Emma Foster

The impact of a school-based nutrition education intervention on dietary intake and cognitive and attitudinal variables relating to fruits and vegetables

OBJECTIVE To assess the impact of a school-based nutrition education intervention aimed at increasing the consumption of fruits and vegetables. DESIGN The intervention programme increased the provision of fruits and vegetables in schools and provided a range of point-of-purchase marketing materials, newsletters for children and parents, and teacher information. Curriculum materials at age 6-7 and 10-11 years were also developed and utilised. Evaluation was undertaken with groups of younger (aged 6-7 years) and older (aged 10-11 years) children. Methods included 3-day dietary records with interview and cognitive and attitudinal measures at baseline, with follow-up at 9 months, in intervention and control schools. SETTING The work was undertaken in primary schools in Dundee, Scotland. SUBJECTS Subjects comprised 511 children in two intervention schools with a further 464 children from two schools acting as controls. RESULTS Children (n=64) in the intervention schools had an average increase in fruit intake (133+/-1.9 to 183+/-17.0 g day(-1)) that was significantly (P<0.05) greater than the increase (100+/-11.7 to 107+/-14.2 g day(-1)) estimated in children (n=65) in control schools. No other changes in food or nutrient intake were detected. Increases in scores for variables relating to knowledge about fruits and vegetables and subjective norms were also greater in the intervention than in the control group, although taste preferences for fruits and vegetables were unchanged. CONCLUSIONS It is concluded that a whole school approach to increasing intakes of fruits and vegetables has a modest but significant effect on cognitive and attitudinal variables and on fruit intake.

Accuracy of estimates of food portion size using food photographs – the importance of using age-appropriate tools

BACKGROUND In order to obtain a measure of nutrient intake, a measure or estimate of the amount of food consumed is required. Weighing foods imposes a large burden on subjects, often resulting in underreporting. Tools are available to assist subjects in providing an estimate of portion size and these include food photographs. The application of these tools in improving portion size estimation by children has not been investigated systematically. OBJECTIVES To assess the accuracy with which children are able to estimate food portion sizes using food photographs designed for use with adults, and to determine whether the accuracy of estimates is improved when age-appropriate portion size photographs are provided. DESIGN Original data from three separate studies, on the accuracy of portion size estimates by adults using food photographs, by children using adult photographs and by children using age-appropriate photographs, are analysed and compared. SUBJECTS One hundred and thirty-five adults aged 18 to 90 years and 210 children aged 4 to 11 years. RESULTS Childrens estimates of portion sizes using age-appropriate food photographs were significantly more accurate (an underestimate of 1% on average) than estimates using photographs designed for use with adults (an overestimate of 45% on average). Accuracy of childrens estimates of portion size using age-appropriate photographs was not significantly different from that of adults. Children overestimated a foods weight by 18% on average and adults underestimated by 5%. CONCLUSIONS Providing children with food photographs depicting age-appropriate portion sizes greatly increases the accuracy of portion size estimates compared with estimates using photographs designed for use with adults.

Nutrition in advanced age: dietary assessment in the Newcastle 85+ study

Background/Objectives:Assessing food choice and/or nutrient intake in older people, particularly the oldest old (85 years and over), presents particular challenges. In some cases the respondent may have little or no involvement in food acquisition or preparation, in others, cognitive/memory impairment may restrict the ability to recall intake, or physical limitations may affect the ability to record intake. The assessment may therefore need to involve whoever provides care for the older person, of whom there may be more than one. For these reasons, there is a need for validated methods for dietary assessment in large populations within this age range. The need is particularly acute in view of the secular increase in the numbers of older people and the interest in the role of nutrition in maintaining health and ameliorating age-related decline. This paper describes a comparison of two different methods of dietary assessment within the Newcastle 85+ Study; a UK cohort study of health and ageing in the oldest old.Methods:Two methods, the food frequency questionnaire (FFQ) (based on broad recall of the previous 12 months intake) and the repeated multiple pass recall (MPR) tool (based on detailed recall of the previous days intake on two separate occasions), were applied in two different groups of approximately 85 individuals aged 85 years. FFQ data were collected during a pilot study conducted between 2003 and 2004, MPR data were collected in the main Newcastle study in 2006. Relative validity was measured by calculation of the ratio of reported energy intake to estimated basal metabolic rate (EI/BMR) and by comparison with dietary intakes reported for subjects of similar age in the UK National Diet and Nutrition Survey.Results:EI/BMR ratios for MPR were 1.56 and 1.39 for men and women, respectively, and for FFQ were 2.18 and 2.14. The FFQ was found to overestimate energy and nutrient intake considerably. The MPR gave more realistic estimates of energy and nutrient intakes, and was found to be acceptable for use in this population group. However, use of this tool required greater investigator (nurse) time, extra resources for training and quality assurance and additional time and expertise in data processing.Conclusions:In the Newcastle 85+ Study, where the overall aims include detailed investigation of diet in relation to many variables describing biological, clinical and psychosocial status, we concluded that MPR was the preferable method, although there remains a need for non-subjective methods for assessing dietary intake, that is, biomarker approaches, which can give a comprehensive and objective assessment of dietary exposure.

Estimation of portion size in children's dietary assessment: lessons learnt

Background/Objectives:Assessing the dietary intake of young children is challenging. In any 1 day, children may have several carers responsible for providing them with their dietary requirements, and once children reach school age, traditional methods such as weighing all items consumed become impractical. As an alternative to weighed records, food portion size assessment tools are available to assist subjects in estimating the amounts of foods consumed. Existing food photographs designed for use with adults and based on adult portion sizes have been found to be inappropriate for use with children. This article presents a review and summary of a body of work carried out to improve the estimation of portion sizes consumed by children.Methods:Feasibility work was undertaken to determine the accuracy and precision of three portion size assessment tools; food photographs, food models and a computer-based Interactive Portion Size Assessment System (IPSAS). These tools were based on portion sizes served to children during the National Diet and Nutrition Survey. As children often do not consume all of the food served to them, smaller portions were included in each tool for estimation of leftovers. The tools covered 22 foods, which children commonly consume. Children were served known amounts of each food and leftovers were recorded. They were then asked to estimate both the amount of food that they were served and the amount of any food leftover.Results:Children were found to estimate food portion size with an accuracy approaching that of adults using both the food photographs and IPSAS.Conclusions:Further development is underway to increase the number of food photographs and to develop IPSAS to cover a much wider range of foods and to validate the use of these tools in a ‘real life’ setting.

Non-diabetic relatives of Type 2 diabetic families: dietary intake contributes to the increased risk of diabetes

Aims  Non‐diabetic first degree relatives of Type 2 diabetic patients are at increased risk of developing diabetes and cardiovascular disease. This is assumed to reflect a shared genetic predisposition. The aim of this study was to test the hypothesis that lifestyle factors, specifically dietary factors, are also important to the increased risk in non‐diabetic relatives.

Children's estimates of food portion size: the effect of timing of dietary interview on the accuracy of children's portion size estimates

For food intakes to be converted into nutrient intakes a measure or estimate of the amount of food consumed is required. A number of methods have been developed to assist subjects in providing an estimate of portion size. Childrens ability to use perception, conceptualisation and memory skills to estimate food portion size has not been investigated systematically. The aim of the present study was to test the effect of the timing of a dietary interview on the accuracy of estimates of food portion sizes made by children, using food photographs, food models and an interactive portion size assessment system, developed for use with children and based on portion sizes of foods consumed by children. Children (n 108) aged 4-14 years were supplied with known quantities of foods and asked to estimate the portion size of each food using each of the three portion size assessment tools. Interviews took place (a) with the food in view, (b) just after the child had eaten the food or (c) 24 h after the child had eaten the food. There were no significant differences in childrens ability to estimate food portion size (either as served or as eaten) with timing of interview. That is, children were as accurate in their estimates of portion size 24 h after consuming the food as when the food was in view. Under these conditions many children were able to estimate food portion size utilising perception, conceptualisation and memory skills.

Validation of the Portuguese self-administered computerised 24-hour dietary recall among second-, third- and fourth-grade children

BACKGROUND Current methods for assessing childrens dietary intake, such as interviewer-administered 24-h dietary recall (24-h DR), are time consuming and resource intensive. Self-administered instruments offer a low-cost diet assessment method for use with children. The present study assessed the validity of the Portuguese self-administered, computerised, 24-h DR (PAC24) against the observation of school lunch. METHODS Forty-one, 7-10-year-old children from two elementary schools, in Lisbon, were observed during school lunch followed by completion of the PAC24 the next day. Accuracy for reporting items was measured in terms of matches, intrusions and omissions; accuracy for reporting amounts was measured in terms of arithmetic and absolute differences for matches and amounts for omissions and intrusions; and accuracy for reporting items and amounts combined was measured in terms of total inaccuracy. The ratio of the estimated weight of food consumed with the actual weight consumed was calculated along with the limits of agreement using the method of Bland and Altman. RESULTS Comparison of PAC24 against observations at the food level resulted in values of 67.0% for matches, 11.5% for intrusions and 21.5% for omissions. The mean for total inaccuracy was 3.44 servings. For amounts, accuracy was high for matches (-0.17 and 0.23 servings for arithmetic and absolute differences, respectively) and lower for omissions (0.61 servings) and intrusions (0.55 servings). PAC24 was found to under-estimate the weight of food on average by 32% of actual intake. CONCLUSIONS PAC24 is a lower-burden procedure for both respondents and researchers and, with slight modification, comprises a promising method for assessing diet among children.

Challenges involved in measuring intake in early life: focus on methods

Assessing dietary intake in people of any age is challenging but measuring the diet of infants and children can be particularly problematic. Young children may lack the cognitive skills, writing skills and food knowledge to record their own food intake. Multiple people may be responsible for the care of the child and to collect an accurate picture of intake it may be necessary to combine parental reports with observation in school or nursery. Where interviews are conducted with the child themselves questions may need to focus on aspects of the diet which children are likely to attend to. For example, children may not be familiar with food names or brands but may be able to describe their texture, colour and images on packaging. Adolescents are likely to be more aware of the foods they consume and have the cognitive and writing skills to record their own food intake but may lack the interest or motivation. Research has focused on reducing the burden of recording intake on the participant. Developments include food photographs for assessment of portion size which remove the need for weighing each food item, and, in recent years, computer-based methods have been developed for self-completion by young people with the aim of motivating them to participate in studies by making dietary reporting more engaging. The present paper discusses methods and challenges in assessing food intake in children followed by details of two such tools developed at Newcastle University, UK, the Young Persons Food Atlas and INTAKE24.

Comparison of INTAKE24 (an Online 24-h Dietary Recall Tool) with Interviewer-Led 24-h Recall in 11–24 Year-Old

Online dietary assessment tools offer a convenient, low cost alternative to traditional dietary assessment methods such as weighed records and face-to-face interviewer-led 24-h recalls. INTAKE24 is an online multiple pass 24-h recall tool developed for use with 11–24 year-old. The aim of the study was to undertake a comparison of INTAKE24 (the test method) with interviewer-led multiple pass 24-h recalls (the comparison method) in 180 people aged 11–24 years. Each participant completed both an INTAKE24 24-h recall and an interviewer-led 24-h recall on the same day on four occasions over a one-month period. The daily energy and nutrient intakes reported in INTAKE24 were compared to those reported in the interviewer-led recall. Mean intakes reported using INTAKE24 were similar to the intakes reported in the interviewer-led recall for energy and macronutrients. INTAKE24 was found to underestimate energy intake by 1% on average compared to the interviewer-led recall with the limits of agreement ranging from minus 49% to plus 93%. Mean intakes of all macronutrients and micronutrients (except non-milk extrinsic sugars) were within 4% of the interviewer-led recall. Dietary assessment that utilises technology may offer a viable alternative and be more engaging than paper based methods, particularly for children and young adults.

Packaged food intake by British children aged 0 to 6 years.

The European Union approach to assessing exposure to chemical migrants from plastic food-contact materials has been to assume an intake of 1 kg of food in contact with a particular material, per 60 kg person per day, which equates to 16.7 g kg−1 body weight. A food packaging surface area–food mass ratio of 6 dm2/1 kg is assumed, equivalent to 0.1 dm2 kg−1 of body weight. Children might be at increased risk to exposure from migrants as they have higher intakes of food per kg body weight compared with adults. In addition, much of the food marketed for/to children is in small portions and therefore the food-contact material area–food mass ratio is relatively high. To determine if, and how, the European Union model might be modified to ensure specific protection against chemical migration into food marketed for children, data on 4-day food intakes of 297 children aged 0–6 years were collected including information on pack size, pack type and food-contact material area–food mass ratio. The 297 children consumed a total of 1646 kg of food and drink (including tap water), of which 978 kg (59%) was packaged with 67% of this packaged in plastics. Mean intakes of food packaged in plastic ranged from 27 g kg−1 body weight (for the infants under 1 year) to 51 g kg−1 body weight (for the 1–4-year-olds). This was higher than the 16.7 g kg−1 body weight derived from the European Union convention. The mean area of packaging in contact with the food consumed daily per kg body weight were 0.65 dm2 kg−1 for the infants under 1 year, 0.81 dm2 kg−1 for the 1–4-year-olds, and 0.66 dm2 kg−1 for the 4–6-year-olds. All 297 children had intakes that exceeded 0.1 dm2 of packaging per kg of body weight assumption.