1. Nutritional Epidemiology Group Centre for Epidemiology and Biostatistics Promoting healthy snacks and lunches to children Janet Cade HDC/STC Spring Conference. 19 th April 2010

2. Nutritional Epidemiology Group Centre for Epidemiology and Biostatistics How to move from…. this …….to this….

3. Nutritional Epidemiology Group Centre for Epidemiology and Biostatistics Background Children’s fruit and vegetable intake is low. Typical intake is 2.5 portions per day. 10-20% eat no fruit or vegetables daily Low intakes are associated with higher CVD and cancer rates obesity - growing problem (NDNS, 2001; Ransley et al, 2007)

4. Nutritional Epidemiology Group Centre for Epidemiology and Biostatistics Foresight Report, 07 By 2050, 60% of males and 50% females could be obese Costs to NHS would be £5.5 billion by 2050, plus wider costs to society and business of £49.9 billion The size of the problem:

5. Nutritional Epidemiology Group Centre for Epidemiology and Biostatistics Obese Kids – the corporate threat? W/S 2002 Average 2 weekly penetration

6. Nutritional Epidemiology Group Centre for Epidemiology and Biostatistics Obesity system map

7. Nutritional Epidemiology Group Centre for Epidemiology and Biostatistics National priority (UK) ‘Our ambition is to be the first major nation to reverse the rising tide of obesity and overweight in the population by ensuring that everyone is able to achieve and maintain a healthy weight. Our initial focus will be on children: by 2020, we aim to reduce the proportion of overweight and obese children to 2000 levels’.

8. Nutritional Epidemiology Group Centre for Epidemiology and Biostatistics

9. Nutritional Epidemiology Group Centre for Epidemiology and Biostatistics Potential areas for intervention: Healthy snacks/ lunches school curriculum whole school approaches Lunches gardening home TV viewing Costs Cooking availability

10. Nutritional Epidemiology Group Centre for Epidemiology and Biostatistics Key ingredients….. Familiarisation Repetition Activities Modelling Environment

11. Nutritional Epidemiology Group Centre for Epidemiology and Biostatistics ‘I don’t like it!’ Food neophobia the innate fear of new foods – most common in children between 2 to 3y but which can persist into adulthood. Savage J, Fisher J and Birch L. Parental influence on eating behaviour: conception to adolescence. Journal of Law, Medicine and Ethics 2007; 35, 22-34 Children prefer some tastes to others however children learn preferences for foods made available to them. Birch, L. (Development of food preferences. Annual Review of Nutrition 1999; 19, 41-62

12. Nutritional Epidemiology Group Centre for Epidemiology and Biostatistics Reducing fear of eating new foods in children give repeated opportunities to taste small amounts of the new food without punishment for refusal/dislike. 2 - 12 tastes of new food before accepted; fear of foods can be changed. support children in trying new tastes in safe and non- coercive settings Cooke L, Wardle J, et al Demographic, familial and trait predictors of fruit and vegetable consumption by pre- school children. Public Heath Nutrition 2003;7,295-302 Birch L. and Fisher J. (1998) Development of eating behaviours among children and adolescents. Paediatrics 1998;101, 539-549

13. Nutritional Epidemiology Group Centre for Epidemiology and Biostatistics School Fruit & Vegetable Scheme (SFVS) provides a piece of fruit or vegetable free to all 4-6 years olds the biggest health initiative for child nutrition since free milk in 1946 Since 2004 over 2 million children in 18 000 schools receive an item of fruit/vegetable everyday cost £42 million to set up with further £77 million + from the Department of Health

14. Nutritional Epidemiology Group Centre for Epidemiology and Biostatistics Follow up ReceptionYear 1Year 2 Fruit & veg intake portions 3 months 0.5 (0.3 to 0.7) 0.7 (0.3 to 1.0) 0.5 (0.2 to 0.9) 7 months 0.2 (0 to 0.4) 0.2 (-0.2 to 0.6) -0.2 (-0.5 to 0.2) School Fruit & Vegetable Scheme: intake after 3 & 7 months Ransley et al Journal Of Epidemiology and Community Health 2007 14 Impact of SFVS (mean difference, 95% CI)

15. Nutritional Epidemiology Group Centre for Epidemiology and Biostatistics Complex Interventions: eg. Project Tomato school elements National curriculum: Science; Design and Technology; PHSE & Citizenship lessons (lessons) Tasting sessions: 4 -12 per term Gardening and growing (linked with RHS Grow it, cook it, eat it programme) Cooking Project Tomato Team Project manual

16. Nutritional Epidemiology Group Centre for Epidemiology and Biostatistics Intervention - home Examples of the different types of items sent home to parents and children 16

17. Nutritional Epidemiology Group Centre for Epidemiology and Biostatistics Did it work?

18. Nutritional Epidemiology Group Centre for Epidemiology and Biostatistics BUT.. Did they use the material? Teacher’s average implementation scores of the Project Tomato school items (range 0-100) 18

19. Nutritional Epidemiology Group Centre for Epidemiology and Biostatistics Results: home items Children’s average implementation scores for Project Tomato Home items (range 0-100) 19

20. Nutritional Epidemiology Group Centre for Epidemiology and Biostatistics What about those who did use the materials? High implementation by parents Children ate 2x as much fruit and veg as low implementation High implementation by children Children ate @40% more fruit and veg Adjusted for baseline fruit and vegetable intake, gender, IMD, and ethnicity. 20

21. Nutritional Epidemiology Group Centre for Epidemiology and Biostatistics Packed lunches: School meals standards Food based standards. A lunch should have: 1.starchy food 2.protein food 3.dairy food 4.fruit 5.Vegetables A lunch should not contain savoury snacks (crisps), confectionery, sweetened drinks Nutrient based standards. A lunch should contain 1.557 kcal (+/- 5%) 2.Less than 21g of fat 3.Less than 16g of Non milk extrinsic sugars (NMES) 4.Less than 499mg of sodium

22. Nutritional Epidemiology Group Centre for Epidemiology and Biostatistics National survey of packed lunches: food provided Proportion of children’s packed lunches meeting the school meal standards Evans et al, 2010

23. Nutritional Epidemiology Group Centre for Epidemiology and Biostatistics SMART lunchbox intervention UK Survey of children’s packed lunches

24. Nutritional Epidemiology Group Centre for Epidemiology and Biostatistics Results: Foods provided & consumed control vs intervention

25. Nutritional Epidemiology Group Centre for Epidemiology and Biostatistics New project new Regional Advisor based in London to work closely with 10 Partner primary schools twilight training sessions for other local schools – Associate Schools can gardening support increasing intake of fruit & veg?

26. Nutritional Epidemiology Group Centre for Epidemiology and Biostatistics Home parents are key! TV costs cooking/environment availability

27. Nutritional Epidemiology Group Centre for Epidemiology and Biostatistics Control of TV advertising April 2007, Ofcom broadcasting restrictions to reduce exposure of children to TV advertising of foods high in fat, saturated fat, salt and sugar (HFSS). At that time, 80% of all food advertising expenditure in children's airtime on terrestrial channels was for HFSS foods. estimate that 40% of all food and drink TV ads seen by children were for HFSS foods

28. Nutritional Epidemiology Group Centre for Epidemiology and Biostatistics Has it made any difference? Ofcom report Dec 2008 34% decrease in HFSS ads to children 4-15y (July 07-08) 22% increase in use of celebrities in HFSS ads – all in adult airtime estimate further decline following ban to children’s channels from Jan 09.

29. Nutritional Epidemiology Group Centre for Epidemiology and Biostatistics For every £1 spent by governments and the W.H.O promoting healthy foods the food industry spends £500 promoting ‘unhealthy foods’.

30. Nutritional Epidemiology Group Centre for Epidemiology and Biostatistics Home – food availability: Food prices – fruit and vegetables considered expensive Taxing policies? – fat tax/thin subsidy (too blunt, disadvantage poorest)

31. Nutritional Epidemiology Group Centre for Epidemiology and Biostatistics Cooking skills 50% of all ready meals in Europe consumed in UK we are forgetting how to cook!

32. Nutritional Epidemiology Group Centre for Epidemiology and Biostatistics if prepared food is so easily accessible, why bother to learn to cook? If you haven’t acquired cooking skills, then fast foods are the most efficient answer. (Lang and Caraher, 2001)

33. Nutritional Epidemiology Group Centre for Epidemiology and Biostatistics Conclusions: school based interventions can improve children’s diet (especially those with lowest fruit and veg intake) (Summerbell et al, 2007) home environment more challenging

34. Nutritional Epidemiology Group Centre for Epidemiology and Biostatistics People are like Potatoes! Some people never seem motivated to participate, but are content to watch others... They are called "Speck Tators." Some are always looking to cause problems and really get under your skin... They are called "Aggie Tators." There are those who are always saying they will, but somehow, they never get around to doing... We call them "Hezzie Tators." (From the laughalot-owner on the Net)