The Scottish Health Survey 2011 - volume 2: children

3 Diet

Linsay Gray and Alastair H Leyland

SUMMARY

• In 2011, children aged 2-15 consumed a mean of 2.7 portions of fruit and vegetables per day (2.7 for boys and 2.8 for girls).
• Between 2003 and 2011 there was no significant change in the mean portions of fruit and vegetables consumed or the proportion of children meeting the recommendation to eat five or more portions.
• 13% of boys and 12% of girls met the recommended daily intake of five or more portions of fruit and vegetables per day in 2011.
• Children's mean daily consumption of fruit and vegetables varied significantly with age, varying from 3.2 portions among those aged 2-4 to 2.5 for those aged 13-15.
• One in ten children (9%) consumed no portions of fruit and vegetables with the likelihood of doing this increasing significantly with age. 5% of children aged 2-4 consumed no portions of fruit and vegetables compared with 14% of those aged 13-15.
• Children with at least one parent who met the recommended daily intake of fruit and vegetables consumed more portions on average, and were more likely to meet the recommended daily intake, than children with parents who did not meet the recommendations.
• There have been some improvements to children's diets since 2003. Consumption of oily fish (once a week or more) among children rose from 8% in 2003 to 14% in 2010/2011. White fish consumption (once a week or more) also increased in this period from 42% to 49%.
• Since 2003 the proportions eating some unfavourable food items has decreased. For example, the proportion of children aged 2-15 consuming crisps once a day or more decreased from 52% to 38% in 2010/2011. Consumption of chips two or more times a week also fell from 54% in 2003 to 42% in 2010/2011.
• There has however been a slight decrease in the proportion of children eating tuna fish once a week or more (from 33% to 29% in 2010/2011) and an increase in the proportion eating red meat two or more times a week (from 53% to 58% in 2010/2011).
• Eating habits were broadly similar for boys and girls, with some notable exceptions. In 2010/2011, boys were more likely than girls to eat meat products at least twice a week (43% versus 35%) and biscuits once a day or more (44% versus 36%), whereas girls were more likely than boys to eat tuna fish at least once a week (33% versus 25%).

3.1 INTRODUCTION

Much of Scotland's poor health can be attributed to its unhealthy diet. Previous research has shown that children and young people in Scotland follow a diet that falls short of national recommendations and is less healthy than that of children in other European countries.^[1] Low consumption of fruit and vegetables is a risk factor for cardiovascular disease, cancer, hypertension, type 2 diabetes and obesity. The World Health Organisation (WHO) recommends adults eat at least five varied portions - where a portion is defined as 80g - of fruit and vegetables a day.

The fruit and vegetable consumption chapter in the 2008 and 2010 Scottish Health Survey (SHeS) reports^[2] and the diet chapter in the 2009 report^[3] provided overviews of the policy context from the mid 1990s onwards. They outlined a number of actions taken by the Government and NHS Scotland to improve diets in Scotland, including initiatives designed to encourage more fruit and vegetable consumption, in line with the recommendation to eat at least five portions of fruit and vegetables a day. These included:

• The Scottish Diet Action Plan,^[4] which outlined the Scottish Dietary Targets.^[5]
• The White Paper Towards a Healthier Scotland.^[6]
• The Scottish Executive's Improving Health in Scotland - the Challenge paper.^[7]
• The Hungry for Success initiative.^[8]
• A framework for implementing the Diet Action Plan: Eating for health meeting the challenge.^[9]
• The Scottish Government's Better Health, Better Care Action Plan.^[10]
• Healthy Eating, Active Living: An action plan to improve diet, increase physical activity and tackle obesity (2008-2011).^[11]
• The Scottish Government's Preventing Obesity Route Map.^[12]
• The Schools (Health Promotion and Nutrition) (Scotland) Act.^[13]

Children and young people feature prominently in the Scottish Government's Preventing Obesity Route Map Action Plan^[14] published in 2011. The plan includes actions to reduce energy consumption and encourage active living with the long-term goal to reduce overweight and obesity in the Scottish population. It outlines strategies for liaising with the food and drink industries, consumer groups, schools and the public sector, focusing on education, facilitating behaviour change and reshaping food environments by addressing food product reformulation, portion sizes, stocking policies, pricing, labelling and packaging, and marketing. Allied to the Action Plan, a set of 16 indicators and associated desired outcomes will help monitor its progress.^[15] SHeS provides data for 7 of the indicators including the long-term goal of 'less children in Scotland overweight and obese'.^[16]

The school environment plays a vital role in improving children's diets, by providing healthy food and drinks to pupils and supporting children and young people to make healthy choices. School meal standards and the school environment have improved through policy and legislation.^[17],[18] A pilot project carried out in Glasgow in which S1 pupils in 8 schools were encouraged to stay in school at lunchtime, eat healthily and take part in activities was perceived to be successful in encouraging pupils to stay on site. School meal uptake rates among the S1 pupils remained higher than the previous year.^[19]

Children's food purchases and consumption during and around the school day - but outwith school grounds - are also being examined. A recent study assessing the quality of popular foods purchased by pupils from outlets near five Glasgow secondary schools against Scottish nutrient standards for school lunches found a large contrast with the nutritional quality of the food available within school.^[20] It also noted that many secondary pupils who eat out of school at lunch time buy unhealthy convenience food of very poor nutritional quality. In addition to assessing progress towards the Scottish Dietary Targets, the most recent of the Food Standards Agency in Scotland's national studies of children's diets also explored food purchases outwith school. Results from the study are due to be published in autumn 2012.

The association between healthy weight and wellbeing noted above has also been reflected in the new National Mental Health Indicators for children and young people in Scotland.^[21] The percentage of 2 to 15 year olds who ate five or more portions of fruit and vegetables in the previous day is one of the indicators and has been included as part of the individual contextual domain as a measure of healthy living.

Detailed measures of fruit and vegetable consumption were introduced into SHeS in 2003 and have been included annually since 2008. This chapter updates the trends in fruit and vegetable consumption among children since 2003 and examines the association between child fruit and vegetable consumption and parental consumption patterns. The trend in children's eating habits since 2003 is also explored.

3.2 METHODOLOGY

3.2.1 Measures of eating habits

Two different modules of questions were used to assess eating habits. One assessed fruit and vegetable consumption, and was designed to provide sufficient detail to monitor the '5-a-day' policy effectively. Each year this module is asked of all adults and children aged 2 and over. The second has been asked of children aged 2-15 annually since 2008. It uses a modified version of the Dietary Instrument of Nutrition Education (DINE) questionnaire developed by the Imperial Cancer Research Fund's General Practice Research Group to assess participants' usual intake of a wide range of nutrients, including protein, starch, fat and fibre.^[22] This chapter reports the findings from the fruit and vegetable module for children. It also presents 2008/2009 and 2010/2011 results for the adapted DINE questionnaire.

Fruit and vegetable module

To determine the total number of portions that had been consumed in the 24 hours preceding the interview, the fruit and vegetable module asked about the following food types: vegetables (fresh, frozen or canned); salads; pulses; vegetables in composites (e.g. vegetable chilli); fruit (fresh, frozen or canned); dried fruit; and fruit in composites (e.g. apple pie). A portion was defined as the conventional 80g of a fruit or vegetable. As 80g is difficult to visualise, a 'portion' was described using more everyday terms, such as tablespoons, cereal bowls and slices. Examples were given in the questionnaire to aid the recall process, for instance, tablespoons of vegetables, cereal bowls full of salad, pieces of medium sized fruit (e.g. apples) or handfuls of small fruits (e.g. raspberries). In spite of this, there may be some variation between participants' interpretation of 'a portion'. These everyday measures were converted back to 80g portions prior to analysis.

In the absence of consistent guidelines about the recommended daily intake of fruit and vegetables for children (in terms of grams per day rather than number of portions), portion sizes were standardised in this study as 80g (or one glass of 100% fruit juice) for both adults and children.^[23] The following table shows the definitions of the portion sizes used for each food item included in the survey.

Food item	Portion size
Vegetables (fresh, frozen or canned)	3 tablespoons
Pulses (dried)	3 tablespoons
Salad	1 cereal bowlful
Vegetables in composites, such as vegetable chilli	3 tablespoons
Very large fruit, such as melon	1 average slice
Large fruit, such as grapefruit	Half a fruit
Medium fruit, such as apples	1 fruit
Small fruit, such as plum	2 fruits
Very small fruit, such as blackberries	2 average handfuls
Dried fruit	1 tablespoon
Fruit in composites, such as stewed fruit in apple pie	3 tablespoons
Frozen fruit/canned fruit	3 tablespoons
Fruit juice	1 small glass (150 ml)

Since the '5-a-day' policy stresses both volume and variety, the number of portions of fruit juice, pulses and dried fruit was capped so that no more than one portion could contribute to the total number of portions consumed. Interviewers recorded full or half portions, but nothing smaller.

The DINE questionnaire

Some small changes were made to the DINE questionnaire from 2008 onwards to better meet the Scottish Government's information needs about diet:

• The question about breakfast cereal was amended to measure sugar content as well as fibre.
• The bread question removed the option "soft-grain" and added an explicit code for wholemeal/white hybrid breads.^[24]
• The question about spreading fats (butter / margarine) was cut.
• A new instruction was added to the question about non-diet soft drinks to cover flavoured waters.
• New questions about diet / low calorie soft-drinks, milk (for children) and plain water (tap or bottled) were added.

3.3 FRUIT AND VEGETABLE CONSUMPTION

3.3.1 Trends in child consumption of fruit and vegetables since 2003

Information on the quantity of fruit and vegetables children had consumed in the 24 hours prior to the interview is presented in Table 3.1 for 2003 onwards. The fruit and vegetable questions were asked of children aged 2-15 from 2008 onwards and aged 5-15 prior to this. For this reason, the trends in consumption patterns since 2003 are based on children aged 5-15.

The mean number of portions consumed by children aged 5-15 changed little over the period: in 2003 the mean number consumed was 2.6; it was 2.7 in both 2008 and 2009, and 2.6 in 2010 and 2011. The proportions consuming the recommended five or more portions of fruit and vegetables varied only slightly over the survey years: rising slightly from 12% in 2003 to 14% in both 2008 and 2009, before dropping back to 12% in 2010 where it remained in 2011. Portions consumed and proportions eating the recommended quantity of fruit and vegetables were generally similar for boys and girls across the survey years.

Figures for children aged 2-15 are available from 2008 onwards. Since then, the proportion eating five or more portions a day has varied from 12% to 15% with no clear pattern or significant trend. Similarly, the mean number of portions consumed has ranged between 2.6 and 2.8 portions over this period.
Table 3.1

3.3.2 Portions of fruit and vegetables consumed by children in 2011

Detailed information on the quantity of fruit and vegetables children aged 2-15 had consumed in the 24 hours prior to the interview in 2011 is also presented in Table 3.1. In 2011, children consumed an average of 2.7 portions of fruit and vegetables per day, with similar numbers for boys and girls (2.7 and 2.8 respectively). There was some variation across the age groups: children aged 2-4 consumed the highest number of portions (3.2) while consumption was lowest among those aged 13-15 (2.5 portions). The mean number of portions consumed declined with age among boys from 3.2 portions for 2-4 year olds to 2.3 portions for those aged 13-15. In contrast the figures for girls ranged from 2.5 to 3.1 portions but with no obvious pattern.

13% of children (13% of boys and 12% of girls) aged 2-15 met the recommended daily intake of five or more portions of fruit and vegetables in 2011. The proportion consuming the recommended amount was highest in the youngest age group (17%), ranged from between 12% and 14% for those aged 8-15, and was lowest among children aged 5-7 (9%) but these differences were not significant. At the other extreme, one in ten (9%) children did not consume any portions of fruit and vegetables in the previous 24 hours (10% of boys and 9% of girls). Prevalence of consuming no portions varied significantly by age for boys and girls. Children aged 13-15 were most likely to have consumed no portions (14%) and this then declined with age to 5% for those aged 2-4. Patterns for consuming no portions and for consuming five or more portions were similar for boys and girls.
Figure 3A, Table 3.1

Figure 3A
Proportion of children ages 2-15 eating five or more portions, no portions, and mean portions consumed, per day, by age, 2011

3.3.3 Child fruit and vegetable consumption, 2008-2011 combined by parental consumption patterns

Table 3.2 and Figure 3B show the quantity of fruit and vegetables consumed by boys and girls according to parents' fruit and vegetable consumption. In all four years the survey included a boost sample of households in which children were interviewed but adults were not. This table is therefore based on children in the main sample where at least one of their parents was also interviewed (and answered the questions on fruit and vegetables). The data have been re-weighted so this analysis shows the pattern of association between child and parental consumption, and provides population estimates of the prevalence of child fruit and vegetable consumption in households with different parental consumption patterns. For households with fruit and vegetable data for two parents, the measure of parental consumption was based on whichever parent's consumption was the highest.^[25]

As Figure 3B illustrates, children's fruit and vegetable consumption was significantly and positively associated with parental consumption. For example, the mean number of portions consumed steadily increased in line with higher parental consumption from 1.4 for those whose parents consumed no portions to 3.7 for those with at least one parent consuming the recommended five a day. The patterns for boys and girls were very similar (from 1.3 to 3.6 and from 1.5 to 3.8 portions, respectively).

The correspondence between child and parental eating patterns was most notable for the group whose parents ate no portions on the previous day - 34% of children in this group ate no fruit or vegetables compared with just 4% of those with at least one parent consuming five or more portions per day. Similarly, only 2%-3% of children whose parents consumed fewer than two portions of fruit and vegetables met the five a day recommendation, compared with 28% of children with at least one parent who consumed the recommended amount.
Figure 3B, Table 3.2

Figure 3B
Proportion of children ages 2-15 eating five or more portions, no portions, and mean portions consumed, per day, by parental consumption level, 2008-2011

3.4 EATING HABITS

3.4.1 Trends in children's eating habits since 2003

Section 3.2.1 noted that additional questions about the eating habits of children have been asked each survey year since 2003. This section presents figures for consumption of a selection of food and drink items for children aged 2-15 in 2003, 2008/2009 combined, and 2010/2011 combined. In general, the changes observed for some of the food and drink items suggest an improvement in children's diets since 2003. For example, the proportion of children eating oily fish at least once a week has risen from 8% in 2003 to 14% in 2010/2011, while consumption of white fish also increased over this same period from 42% to 49%. There was also an increase in the proportion of children aged 2-15 drinking skimmed/semi-skimmed milk (from 51% in 2003 to 58%). Since 2003, there have also been decreases in the proportions eating some of the unfavourable food items. For example, the proportions of children aged 2-15 consuming crisps once a day or more, chips two or more times a week, sweets or chocolates once a day or more and biscuits once a day or more declined by around 8 to 14 percentage points between 2003 and 2010/2011.

Less positively, since 2003 there have been slight decreases in the proportions eating tuna fish once a week or more, and increases in the proportions eating red meat two or more times a week and cakes two or more times per week. Most of the changes observed in eating habits since 2003 occurred between 2003 and 2008/2009 with little change since then.

It was noted in Section 3.2 that the method of recording hybrid high fibre/white breads changed in 2008. There was a large increase observed in the consumption of this particular kind of bread between the three time points (data not shown). While some of this increase will be due to the greater availability of this kind of bread in recent years, it is also likely that the 2003 questionnaire underestimated consumption levels. The high fibre bread figures in 2003, 2008/2009 and 2010/2011 are not, therefore, directly comparable.

Eating habits were broadly similar for boys and girls, but with some notable exceptions. In 2010/2011, boys were more likely than girls to eat meat products at least twice a week (43% versus 35%) and biscuits once a day or more (44% versus 36%), whereas girls were more likely than boys to eat tuna fish at least once a week (33% versus 25%).
Table 3.3