher intakes in Southern compared to the Northern regions.
Fruit and vegetable consumption patterns are determined by a wide range of factors:
- Age, gender and socio-economic status – the influence of these seems to be mediated by other factors, e.g. food preferences, knowledge, skills and affordability.
- Personal factors, e.g. self-efficacy, self-esteem, perceived time constraints, personal values and perception of the healthiness of one’s own diet.
- Social environment - social support, social cues and meal patterns and atmosphere at meal time etc. influence food preferences and attitudes towards fruit and vegetables, thus determining our food choices and dietary behaviours.
Increasing fruit and vegetable consumption is a priority for international organisations as well as national governments, which has resulted in many initiatives. There are certain elements that have been shown to improve the results of intervention programmes. Among these are:
- Multi-component strategies addressing both personal factors such as knowledge and skills, as well as the physical and social environment by e.g. increasing the availability of fruits and vegetables and addressing attitudes and practices not only in the defined target group, but also in their social networks.
- Support and involvement of decision makers and representatives of the target population in programme planning and running in order to create support and ownership and to develop strategies that are accepted by the target group.
- Programme duration of at least 12 months.
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- Rissanen TH, et al. (2003). Low intake of fruits, berries and vegetables is associated with excess mortality in men: the Kuopio Ischaemic Heart Disease Risk Factor (KIHD) Study. Journal of Nutrition 133(1):199-204.
- Harding AH, et al. (2008). Plasma vitamin C level, fruit and vegetable consumption, and the risk of new-onset type 2 diabetes mellitus: the European prospective investigation of cancer--Norfolk prospective study. Archives of Internal Medicine 168(14):1493-1499.
- World Cancer Research Fund (WCRF) Panel (2007). Food, Nutrition, Physical Activity, and the Prevention of Cancer: A Global Perspective. World Cancer Research Fund: Washington, DC
- European Commission (2006). Health and food. Special Eurobarometer 246 / Wave 64.3 – TNS Opinion & Social. European Commission: Brussels.
- Yngve A, et al. (2005). Fruit and vegetable intake in a sample of 11-year-old children in 9 European countries: The Pro Children Cross-sectional Survey. Annals of Nutrition and Metabolism 49:236-245.
- World Health Organization (2006). Comparative analysis of nutrition policies in the WHO European Region. WHO: Copenhagen, Denmark.
- European Food Safety Authority (2010). The EU Menu. [accessed March 2010].
- World Health Organization (2008). WHO European Action Plan for Food and Nutrition 2007-2012. WHO: Copenhagen, Denmark.
- Elmadfa I, et al. (2009). European Nutrition and Health Report 2009. Forum Nutrition 62:1-405.
- The DAFNE databank. [accessed March 2010]
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- World Health Organization (2009). Global Health Risks Summary Tables. WHO: Geneva, Switzerland.
- World Health Organization(2009). Global Health Risks. WHO: Geneva, Switzerland.
- Dibsdall LA, et al. (2003). Low-income consumers' attitudes and behaviour towards access, availability and motivation to eat fruit and vegetables. Public Health Nutrition 6:159-168.
- World Health Organization (2005). Effectiveness of interventions and programmes promoting fruit and vegetable intake. WHO: Geneva, Switzerland.
- Kamphuis CB, et al. (2007). Perceived environmental determinants of physical activity and fruit and vegetable consumption among high and low socioeconomic groups in the Netherlands. Health Place 13:493-503.
- Elfhag K, et al. (2008). Consumption of fruit, vegetables, sweets and soft drinks are associated with psychological dimensions of eating behaviour in parents and their 12-year-old children. Public Health Nutrition 11:914-923.
- Bere E, et al. (2008). Why do boys eat less fruit and vegetables than girls? Public Health Nutrition 11:321-325.
- Friel S, et al. (2005). Who eats four or more servings of fruit and vegetables per day? Multivariate classification tree analysis of data from the 1998 Survey of Lifestyle, Attitudes and Nutrition in the Republic of Ireland. Public Health Nutrition 8:159-169.
- Rasmussen M, et al. (2006). Determinants of fruit and vegetable consumption among children and adolescents: a review of the literature. Part I: Quantitative studies. International Journal of Behavioural Nutrition and Physical Activity 3:22.
- Cooke LJ, et al. (2004). Demographic, familial and trait predictors of fruit and vegetable consumption by pre-school children. Public Health Nutrition 7:295-302.
- Bere E, Klepp KI. (2004). Correlates of fruit and vegetable intake among Norwegian schoolchildren: parental and self-reports. Public Health Nutrition 7:991-998.
- Shaikh AR, et al. (2008). Psychosocial Predictors of Fruit and Vegetable Consumption in Adults: A Review of the Literature. American Journal of Preventive Medicine 34:535-543.e11.
- Pearson N, et al. (2009). Family correlates of fruit and vegetable consumption in children and adolescents: a systematic review. Public Health Nutrition 12:267-283.
- European Commission. DG Agriculture and Rural Development. School Fruit Scheme. [accessed July 2011]
- Benton D. (2004). Role of parents in the determination of the food preferences of children and the development of obesity. International Journal of Obesity Related Metabolic Disorders 28:858-869.
- Havermans RC, et al. (2010). Increasing Children's Liking and Intake of Vegetables through Experiential Learning. In: Bioactive Foods in Promoting Health. pp. 273-283. [RR Watson and VR Preedy, editors]. San Diego: Academic Press.
- Pollard J, et al. (2002). Motivations for fruit and vegetable consumption in the UK Women's Cohort Study. Public Health Nutrition 5:479-586.
- Baker AH, Wardle J. (2003). Sex differences in fruit and vegetable intake in older adults. Appetite 40:269-275.
- Knai C, et al. (2006). Getting children to eat more fruit and vegetables: A systematic review. Preventive Medicine 42:85-95.
- Sorensen G, et al. (2004). Worksite-based research and initiatives to increase fruit and vegetable consumption. Preventive Medicine 39 Suppl 2:S94-100.
- Kristjansdottir AG, et al. (2009). Children's and parents' perceptions of the determinants of children's fruit and vegetable intake in a low-intake population. Public Health Nutrition 12:1224-1233.
- Ciliska D, et al. (2000). Effectiveness of Community-Based Interventions to Increase Fruit and Vegetable Consumption. Journal of Nutrition Education 32:341-352.
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Kohler Generators GM62345-SKP1-QS Details and Specifications
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Spark Plugs (2)