Strategies to encourage healthy eating
among children and young adults
PHC854 Ruxton C, Derbyshire E (2014) Strategies to encourage healthy eating among children
and young adults. Primary Health Care. 24, 5, 33-41. Date of submission: November 25 2013.
Date of acceptance: January 27 2014.
Abstract
There is a need for children and young people to improve their diets to meet recommended targets for fat, sugar, fibre, vitamins and minerals. Yet, efforts to promote healthy eating in research studies or in national campaigns have been unsuccessful or resulted in small changes to behaviour. The available evidence, albeit limited, suggests that the most effective healthy eating strategies involve techniques such as providing personalised information and incentives, supporting behavioural change, encouraging self-efficacy, where patients take control over their health, and using social media and technology to deliver messages. Nurses have an important role in supporting dietary improvement in children and young people, particularly to increase intakes of nutrients known to support growth and development, such as iron, calcium, vitamin D and long-chain omega-3 fatty acids. Advice should include both food consumption and appropriate use of dietary supplements as the latter can help bridge the gap between recommendations and current low intakes of certain nutrients.
Evidence from healthy eating trials
Table 4 provides evidence from international studies that have attempted to improve dietary intakes
in children and young adults. Of the studies identified, educational sessions, teacher training and the distribution of newsletters and brochures appear to be the most successful and commonly used interventions. Providing free FV has improved school pupils’ micronutrient intakes (Clarke et al 2009), but not total daily intakes (Schagenet al 2005), and supplying children with food boxes and bags led to children having lunches that were more in line with UK government standards (Evans et al 2010). Most interventions have focused on ways to improve FV intakes in children and young people. In Australia, the fruit and vegetable sense session – an educational scheme targeted at parents – led to significant improvements in children’s FV intakes, which increased by about 0.62 servings (Glasson et al 2012). Young economically disadvantaged Americans aged 18-24, provided with educational materials and supported by telephone follow up, also had improved FV intakes (Nitzkeet al 2007). Average intakes following intervention were 4.9 servings a day, compared with 4.6 servings a day in the control group.
The American HEALTHY study (Siega-Rizet al 2011) also investigated the effects of making simple changes in the school cafeteria, snack bars, school stores and vending machines. These changes led to daily fruit intakes increasing by an average of 10%, compared with intakes in control schools. An Italian study tested the effects of education programmes delivered to teachers; compared with baseline, FV intakes were 45% higher in schools where teachers had attended a course led by a nutritionist and 38% higher when teachers participated in self-training programmes (Panunzioet al 2011). Two recent studies looked at ways to improve fibre and wholegrain intakes in children and young people. Constipation occurs in 5-30% of children (National Institute for Health and Care Excellence 2010) and may be partially attributed to low fibre intakes (Stewart and Schroeder 2013). One behavioural intervention combining a self-monitoring and reward system helped to improve significantly fibre intakes in children with functional constipation after three months, but these effects were not sustained at six or 12 months, indicating that it may be difficult for children to maintain high fibre diets (Sullivan et al 2012).
A study in eight UK schools in low income and/ or ethnically diverse areas asked girls aged 12-16 years to complete a computerised test. They were then randomised to receive a tailored intervention leaflet or a generic leaflet with a view to improving wholegrain intakes. Girls receiving the intervention ate about 0.35 more servings of brown bread weekly than the control group compared with baseline, indicating that the tailored leaflet was more effective (Rees et al 2010). That said, the effects of this intervention were rather small, indicating that more could be done to improve dietary intakes in teenage girls. Three major studies have looked at ways to modify
beverage habits in young people. The CHOICE (Choose Healthy Options Consciously Everyday) study randomized young people to swap calorie-containing beverages for water or ‘diet’ beverages. Young people drinking diet beverages had significantly lower energy intakes than the water group, while FV intakes significantly improved in the water group (Piernaset al 2013). Overall, these findings show that changing beverage habits may also lead to alterations in dietary habits, but more work is needed to confirm this. The HEALTHY study mentioned earlier also found that changing the food and beverage options available in schools led to significant improvements in water intakes, increasing them by about 56mL compared with intakes in control schools (Siega-Rizet al 2011). Two trials looked into how alcohol intakes could be reduced in young people. An Australian study focusing on parent education and student awareness about the effects of alcohol misuse found that these approaches helped to reduce students’ alcohol use. They were also less likely to use alcohol frequently or progress to heavy use (Toumbourouet al 2013). However, a Swiss study found that an alcohol intervention conducted on 16 to 18 year olds was ineffective, possibly because heavier drinkers may have needed a more intensive programme (Gmelet al 2012). Other studies have offered more general advice to children and young people. For example,
Paineauet al (2010) found that small dietary changes such as changing serving sizes, cooking methods or
substituting foods worked best, and participants were more likely to improve nutrition choices. A ten-week multi-interventionprogramme comprising lectures, brochures and text messages to students significantly improved their dietary intakes and boosted energy levels, as well as their daily intakes of carbohydrate, calcium, vitamin C, thiamine, fruit, fish, eggs and milk. Correspondingly, it resulted in a reduction in their intakes of processed foods compared with a control group (Shahrilet al 2012). Overall, these findings suggest that, while most dietary interventions have had a degree of success, the level of change is generally small. In addition, few studies have shown sustained effects, indicating that
many interventions provide short-term benefits only.
Healthy eating campaigns in the UK
A number of healthy eating campaigns have been established with a view to improving dietary behaviours
and reducing the risk of obesity among young people. Some have been more successful than others. For
example, the UK School Fruit and Vegetable Scheme (SFVS), which still runs today, is a Department
for Education programme introduced in 2004 that entitles every child between the ages of four and
six to a piece of fruit or vegetable each school day (NHS Supply Chain 2013). The efficacy of the SFVS was evaluated by Schagenet al (2005) who found a non-significant improvement in FV intakes in the intervention group (3.65 daily FV portions) compared with the control group (3.28 FV portions), although it was noted that home FV intakes appeared to drop when free FV was offered at school. A similar European Union-wide programme, known as the School Fruit Scheme, has also now been established to provide sustainable FV to schools (European Commission 2009). The Children’s Food Trust (2013a) has developed a number of policies with a view to improving children’s health. These include banning savoury snacks high in salt and fat, such as crisps, and allowing only nuts, seeds and FV with no added salt, fat or sugar. A similar policy has also been applied to drinks, with only water, low-fat milk, fruit juice or combinations of these allowed (Children’s Food Trust 2013b), although the efficacy of these policies is yet to be reported. Certain celebrity campaigns, such as Jamie Oliver’s school meals, have influenced government policy and may provide benefits. An independent study of 11-year-old pupils eating Jamie Oliver’s school meals showed that their performance improved by 8% in science and 6% in English, while absenteeism due to ill health fell by 15% (Waite 2009). The Food Dudes healthy eating programme is an example of an earlier motivational campaign aimed at improving FV intakes in children aged 2-7 years. Children were provided with a video of the Food Dudes telling them that if they ate more FV, they could join the Dudes’ struggle to save the health of the children of the world and defeat the evil ‘General Junk’. Non-food treats, such as stickers, badges and pencils, were awarded to children who consumed sufficient quantities of targeted foods. By the end of the intervention (two to three weeks later) children were eating 100% of their fruit and 83% of their vegetables, and intakes remained relatively high even six months later (Horne et al 2004). Ireland adopted the Food Dudes programme in 2007. The government’s UK-wide Healthy Start scheme is available for pregnant teenagers and for women with children under the age of four who also receive income support or child tax credits (Healthy Start 2013). The scheme provides free vouchers that can be spent each week on milk, fresh and frozen FV and infant formula milk. Free vitamins are also provided, but problems relating to their supply and distribution have resulted in just 10% of eligible individuals receiving supplements (DH 2013). Other campaigns have been developed with a view
to lowering alcohol intakes among young people in the UK. The Dr
Strategies to encourage healthy eating
among children and young adults
PHC854 Ruxton C, Derbyshire E (2014) Strategies to encourage healthy eating among children
and young adults. Primary Health Care. 24, 5, 33-41. Date of submission: November 25 2013.
Date of acceptance: January 27 2014.
Abstract
There is a need for children and young people to improve their diets to meet recommended targets for fat, sugar, fibre, vitamins and minerals. Yet, efforts to promote healthy eating in research studies or in national campaigns have been unsuccessful or resulted in small changes to behaviour. The available evidence, albeit limited, suggests that the most effective healthy eating strategies involve techniques such as providing personalised information and incentives, supporting behavioural change, encouraging self-efficacy, where patients take control over their health, and using social media and technology to deliver messages. Nurses have an important role in supporting dietary improvement in children and young people, particularly to increase intakes of nutrients known to support growth and development, such as iron, calcium, vitamin D and long-chain omega-3 fatty acids. Advice should include both food consumption and appropriate use of dietary supplements as the latter can help bridge the gap between recommendations and current low intakes of certain nutrients.
Evidence from healthy eating trials
Table 4 provides evidence from international studies that have attempted to improve dietary intakes
in children and young adults. Of the studies identified, educational sessions, teacher training and the distribution of newsletters and brochures appear to be the most successful and commonly used interventions. Providing free FV has improved school pupils’ micronutrient intakes (Clarke et al 2009), but not total daily intakes (Schagenet al 2005), and supplying children with food boxes and bags led to children having lunches that were more in line with UK government standards (Evans et al 2010). Most interventions have focused on ways to improve FV intakes in children and young people. In Australia, the fruit and vegetable sense session – an educational scheme targeted at parents – led to significant improvements in children’s FV intakes, which increased by about 0.62 servings (Glasson et al 2012). Young economically disadvantaged Americans aged 18-24, provided with educational materials and supported by telephone follow up, also had improved FV intakes (Nitzkeet al 2007). Average intakes following intervention were 4.9 servings a day, compared with 4.6 servings a day in the control group.
The American HEALTHY study (Siega-Rizet al 2011) also investigated the effects of making simple changes in the school cafeteria, snack bars, school stores and vending machines. These changes led to daily fruit intakes increasing by an average of 10%, compared with intakes in control schools. An Italian study tested the effects of education programmes delivered to teachers; compared with baseline, FV intakes were 45% higher in schools where teachers had attended a course led by a nutritionist and 38% higher when teachers participated in self-training programmes (Panunzioet al 2011). Two recent studies looked at ways to improve fibre and wholegrain intakes in children and young people. Constipation occurs in 5-30% of children (National Institute for Health and Care Excellence 2010) and may be partially attributed to low fibre intakes (Stewart and Schroeder 2013). One behavioural intervention combining a self-monitoring and reward system helped to improve significantly fibre intakes in children with functional constipation after three months, but these effects were not sustained at six or 12 months, indicating that it may be difficult for children to maintain high fibre diets (Sullivan et al 2012).
A study in eight UK schools in low income and/ or ethnically diverse areas asked girls aged 12-16 years to complete a computerised test. They were then randomised to receive a tailored intervention leaflet or a generic leaflet with a view to improving wholegrain intakes. Girls receiving the intervention ate about 0.35 more servings of brown bread weekly than the control group compared with baseline, indicating that the tailored leaflet was more effective (Rees et al 2010). That said, the effects of this intervention were rather small, indicating that more could be done to improve dietary intakes in teenage girls. Three major studies have looked at ways to modify
beverage habits in young people. The CHOICE (Choose Healthy Options Consciously Everyday) study randomized young people to swap calorie-containing beverages for water or ‘diet’ beverages. Young people drinking diet beverages had significantly lower energy intakes than the water group, while FV intakes significantly improved in the water group (Piernaset al 2013). Overall, these findings show that changing beverage habits may also lead to alterations in dietary habits, but more work is needed to confirm this. The HEALTHY study mentioned earlier also found that changing the food and beverage options available in schools led to significant improvements in water intakes, increasing them by about 56mL compared with intakes in control schools (Siega-Rizet al 2011). Two trials looked into how alcohol intakes could be reduced in young people. An Australian study focusing on parent education and student awareness about the effects of alcohol misuse found that these approaches helped to reduce students’ alcohol use. They were also less likely to use alcohol frequently or progress to heavy use (Toumbourouet al 2013). However, a Swiss study found that an alcohol intervention conducted on 16 to 18 year olds was ineffective, possibly because heavier drinkers may have needed a more intensive programme (Gmelet al 2012). Other studies have offered more general advice to children and young people. For example,
Paineauet al (2010) found that small dietary changes such as changing serving sizes, cooking methods or
substituting foods worked best, and participants were more likely to improve nutrition choices. A ten-week multi-interventionprogramme comprising lectures, brochures and text messages to students significantly improved their dietary intakes and boosted energy levels, as well as their daily intakes of carbohydrate, calcium, vitamin C, thiamine, fruit, fish, eggs and milk. Correspondingly, it resulted in a reduction in their intakes of processed foods compared with a control group (Shahrilet al 2012). Overall, these findings suggest that, while most dietary interventions have had a degree of success, the level of change is generally small. In addition, few studies have shown sustained effects, indicating that
many interventions provide short-term benefits only.
Healthy eating campaigns in the UK
A number of healthy eating campaigns have been established with a view to improving dietary behaviours
and reducing the risk of obesity among young people. Some have been more successful than others. For
example, the UK School Fruit and Vegetable Scheme (SFVS), which still runs today, is a Department
for Education programme introduced in 2004 that entitles every child between the ages of four and
six to a piece of fruit or vegetable each school day (NHS Supply Chain 2013). The efficacy of the SFVS was evaluated by Schagenet al (2005) who found a non-significant improvement in FV intakes in the intervention group (3.65 daily FV portions) compared with the control group (3.28 FV portions), although it was noted that home FV intakes appeared to drop when free FV was offered at school. A similar European Union-wide programme, known as the School Fruit Scheme, has also now been established to provide sustainable FV to schools (European Commission 2009). The Children’s Food Trust (2013a) has developed a number of policies with a view to improving children’s health. These include banning savoury snacks high in salt and fat, such as crisps, and allowing only nuts, seeds and FV with no added salt, fat or sugar. A similar policy has also been applied to drinks, with only water, low-fat milk, fruit juice or combinations of these allowed (Children’s Food Trust 2013b), although the efficacy of these policies is yet to be reported. Certain celebrity campaigns, such as Jamie Oliver’s school meals, have influenced government policy and may provide benefits. An independent study of 11-year-old pupils eating Jamie Oliver’s school meals showed that their performance improved by 8% in science and 6% in English, while absenteeism due to ill health fell by 15% (Waite 2009). The Food Dudes healthy eating programme is an example of an earlier motivational campaign aimed at improving FV intakes in children aged 2-7 years. Children were provided with a video of the Food Dudes telling them that if they ate more FV, they could join the Dudes’ struggle to save the health of the children of the world and defeat the evil ‘General Junk’. Non-food treats, such as stickers, badges and pencils, were awarded to children who consumed sufficient quantities of targeted foods. By the end of the intervention (two to three weeks later) children were eating 100% of their fruit and 83% of their vegetables, and intakes remained relatively high even six months later (Horne et al 2004). Ireland adopted the Food Dudes programme in 2007. The government’s UK-wide Healthy Start scheme is available for pregnant teenagers and for women with children under the age of four who also receive income support or child tax credits (Healthy Start 2013). The scheme provides free vouchers that can be spent each week on milk, fresh and frozen FV and infant formula milk. Free vitamins are also provided, but problems relating to their supply and distribution have resulted in just 10% of eligible individuals receiving supplements (DH 2013). Other campaigns have been developed with a view
to lowering alcohol intakes among young people in the UK. The Dr
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