Sei sulla pagina 1di 7
Appetite 120 (2018) 609 e 615 Contents lists available at ScienceDirect Appetite journal homepage:

Contents lists available at ScienceDirect

Appetite

journal homepage: www.elsevier.com /locate/appet

Appetite journal homepage: www.elsevier.com /locate/appet Evaluation of a pilot sensory play intervention to increase

Evaluation of a pilot sensory play intervention to increase fruit acceptance in preschool children

H. Coulthard * , I. Williamson, Z. Palfreyman, S. Lyttle

Division of Psychology, Faculty of Health & Life Sciences, Hawthorn Building, De Montfort University, Leicester, LE1 9BH, United Kingdom

De Montfort University, Leicester, LE1 9BH, United Kingdom article info Article history: Received 22 September 2016

article info

Article history:

Received 22 September 2016 Received in revised form 14 July 2017 Accepted 6 October 2017 Available online 7 October 2017

Keywords:

Fruit consumption

Neophobia

Child

Intervention

Sensory processing

Healthy eating

abstract

Recent research has found an association between dislike of messy play and higher levels of food neo- phobia in children. The aim of the present study was to pilot and assess a ve week intervention with preschool children, to examine whether engagement in tactile sensory tasks leads to increased fruit acceptance. Interventions were carried out to examine whether weekly sessions of sensory play com- bined with fruit exposure, would increase acceptance and enjoyment of fruits to a greater extent than two non-sensory play conditions featuring fruit exposure or normal play activities alone. One hundred children aged 18 months to four years were recruited from ten playgroups in the Midlands area of the United Kingdom (UK) of which 83 completed the interventions. Participants were randomly assigned to one of four conditions: combined sensory play (fruit and non-food), non-food sensory play, fruit taste exposure, and control play. There were baseline differences in child fruit acceptance, so this was entered as a covariate into subsequent analyses. It was found that children in both the combined sensory play and non-food sensory play conditions enjoyed signi cantly more fruits at follow up than children in the control play condition, whilst children in the non-food sensory play group also enjoyed signi cantly more fruits than the fruit exposure group. These ndings suggest that sensory play, with fruit and/or non-food substances, combined with exposure may be an effective strategy to increase tasting and fruit acceptance in children.

© 2017 Published by Elsevier Ltd.

1. Introduction

Naturally occurring foods such as fruits and vegetables are known to have health bene ts (e.g. Dauchet, Amouyel, Hercberg, & Dallongeville, 2006 ), but are amongst the most rejected and dis- liked food groups. In particular children after the age of two are particularly resistant to tasting and accepting novel fruits and vegetables, as part of the expression of the neophobic food response, and will often reject these foods on sight ( Cooke, Wardle, & Gibson, 2003; Howard, Mallan, Byrne, Magarey & Daniels, 2012; Pliner, 1994 ). Recently there has been an increased interest in the contribution of sensory processing to the hedonic experience of eating and hence the acceptance of foods. Eating is an intensely multi-sensory experience; we see food, smell it and even touch it with our hands before deciding to taste it. It is becoming increasing apparent that the hedonic sensory experience of eating a given food differs between individuals, and may to some extent explain

* Corresponding author. E-mail address: hcoulthard@dmu.ac.uk (H. Coulthard).

0195-6663/ © 2017 Published by Elsevier Ltd.

individual differences in food rejection behaviours such as food neophobia. It is acknowledged that individuals vary in the extent to which they perceive and respond to sensory stimuli in the environment, such as the feeling of sand or the smell of perfume ( Dunn, 1997 ). Eating involves sensory integration across a range of sensory mo- dalities; not only the obvious modalities of olfaction and taste, but also the visual appearance of food and the feel of food in the mouth. In both behavioural ( Coulthard & Thaker, 2015; Coulthard & Sahota, 2016; Nederkorn, Jansen & Havermans, 2015 ); and questionnaire studies ( Coulthard & Blissett, 2009 ), it has been found that tactile processing, which relates to evaluation of the feel of different substances (both food and non-food) may be associated with the acceptance of foods. This in some ways is not surprising, as the texture of a food is processed within the mouth. More speci cally, it is also found that the texture of a given food is a major determinant of liking and acceptability ( Werthmann et al., 2015; Zeinstra, Koelen, Kok, & de Graaf, 2010 ). The mouth is said to be the nal sentry post through which substances pass from the external world to the internal body, and it is important for survival to judge

610

H. Coulthard et al. / Appetite 120 (2018) 609e 615

whether foods are safe prior to ingestion ( Rozin, Haidt, & McCauley, 2008 ). The texture of some foods change as they become unsafe to eat, for example they may become slimy and mushy as they rot. It is therefore likely that texture evaluation may be an important aspect of food acceptance and rejection, with slimy textures being the most disliked ( Martins & Pliner, 2006 ). One of the most effective strategies for increasing acceptance of foods in infants and children is to increase familiarity with their taste through the technique of taste exposure ( Ahern, Caton, Blundell & Hetherington, 2014; Holley, Haycraft, & Farrow, 2015; Horne et al., 2011 ). However, taste exposure becomes increasingly less effective after the age of two years as more exposures are required to increase preference ( Howard et al. 2012; Sullivan & Birch, 1990 ) and food rejection increasingly occurs on sight rather than taste ( Birch, McPhee, Shoba, Pirok, & Steinberg, 1987; Dovey et al., 2012 ). Interventions in preschool children have traditionally encompassed taste exposure alongside other proven strategies such as modelling (copying others) and rewards ( Holley et al., 2015; Horne et al., 2011; Laureati, Bergamaschi, & Pagliarini, 2014 ). Generally these interventions have been found to be effective compared to control groups, but have tended not to look at indi- vidual child differences in outcomes. In addition, the rewards associated with these interventions tend to be costly, and some- times the interventions themselves are expensive when translated into a school environment and are not self-sustaining. There has been a very recent shift in using games to increase novel food consumption, as they are low cost, fun and intrinsically rewarding. For older children, research has examined games which encompass collaborative FV consumption targets in the canteen, with each target releasing a different stage of a story about catching villains and saving heroes ( Jones, Madden, & Wengreen, 2014 ) or playing bingowith real fruits and vegetables ( Coulthard & Ahmed, 2017 ). Games with younger children have encompassed sensory play with food and non-food substances, for example making pictures with FV ( Coulthard & Sealy, 2017 ) and afterwards tasting the featured foods. Sensory play with foods allows multi- sensory exploration and exposure to the appearance, smell, and feel of foods without pressure to taste. This method means that con- sumption is not the end activity of the task, rather that the food is used as a play substance ( Coulthard & Ahmed, 2017 ; Coulthard & Sealy, 2017 ). There have been several research studies which have examined whether sensory education tasks with foods can desensitise chil- dren to the novel aspects of their sensory properties, and make these foods more familiar and consequently accepted. In older children tasks have centred on education of the senses through classes de gout , where 8 e 11 year old children are trained to identify the different sensory properties of foods through their smell and taste. In younger children, interventions have ranged from sensory education across the senses, for example, opening up fruits to look at their seeds ( Dazeley & Houston-Price, 2015; Hoppu, Prinz, Ojansivu, Laaksonen, & Sandell, 2015 ) to imaginative games with a fruit and vegetable theme ( Witt & Dunn, 2012 ). However, as yet, there have been no intervention studies which have used game based activities where the food itself is the play stimuli. The aim of the present study was to construct an intervention based on sensory play, and examine whether this would be asso- ciated with increased fruit consumption in preschool children. The decision to focus on fruits rather than FV was taken, as there is a move to view these as separate food groups (e.g. Dovey et al., 2012 ). For the purposes of this intervention, we selected food stimuli that would leave a trace on the body, and could also be consumed raw. Therefore it was decided to use fruit stimuli, as these offered a more exible range of foods to choose from. It was hypothesised that taking part in a ve week sensory play intervention combined

with taste exposure would be associated with subsequent increased fruit acceptance, compared to groups who were given either taste exposure or non-food play activities over the ve week period. There were two sensory play interventions, one with fruit and non-food sensory games and a second group that only took part in non-food sensory games. The rationale for these two different sensory play conditions was to examine whether playing with fruit would lead to greater tasting than multisensory exposure through messy play ( Coulthard & Sealy, 2017 ). A secondary aim was to examine whether there were differences in enjoyment of the different games, in particular whether children disliked the feel of more slimy fruit and non-food substances compared to other textures.

2. Method

2.1. Participants

One hundred children and an accompanying parent were recruited from preschool playgroups (n ¼ 10) in the East and West Midlands of the United Kingdom (UK). They were invited to take part in a study on fruit consumption in preschool children, so that they were blind to the different experimental conditions. Children with known allergies to foods were excluded from the study. As lychee was used to test willingness to try an unfamiliar fruit at the end of the study, previous consumption of lychee was used an exclusion criterion. The initial sample comprised 48 boys and 52 girls, with a mean age of 2.60 (SD ¼ 0.81) years. The majority of the sample was White British (82%, n ¼ 68), with the remainder of the sample from White European (7%, n ¼ 6), South Asian (5%, n ¼ 4) and Mixed Heritage (6%, n ¼ 5) backgrounds. Seventeen partici- pants were not included as they failed to complete the baseline measures (n ¼ 2) or complete the ve week intervention or nal session (n ¼ 15). As this was a voluntary play group and we didn't have contact details for the caregivers, we were unable to collect reasons for drop-out. Eighty-three children completed the 5 week intervention study, and a follow up session to examine fruit acceptance, and were included in the nal analyses. The nal sample had 38 boys and 45 girls, with a mean age of 2.75 (0.82) years. Each playgroup was assigned to one experimental condition, so caregivers were not aware of the different conditions until after the follow up tasting measure was carried out, to prevent demand characteristics.

2.2. Design

A between participants experimental design, with cluster ran- domisation was carried out. Each playgroup was randomly assigned to one experimental group using number generation. There was one factor with four levels; the experimental group to which each child was assigned (Combined sensory play with exposure, non- food sensory play with exposure, taste exposure and control play). For each condition, twenty-ve children were recruited. Caregivers were asked to provide information on a range of factors designed to help describe and understand the sample and to assess any baseline differences so these could be controlled for in subse- quent analyses. These possible covariates included parental edu- cation, age of child, age of parent, child food neophobia, range of fruits accepted, child FV consumption, parental FV consumption.

2.3. Materials and procedure

Child Food Neophobia Scale (CFNS). To measure the relation- ship between the child's willingness to try new foods and their acceptance of FV six of the ten items from the CFNS were used,

H. Coulthard et al. / Appetite 120 (2018) 609 e615

611

originally developed by Pliner and Hobden (1992) . This shortened form is considered to be more suitable for use with young children (below 6 years) and has high Cronbach alpha scores ( a ¼ 0.84; Wardle, Carnell, & Cooke, 2005 ). The CFNS has been validated against behavioural measures of child neophobia ( Pliner, 1994 ). An example of an item is ' , My child is afraid to eat things s/he has never had before . All items are scored on a 4-point scale from strongly agree to strongly disagree, with a high score indicating greater child food neophobia. Portions of Fruit and Vegetables (parent and child). To mea- sure the typical portions of FV consumed by the child and parent in

a typical week, the parent completed a Likert scale for both

themselves and their child. This format has commonly been used in similar research ( Wardle et al., 2005 ), has been validated against 4- day diaries ( Bingham, Gill, Welch et al., 1994 ) and is a direct replication of that used by Coulthard and Blissett (2009) . In the child version, the parent was asked to rate how often, in a typical day, their child ate a portion of a) fruit and b) vegetable. The questions were comprised of the statement How often does your child eat followed by the food-group (1) vegetables (not potatoes), (2) fruit. The de nition of a portion was clearly de ned in the in- structions in accordance with UK government guidelines ( Department of Health, 2012 ), and was explained to the parent as the amount that can be held in the hand of the individual in question. Parents were asked to report the amount the child ate, so that if they typically only ate half a portion offered they wrote down half a portion, not one portion. They then lled in a similar scale for their own consumption. The sum of (1) fruit and (2) vegetable consumption were also totalled together to give a daily FV con- sumption score. Fruits Accepted. To assess the amount and variety of fruits previously tried and accepted by the child we asked parents to complete a checklist of 34 fruits commonly found in UK shops and supermarkets. This checklist has been used in a similar study ( Coulthard & Blissett, 2009 ). For each fruit listed the parent is required to mark whether their child has tried the fruit by marking either likes , dislikes ’ ‘ never tried or don't know . In the current study we used the range of fruits liked as a single fruit acceptance score, which was calculated by totalling the number of like re- sponses (0 e 34, with higher scores indicating a greater number of fruits liked). Tactile Sensitivity. To measure the relationship between the child's tactile processing and their relationship to fruit consump- tion we assessed tactile sensitivity through the tactile processing subscale of The Sensory Prole (SP; Dunn, 1999 ). The Tactile pro- cessing subscale of the SP has good reports of internal consistency ( Dunn, 1999 ) and high discriminate validity ( > 95%) of dis- tinguishing children with and without problems with sensory modulation ( McIntosh, Miller, & Shyu, 1999 ). We used the toddler version of the SP, which is suitable for use from 18 to 36 months ( Dunn & Daniels, 2002 ). Of the 15 items in the tactile processing subscale, we selected 10 pertaining to the tactile sensitivity (low threshold to touch). An example item is: My child avoids getting his/ her face wiped. Each item was scored on a ve point scale; Almost always (5), Frequently (4), Occasionally (3), Seldom (2), Almost never (1). Scores ranged from 10 to 50, with a high score being indicative of high tactile sensitivity. Non-food sensory play tasks. There were ve different non- food sensory play tasks, one of each was carried out each week with two of the experimental groups (combined sensory play and

non-food sensory play). Each task had a play narrative, and the texture of the substances varied each week (bubble mixture, our/ babyoil mixture, sand, goo, corn our/water mixture). An example

of a task was the buried treasure game. A bowl (20 cm 20 cm) was

lled with play sand, and play coins were hidden underneath the

sand. The child sat at the table in front of the bowl with their parent, and the researcher said There is some treasure buried in the sand. Can you nd the buried treasure by digging it out? For each child the researcher and the parent evaluated the child's enjoyment

of the feel of the game using a ve point scale from strongly agree (5) to strongly disagree (1), with a higher score indicating higher enjoyment of the feel of the game. Inter-rater reliability of the evaluation of liking the non-food sensory games between the parent and researcher was evaluated using mean interclass corre- lation (ICC) analysis. The levels of absolute agreement ranged from 0.75 to 0.92 between the two scorers, which was above acceptable levels of (ICC ¼ 0.6), therefore a mean score for enjoyment of each non-food sensory play task was calculated, ranging from 1 to 5 with

a higher score indicating higher enjoyment of the task. Fruit sensory play tasks. Children allocated to the combined sensory play condition also participated in ve different fruit sensory play tasks, with one of each being carried out each week based on a single fruit (blueberries, prunes, raspberries, passion

fruit, melon). The rationale for choosing these fruits was to ensure

a range of colour, texture and shape, to ensure a wide variety of

sensory experience and possible games. Each task had a narrative which focussed on the eventual aim of getting the child to put the food on their skin. The fruit was presented in a small bowl on the play table, and the child sat in front of the bowl with his/her mother. An example of a narrative was, We are going to play the ladybird game today, where we turn into ladybirds by putting spots on ourselves. Can you get some spots and put them on you (points to a bowl of blueberries). For each play task the researcher and the parent rated the child's enjoyment of the task on a ve point scale from strongly agree to strongly disagree with a high score indicating higher enjoyment of the game. Inter-rater reli- ability of the evaluation of enjoyment of the fruit play tasks be- tween the parent and researcher was evaluated using mean interclass correlation (ICC) analysis. The levels of absolute agree- ment ranged from 0.60 to 0.74 between the two scorers, which was above acceptable levels of (ICC ¼ 0.6), therefore a mean score for enjoyment of each of the fruit play tasks was calculated, ranging from 1 to 5 with a higher score indicating higher enjoy- ment of the fruit play task. Fruit taste exposure. On each of the ve weeks, the children in the two sensory play conditions and the exposure group were given

a small piece of fruit to taste. The fruit was always the same as that

used in the fruit sensory play task that week (blueberry, prune, raspberry, passion fruit, melon). The fruit tasting always occurred after the sensory play tasks had nished. These fruits had been prepared prior to the testing occasion in a food preparation envi- ronment. Each child was given a small piece of the fruit (approxi- mately 2 cm in size) on a white paper plate, and the researcher said I would like you try a piece of this . If the child was reluctant, they were prompted twice. Both the parent and researcher rated how much the child appeared to enjoy the fruit on a ve point scale from strongly agree (5) to strongly disagree (1), with a higher score indicating higher enjoyment of the fruit. Children were given a score of 0 if they refused to taste the fruit. Inter-rater reliability of the evaluation of liking the fruits between the parent and researcher was evaluated using mean interclass correlation (ICC) analysis. The levels of absolute agreement ranged from 0.89 to 0.95 between the two scorers, which was above acceptable levels of

(ICC ¼ 0.6), therefore a mean score for enjoyment of each of the fruits was calculated, ranging from 1 to 5 with a higher score indicating higher enjoyment of the fruit. Control play condition. In the control group, for the duration of the ve week intervention, the researcher came and played a game with the child each week which did not encompass messy play or exposure to fruits. Control group games included a shape sorting

612

H. Coulthard et al. / Appetite 120 (2018) 609e 615

game, a ring game, a jigsaw puzzle and block building game. The main aim of these games was to control for familiarisation with the researcher, and these games were not rated for enjoyment by the researcher and the parent. Week 6 follow up taste test (fruit liked). In week 6 all children were given a fruit taste test. They were presented with three fruits, one universally familiar fruit (banana), one fruit that had been used in the interventions (raspberry) and one fruit that was con rmed to be novel to all the children (fresh lychee). Each of the fruits was rated for baseline liking by the parent and how much the child enjoyed it on the taste testing occasion by both the researcher and the parent. The presentation and rating procedure was exactly the same as for the exposure tasks which had been carried out every week (see fruit taste exposure ). Inter-rater reliability of the evalua- tion of liking the fruits between the parent and researcher was evaluated using mean interclass correlation (ICC) analysis. The levels of absolute agreement ranged from 0.72 to 0.80 between the two scorers, which was above acceptable levels of (ICC ¼ 0.6). Therefore a mean score for enjoyment of each of the fruits was calculated, ranging from 1 to 5 with a higher score indicating higher enjoyment of the fruit. For each of the fruits a difference in acceptance score was calculated where the parent rating for how much the food was normally liked (1 e5 point scale, or 0 for never tried before) was subtracted from mean score for how much they enjoyed it on week 6 testing occasion (1 e5 point scale, or 0 for refusal to taste). The nal score for each of the foods indicated how much more they liked the fruit than they normally did on a scale from þ 5 to 5, with a high score indicating a higher change in enjoyment. In addition, a total score for the sum of the three dif- ference in acceptance scores, the nal fruit liked score, was calculated which ranged from þ 15 to 15, with a higher score indicating a greater change in preference for the fruits. Data analysis. All statistical tests were carried out on IBM SPSS statistical software version 22 ( IBM, 2013 ). Statistical signi cance was set at p 0.05 unless otherwise stated. Kolmogorov-Smirnov tests for normality and inspection of stem and leaf plots indicated that the majority of variables were normally distributed conse- quently parametric tests were carried out on the data. One way unrelated analyses of variance were carried out to examine de- mographic and baseline differences in age (child and parent), daily FV consumption (portions; child and parent), child tactile sensi- tivity, child food neophobia and range of fruits accepted (child), between the four experimental groups ( Table 1 ). It was found that there were differences in the range of fruits children accepted at baseline and the age of the child, so these were entered as cova- riates in subsequent analyses. One way analyses of covariance (ANCOVA) were carried out to examine differences in tasting and enjoying fruits at week 6 between the four experimental groups, after controlling for fruit acceptance (child) and age (child). Custom interaction models were carried out and it was found that the as- sumptions of linearity were met p > 0.05 in both interactions. Levene's test indicated that homogeneity of variance could be assumed for all analyses (p > 0.05). Pearson product-moment correlations were carried out to examine associations between rated enjoyment of the fruit games, non-food messy play games and liking the fruit at each of the ve intervention weeks. Finally, one way related analyses of variance (ANOVA) were carried out with Bonferroni post hoc tests, to examine differences in enjoyment of the ve fruit sensory play tasks and between the ve non-food sensory play tasks. In analyses where Mauchley's test indicated that sphericity had been violated ( p < 0.05 ), a Greenhouse Geiser correction was applied.

3. Results

3.1. Baseline characteristics across the four experimental groups

Table 1 shows the differences in the baseline characteristics of the child participants and their parents between the four condi- tions. It was found that there were two baseline differences be- tween the four experimental groups. Firstly there were differences in child age across the sample, F (3, 81) ¼ 4.62, p < 0.05, h ¼ 0.13, which indicated a large effect size. Bonferroni post hoc tests showed that the fruit exposure group and the combined sensory play group were younger than the non-food sensory play and the play control group. There were also differences in range of fruits accepted (child), F (3, 81) ¼ 4.67, p < 0.01, h ¼ 0.16, which indicated a large effect size. Bonferroni post hoc tests showed that children in the combined sensory play group had a lower baseline liking of fruits than those in the non-food sensory play condition (p < 0.05), the exposure condition ( p < 0.05 ) and the control condition ( p < 0.05 ).

2

p

2

p

3.2. Differences in fruit enjoyment post intervention between the

four experimental groups

One way analyses of covariance were carried out to examine whether there were differences in fruit enjoyment post- intervention, after controlling for the covariates of baseline fruits accepted (Child). There were differences in post-intervention total fruit enjoyment across the four experimental groups, F (3, 82) ¼ 5.46, p < 0.05 , h ¼ 0.18 which indicated a large effect size (see Table 2 ). It was found that children in the non-food sensory play condition enjoyed more fruits at follow up than children in the taste exposure or control condition. In addition, children in the combined sensory play condition enjoyed more fruits at follow up than children in the control condition. There were differences in lychee enjoyment post-intervention across the four experimental

¼ 0.12 which indicated a

groups, F (3, 82) ¼ 3.47, p < 0.05 , h

moderate effect size. In particular, children in the non-food sensory play condition enjoyed lychee more than children in the exposure or control conditions ( p < 0.05 ). Although there were no differences

in enjoyment of the novel fruit, Lychee, between the combined play condition and the other conditions, there was a trend for children in the combined play condition to enjoy lychee more than those in the taste exposure condition ( p < 0.10 ). There were also differences in raspberry liked at week 6, in particular raspberry was more liked in both the sensory play conditions compared to the control group ( p < 0.05 ). In addition banana at week 6 was liked more by children in the non-food sensory play group compared to control group children ( p < 0.05 ).

2

p

2

p

3.3. Relationships between sensory play tasks and fruit enjoyment

Pearson product moment correlations were carried out to examine relationships between enjoyment of play tasks and enjoyment of the exposure fruit across the ve week intervention period. It was found that enjoyment of the exposure fruit was associated with enjoyment of playing a game with the fruit (n ¼ 21) and also playing a game with a non-food substance (n ¼ 41) (see Table 3 ).

3.4. Differences in enjoyment of the sensory play tasks

Generally children in the combined sensory play condition, who took part in both fruit and non-food play tasks (n ¼ 21), were rated as enjoying the non-food play tasks more than the fruit play tasks, t(20) ¼ 6.47, p < 0.001. There were differences in enjoyment of the

H. Coulthard et al. / Appetite 120 (2018) 609 e615

613

Table 1 Differences in baseline variables across the four conditions (sensory combined play, sensory non-food play, taste exposure and control) in a sample of 1 e4 year old children (N ¼ 83).

 

Combined Sensory play þ taste exposure (n ¼ 21)

Nonfood sensory play þ taste exposure (n ¼ 20)

Taste exposure (n ¼ 21)

Control (n ¼ 21)

Total

Child age (years) Child Sex (Male, female) Parental age (years) Parental education (years) a Parental FV (portion/day) b Child FV (portion/day) b Tactile sensitivity Child food neophobia Fruit accepted (sum)

2.18(0.65)

2.96(0.83)

2.56(0.84)

2.75(0.71)*

2.75 (0.82)

6, 15

10, 10

10, 11

13, 8

39, 44

33.17 (7.64)

31.04(8.50)

36.19(4.53)

35.62 (4.53)

33.97 (7.11)

13.81(4.72)

16.68(3.73)

16.45(2.98)

17.00(1.86)

16.06(3.58)

2.88(1.69)

4.00(2.49)

3.93(1.75)

4.28(1.64)

3.72(1.99)

3.36(2.35)

4.48(2.09)

4.20(2.27)

4.12(1.31)

4.03(2.09)

15.16(3.64)

15.58(4.10)

14.31(3.47)

13.46(2.53)

14.73(3.55)

15.00(3.70)

12.40(3.55)

12.88(2.40)

13.00(4.44)

13.36(3.71)

10.22(4.10)

15.12(5.54)

15.44(5.91)

15.80(5.67)**

14.022

p < 0.05*, p < 0.001**.

a This was de ned as the period of time spent in education since the age of 4 years on entry to school. 16 years in education refers to degree level education.

b A portion was de ned as the amount of fruit or vegetable that can be held in the hand of the individual. Potatoes were not considered as a vegetable.

Table 2 Differences in fruit tasting post intervention between the four conditions (sensory combined play, sensory non-food play, taste exposure and contr ol) in a sample of 1 e4 year old children (N ¼ 83).

 

Combined Sensory play þ taste exposure (n ¼ 21) Mean (SD)

Non-food sensory play þ taste exposure (n ¼ 20) Mean (SD)

Taste exposure (n ¼ 21) Mean (SD)

Control (n ¼ 21) Mean (SD)

Lychee liked b Raspberry liked c Banana liked d Total fruit liked a

1.37(1.46)

2.32(2.06)

0.94(2.05)*

1.33(1.85)

0.53(1.62)*

0.24(1.37)*

0.13(2.31)

0.70(1.34)

0.83(1.86)

0.13(0.64)*

0.75(1.39)

1.55(2.01)

1.12(1.65) *

2.76(2.64) *

0.31(4.06)

0.93(4.07)

Differences relative to the control condition denoted by *, p < 0.05. All scores are difference scores.

2

a Covariates: Child fruit acceptance F (1, 82) ¼ 5.46*, h ¼ 0.18 Child age F (1, 82) ¼ 0.03, ns.

p

b Covariates: Child fruit acceptance F (1, 82) ¼ 7.97* h ¼ 0.10, Child age F (1, 82) ¼ 0.03, ns.

2

p

c Covariates: Child fruit acceptance F (1, 82) ¼ 0.39 nsChild age F (1, 82) ¼ 0.01, ns.

d Covariates: Child fruit acceptance F (1, 82) ¼ 1.41 ns Child age F (1, 82) ¼ 0.28, ns.

non-food sensory play games across the ve week intervention period in the two sensory play conditions (n ¼ 41), F (4, 156) ¼ 9.45, p < 0.001, h ¼ 0.20, which indicated a large effect size (see Table 4 ). In particular, games which incorporated clear goo and sand were less enjoyed than games which involved bubble mixture and those which involved baby oil and our (p < 0.05). There were also some differences in enjoyment of fruit play across the ve weeks by children in the combined sensory play group (n ¼ 21), F (2.55, 45.94) ¼ 3.16, p < 0.05 , h ¼ 0.15, which indicated a large effect size; the raspberry and passion fruit games were enjoyed less than the blueberry, melon and prune games ( p < 0.05 ).

2

p

2

p

4. Discussion

The main aim of the current study was to examine whether preschool children taking part in a ve week intervention of two different forms of sensory play combined with taste exposure

Table 3 Associations between enjoyment of the exposure fruit across the ve weeks, and play tasks in the two sensory play conditions in a sample of 1 e4 year old children.

 

Fruit game enjoyed (n ¼ 21)

Non-food game enjoyed (n ¼ 41)

Blueberry enjoyed

0.71**

0.34*

Prune enjoyed

0.48**

0.21ns

Raspberry enjoyed

0.63**

0.40*

Passionfruit enjoyed

0.56**

0.46**

Melon enjoyed

0.66**

0.55**

would have greater fruit acceptance than children who received ve weeks of taste exposure or ve weeks of non-sensory play. On the whole it was found that the sensory play groups showed a greater increase in enjoyment of fruits post-intervention compared to the exposure or control groups. The greatest increase in enjoy- ment was found in the non-food sensory play conditions, where children had greater enjoyment of fruits than children in both the exposure and control conditions. Children in the combined sensory play group, which comprised both fruit-based and non-food tactile sensory play plus fruit exposure, had a slightly increased enjoy- ment of fruits in comparison to the control condition but not the fruit exposure condition. From these pilot ndings playing sensory games with fruit had no additional bene t to fruit acceptance than that given by non-food sensory play. However, the sample size and the use of fruit which was already liked, may have contributed to this unexpected nding. These ndings support previous cross sectional research that enjoyment of sensory play with non-food substances is related to food neophobia ( Coulthard & Thaker, 2015; Coulthard & Sahota, 2016; Neederkorn et al., 2015 ). Although we didn't nd a clear bene t of fruit play over and above non-food play, overall these ndings support embedding an element of multisensory education into child based fruit and vegetable interventions ( Dazeley & Houston-Price, 2015 ; Hoppu et al., 2015; Witt & Dunn, 2012 ). Within each week, there were strong positive associations be- tween enjoyment of the fruit play task, enjoyment of the messy play task and enjoyment of tasting the fruit. This supports and strengthens previous cross sectional ndings that enjoyment of messy play tasks is associated with food acceptance. Most previous

614

H. Coulthard et al. / Appetite 120 (2018) 609e 615

Table 4 Mean enjoyment ratings of the sensory play games across the ve weeks in a sample of 1 e4 year old children.

 

Week 1

Week 2

Week 3

Week 4

Week 5

Fruit Fruit sensory play condition (n ¼ 21) Substance Both sensory play conditions (n ¼ 41)

Blueberry

Prunes

Raspberries

Passion fruit

Melon

3.62(0.86)

2.83(1.62)

2.76(0.87)*

2.29(1.39)*

2.95(1.75)

Bubble mixture

Baby oil and cornfour

Goo (agar agar)

Sand

Corn our and water

4.41(0.92)

4.52(0.84)

3.57(1.12)*

3.73(1.49)*

3.85(1.30)

studies have examined children on one testing occasion, sometimes with only two substances ( Coulthard & Sahota, 2016; Coulthard & Thaker, 2015 ) or with a variety of food and non-food substances ( Nederkoorn, Jansen, & Havermans, 2015 ). Often these studies have examined global enjoyment of touching messy substances with parental reports of food neophobia. This study examined enjoy- ment of non-food sensory play across substances ranging in texture from a familiar bubble mixture to goo which is slimy and leaves a trace on the hands. It could be argued that certain textures are more likely to elicit disgust responses ( Martins & Pliner, 2006 ), and that slimy textures are more similar to foods that have started to spoil and rot. In both fruit and non-food conditions, the games that were least liked by the child participants were those that were gooey or slimy, in particular the games that involved goo or passion fruit, which has an unusual texture of seeds in a glutinous pulp. It is possible that the dislike of gooey, slimy substances is culture spe- ci c, and dependent on the food environment, as some national cuisines do contain commonly consumed foods with a more glutinous texture. It would be interesting to examine whether dislike of the feel of gooey and slimy substances varies according to familiarisation with these substances in foods. It may be that any substance which leaves a residue on the hand is liked less than cleaner substances. The main limitation of the present study was that, as this was a pilot intervention, there were relatively small sample sizes in the experimental conditions. One of the reasons for the small sample size was that we delivered the intervention to one child at a time within the playgroup setting. This meant that we could examine differences in the child's enjoyment of the play activities across the ve weeks, and has provided a much richer data set of performance at each week that is missing from other sensory education studies. Other intervention studies have used private nursery or preschool settings, and delivered the intervention to a group ( Dazeley & Houston-Price, 2015; Hoppu et al., 2015; Witt & Dunn, 2012 ), which though cost effective does not allow evaluation of the tasks in more detail. In collecting ratings of all tasks our ndings can be used to plan future interventions in relation to which activities and substances are likely to be more or less accepted. The difference between our study and previous research is that our games are not based on sensory education, which centres on teaching children about the sensory qualities of the food, for example different tastes such as sweet and sour, and the smell of different foods (e.g. Dazeley & Houston-Price, 2015 ). Rather the fruits themselves were used as materials to be played with. The aim of encouraging children to engage with the substance on their skin was to encourage habituation to the sensory characteristics of the fruit, without the immediate pressure to try. This desensitisation method is proposed for use by therapists who work with children with sensory processing disorders ( Dunn, 1997 ), and also in non- research nursery groups ( Thomas, 2007). There has been no eval- uation of the effectiveness of using foods as stimuli to desensitise children to the non-taste characteristics of foods in an empirical study. It was found, within each week of the intervention, that enjoyment of fruit play was associated with enjoyment of tasting the fruit afterwards. We found, generally, that children preferred

playing sensory games with non-food substances to fruit sub- stances. This may be because children are taught from an early age by many parents not to play with their food, and therefore this may have seemed a naughty thing to do, especially as a parent was present on all occasions. In addition, we found that our group that received the fruit play intervention had much lower baseline fruit acceptance and were a slightly younger sample. Although age was not associated with food acceptance in the sample as a whole, baseline fruit acceptance was associated with taste exposure enjoyment and with enjoyment of fruits in week 6. Therefore, the slightly poorer performance of this sample could have been due to sample effects, despite the fact that we controlled for fruit accep- tance when evaluating differences between the groups at the end of the intervention. This problem was probably accentuated by the small n in each condition, which reduced statistical power. In the future it would be crucial to examine in greater detail the short term effects of getting children to play games with fruits and veg- etables prior to tasting in a larger sample size with a control group that has been matched for child age and baseline food acceptance variables. Exposure techniques in young children usually suggest repeated

presentation of the food to increase liking ( Birch et al., 1987; Holley et al., 2015 ). We offered a variety of exposure, with a different novel fruit each week, which in itself is known to promote acceptance of novel foods in infants ( Coulthard, Fogel, & Harris, 2014 ; Maier-

N oth, Schaal, Leathwood, & Issanchou, 2016 ) but may not have been enough to increase liking for the fruits in this preschool group. It was clear from the ndings that the variety of fruits liked was associated with the outcome liking of familiar and novel fruits. If we had exposed each child to the same ve novel fruits each week, and had used all ve novel fruits in the sensory games, perhaps may have led to greater effects relative to the control group. In addition, this play intervention was based on fruit consumption rather than vegetable and fruit consumption. It is widely accepted that vege- tables are less liked as a food group, partly because they generally contain less sugar and calories than fruits, and sometimes have a bitter back taste ( Caton et al., 2012; Cooke et al., 2003 ). The ratio- nale for using fruits was largely pragmatic; they are easier to pre- pare and buy in ready-prepared packs for testing in a playgroup environment. In addition, fruits tend to have softer, juicy textures, which are ideal for games which aim to leave a trace of substance on the skin. Interestingly Dazeley and Houston-Price (2015) found in their sensory education tasks that engagement in the activities led to greater touching and tasting of vegetables but not fruits. This may be because some of the fruit stimuli in their study were challenging, such as rhubarb, which is rarely eaten raw because it is very astringent whereas their vegetables were more palatable and similar to familiar foods, such as sweet potato. It is important that future research should examine sensory tactile play with vegeta- bles, and whether game-based tasks can encourage initial tasting and liking in this more challenging food group.

5. Conclusion

This pilot intervention study is one of the rst studies to

H. Coulthard et al. / Appetite 120 (2018) 609 e615

615

examine whether sensory play and taste exposure increases tasting and enjoyment of fruits. Although there were some differences in the baseline characteristics of the groups, it seems that generally sensory play interventions combined with exposure lead to greater enjoyment of fruits than the exposure alone or control conditions. Future research would need to examine whether interventions of this nature can be developed for preschool providers and by par- ents in the home environment. Further studies are needed to examine the particular barriers to fruit and vegetable acceptance in children who are more neophobic and have lower baseline accep- tance of fruits and vegetables. What is clear is that non-taste, game- based tasks, which are fun and engaging for young children, may be an excellent way to introduce children to novel foods, and reduce the number of exposures needed for preference to occur.

Funding disclosure

This study was funded by a grant from the Feeding for Life Foundation, which is funded by Danone. The funders had no role in the inception, design, results or write up of this study.

Con icts of interest

Danone manufactures commercial formula milks and baby foods. The authors have no con icts of interest.

Appendix A. Supplementary data

Supplementary data related to this article can be found at

References

Coulthard, H., Harris, G., & Fogel, A. (2014). Exposure to vegetable variety in infants

weaned at different ages. Appetite, 78 , 89 e 94. https://doi.org/10.1016/

Coulthard, H., & Sealy, A. (2017). Play with your food! Sensory play is associated with tasting of fruits and vegetables in preschool children. Appetite, 113 , 84 e 90.

with food neophobia in preschool children. Journal of the Academy of Nutrition and Dietetics, 115 (7), 1134 e1140 . Dauchet, L., Amouyel, P., Hercberg, S., & Dallongeville, J. (2006). Fruit and vegetable consumption and risk of coronary heart disease: A meta-analysis of cohort studies. The Journal of Nutrition, 136 (10), 2588 e 2593 . Dazeley, P., & Houston-Price, C. (2015). Exposure to foods' non-taste sensory properties. A nursery intervention to increase children's willingness to try fruit and vegetables. Appetite , 841 e846 . Department of Health. (2012). National diet and nutrition survey (2008/9-2010/11) . Retrieved 1/6/2015 from: https://www.gov.uk/government/news/st 317 Statistical-press-notice-national diet-and-nutrition-survey-headline-results- from-years-1-2-and-3 combined-2008-09-2010-11. Dovey, T. M., Aldridge, V. K., Dignan, W., Staples, P. A., Gibson, E. L., & Halford, J. C. (2012). Developmental differences in sensory decision making involved in deciding to try a novel fruit. British Journal of Health Psychology, 17 (2), 258 e 272 . Dunn, W. (1997). The impact of sensory processing abilities on the daily lives of young children and their families: A conceptual model. Infants & Young Children, 9 (4), 23 e35 . Dunn, W. (1999). The sensory Pro le: User's manual . San Antonio, TX: Psychological Corporation . Dunn, W., & Daniels, D. B. (2002). Initial development of the infant/toddler sensory prole. Journal of Early Intervention, 25 (1), 27 e41. Holley, C. E., Haycraft, E., & Farrow, C. (2015). 'Why don't you try it again?' A comparison of parent led, home based interventions aimed at increasing chil- dren's consumption of a disliked vegetable. Appetite, 87, 215 e 222 . Hoppu, U., Prinz, M., Ojansivu, P., Laaksonen, O., & Sandell, M. A. (2015). Impact of sensory-based food education in kindergarten on willingness to eat vegetables and berries. Food & Nutrition Research, 59 . https://doi.org/10.3402/ fnr.v59.28795 . Horne, P. J., Greenhalgh, J., Erjavec, M., Lowe, C. F., Viktor, S., & Whitaker, C. J. (2011). Increasing pre-school children's consumption of fruit and vegetables. A modelling and rewards intervention. Appetite, 56 (2), 375 e 385 . Howard, A. J., Mallan, K. M., Byrne, R., Magarey, A., & Daniels, L. A. (2012). Toddlers' food preferences: The impact of novel food exposure, maternal preferences and food neophobia. Appetite, 59 (3), 818 e 825 . IBM Corp Released. (2013). IBM SPSS statistics for windows. Armonk, NY: IBM Corp Version Jones, B. A., Madden, G. J., & Wengreen, H. J. (2014). The FIT game: Preliminary evaluation of a gami cation approach to increasing fruit and vegetable con- sumption in school. Preventive Medicine, 68 , 76 e 79 . Laureati, M., Bergamaschi, V., & Pagliarini, E. (2014). School-based intervention with children, Peer modelling, reward and repeated exposure reduces food neo- phobia and increase liking of fruits and vegetables. Appetite, 83 , 26 e 32 .

Maier-N oth, A., Schaal, B., Leathwood, P., & Issanchou, S. (2016). The lasting in- uences of early food-related variety experience: A longitudinal study of vegetable acceptance from 5 Months to 6 Years in two populations. PLoS ONE, 11 (3), e0151356 . Martins, Y., & Pliner, P. (2006). Ugh! That's disgusting! Identi cation of charac- teristics of foods underlying rejections based on disgust. Appetite, 46 (1), 75 e 85 . McIntosh, D. N., Miller, L. J., & Shyu, V. (1999). Development and validation of the short sensory prole. In W. Dunn (Ed.), Sensory pro le manual (pp. 59 e73). San Antonio, TX: Psychological Corporation . Nederkoorn, C., Jansen, A., & Havermans, R. C. (2015). Feel your food. The in uence of tactile sensitivity on picky eating in children. Appetite, 84 , 7 e10 . Pliner, P. (1994). Development of measures of food neophobia in children. Appetite, 23 , 147 e163 . Pliner, P., & Hobden, K. (1992). Development of a scale to measure the trait of food neophobia in humans. Appetite, 19 (2), 105 e120 . Rozin, P., Haidt, J., & McCauley, C. R. (2008). Disgust. In M. Lewis, J. M. Haviland- Jones, & L. F. Barrett (Eds.), Handbook of emotions (3rd ed., pp. 757 e776) . Sullivan, S. A., & Birch, L. L. (1990). Pass the sugar, pass the salt: Experience dictates preference. Developmental Psychology, 26 (4), 546 e 551. Thomas, L. (2007). Mange-tout: Teaching your child to love fruits and vegetables without tears . London: Joseph . Wardle, J., Carnell, S., & Cooke, L. (2005). Parental control over feeding and chil- dren's fruit and vegetable intake: How are they related? Journal of the American

Dietetic Association, 105 (2), 227 e232 . Werthmann, J., Jansen, A., Havermans, R., Nederkoorn, C., Kremers, S., & Roefs, A. (2015). Bits and pieces. Food texture in uences food acceptance in young children. Appetite, 84 , 181 e187. https://doi.org/10.1016/j.appet.2014.09.025 . Witt, K. E., & Dunn, C. (2012). Increasing fruit and vegetable consumption among pre-schoolers: Evaluation of colour me healthy. Journal of Nutrition Education and Behaviour, 44 (2), 107 e113 . Zeinstra, G. G., Koelen, M. A., Kok, F. J., & de Graaf, C. (2010). The in uence of preparation method on childrens liking for vegetables. Food Quality and Pref- erence, 21 (8), 906 e 914. https://doi.org/10.1016/j.foodqual.2009.12.006 .