Gail Rees

Food and nutrient intakes of primary school children: a comparison of school meals and packed lunches

BACKGROUND New school meal standards are currently being phased in by the government in an attempt to improve the nutritional composition of school food. However, no standards are applied to packed lunches. The present study aimed to compare the food and nutrient intakes of primary school children eating a school meal with those taking a packed lunch. METHODS A sample of 120 children, aged 6-11 years, was observed once at a lunch time and all items consumed were recorded. Nutrient analysis was performed, and differences in nutrient intake between those children consuming packed lunches and school meals were determined. RESULTS Mean energy and protein intakes were similar. The amount of energy provided by starchy carbohydrate was also similar but, compared with school meals, packed lunches provided twice as much energy from sugar (P < 0.001). School meals on average provided more energy from fat (P < 0.001), but intakes of saturated fat were lower in the school meals group (P = 0.021). Packed lunches provided more sodium (P < 0.001), calcium (P < 0.001) and iron (P = 0.016) than the school meals. Very few packed lunches contained vegetables, and fruit intake was particularly low for those having a school meal. CONCLUSIONS Children taking a packed lunch to school were consuming approximately double the amount of sugar and 50% more sodium and saturated fat in their midday meal compared with those having a school lunch. However packed lunches were providing children with more calcium, iron and fruit.

Social and ethnic differences in folic acid use preconception and during early pregnancy in the UK: effect on maternal folate status.

BACKGROUND The role of folate supplementation in preventing neural tube defects is well known; however, preconception supplement use continues to be low, especially amongst the socially disadvantaged. The present study explored periconception folic acid supplement use in a socially deprived, ethnically diverse population. METHODS Pregnant women (n = 402) in the first trimester of pregnancy were recruited in East London. Using a researcher led questionnaire, details were obtained regarding social class, ethnicity and folic acid use. Red cell folate levels were determined for 367 participants during the first trimester. RESULTS Although 76% of participants reported using folic acid supplements during the first trimester, only 12% started preconception and a further 17% started before neural tube closure. Mothers from higher social groups or with higher levels of education were more likely to use folic acid and started taking it earlier. Ethnic differences were also seen in preconception usage (Africans, 5%; West Indians, 8%; Asians, 12%; Caucasians, 19%; P = 0.038). Participants who took folic acid supplements had significantly higher mean (SD) red cell folate concentrations than those who took none [936 (*\1.6) and 579 (*\1.6) nmol L(-1), respectively; P < 0.001]. CONCLUSIONS Folic acid supplement use preconception and prior to neural tube closure continues to be low, exhibiting both social and ethnic disparities.

Effect of multiple-micronutrient supplementation on maternal nutrient status, infant birth weight and gestational age at birth in a low-income, multi-ethnic population

Poor nutrient intake during pregnancy can adversely affect both infant and maternal health. The aim was to investigate the efficacy of multiple-micronutrient supplementation during pregnancy in a socially deprived population in the developed world. We conducted a randomised, double-blind, placebo-controlled trial of multiple-micronutrient supplementation including 20 mg Fe and 400 microg folic acid, from the first trimester of pregnancy in 402 mothers, in East London, UK. Nutrient status was measured at recruitment, and at 26 and 34 weeks of gestation. Infants were weighed at birth. At recruitment the prevalence of anaemia was 13 %, vitamin D insufficiency 72 %, thiamin deficiency 12 % and folate deficiency 5 %, with no differences between groups. Only 39 % of women completed the study; rates of non-compliance were similar in both groups. Intention-to-treat analysis showed that participants receiving treatment had higher mean Hb at 26 weeks of gestation (110 (sd 10) v.108 (sd 10) g/l; P = 0.041) and 34 weeks of gestation (113 (sd 12) v.109 (sd 10) g/l; P = 0.003) and packed cell volume concentrations at 26 weeks of gestation (0.330 (sd 0.025) v. 0.323 (sd 0.026) l/l; P = 0.011) and 34 weeks of gestation (0.338 (sd 0.029) v. 0.330 (sd 0.028) l/l; P = 0.014) compared with controls. Analysis of compliant women showed supplemented women had higher median concentrations of serum ferritin, erythrocyte folate and 25-hydroxyvitamin D later in gestation than controls. In the compliant subset (n 149), placebo mothers had more small-for-gestational age (SGA) infants (eight SGA v. thirteen; P = 0.042) than treatment mothers. Baseline micronutrient deficiencies were common; the multiple-micronutrient supplement was well-tolerated and improved nutrient status. Multiple-micronutrient supplements from early pregnancy may be beneficial and larger studies are required to assess impact on birth outcomes and infant development.

Randomised-controlled trial of a fibre supplement on the symptoms of irritable bowel syndrome.

The aim of this study was to assess the effect of coarse wheat bran on specific bowel function parameters and symptoms in patients with irritable bowel syndrome (IBS). A longitudinal, prospective, randomised, placebo-controlled trial was undertaken. The duration of treatment was eight to 12 weeks and this consisted of 10-20g/day of coarse wheat bran or a low fibre placebo taken in addition to the normal diet. Twenty-eight outpatients fulfilling the Rome criteria for constipation-predominant IBS were recruited to the trial (14 in the treatment group; 14 in the placebo group). Twelve people completed the trial in the treatment group and ten in the placebo group. The main outcome measures included changes in symptoms recorded in a diary, changes in objective measurements of bowel function and subjective overall feelings of improvement. The bran group significantly increased their non-starch polysaccharide (NSP) intake over that of the placebo group (p<0.05). Mean stool wet weight increased significantly more in the bran group than in the placebo group (p<0.05), but other bowel function measurements and all recorded symptoms were not different. Many patients reported changes in bowel habit that were not reflected in the objective measurements. The addition of coarse wheat bran to the diet increased NSP ingestion and stool wet weight in this group of IBS patients, but no evidence was obtained that such treatment was of benefit to these patients, other than a placebo effect on symptoms.

Gastrointestinal Symptoms and Diet of Members of an Irritable Bowel Self-help Group

A self-administered questionnaire was completed by 103 members of a self-help group for irritable bowel syndrome (IBS) and 130 controls, to compare the presence of IBS symptoms. Dietary fibre prescription, compliance and effi cacy were documented in the IBS group. There were significant differences in the frequency of defaecation and number of symptoms present between the two groups. Most of the IBS subjects had been prescribed a high fibre diet but adherence to the diet and symptomatic improve ment were poor. In contrast many IBS sufferers were following a range of diets not prescribed by their doctor. The seriousness of the IBS condition was highlighted by the fact that 8% of the IBS group had retired early due to their condition.

A qualitative study exploring parental accounts of feeding pre-school children in two low-income populations in the UK

Good nutrition in the early years of life is essential, yet the diets of many pre-school children in the UK are known to be poor. Understanding the decisions parents make when feeding young children is very important in determining what type and nature of interventional support may be developed to promote good nutrition. The aim of this study was to explore using qualitative methods, parental perceptions of feeding their children in order to inform the development of a nutrition intervention. Focus groups (n = 33) and individual interviews (n = 6) were undertaken with parents, most of whom were attending childrens centres in two deprived populations from one urban (Islington, north London) and one rural (Cornwall) location in England. Accounts of feeding pre-school children were primarily concerned with dealing with the practicalities of modern life, in particular the cost of food and the need to manage on a restricted household budget. Time pressures, a lack of perceived knowledge and confidence in preparing food and managing conflict over food choices between family members were also strong themes. Parents commonly reported differences between how they would like to feed their children and the reality of what they were able to do in their circumstances. These findings suggest that the poor eating habits of many pre-school children may be less a case of parental ignorance but rather the product of a range of coping strategies. Designing an intervention, which helps parents to build their confidence and self-efficacy, may enable them to make positive changes to their childrens diets.

A computerised tailored intervention for increasing intakes of fruit, vegetables, brown bread and wholegrain cereals in adolescent girls

OBJECTIVE To evaluate the effectiveness of a computer-generated tailored intervention leaflet compared with a generic leaflet aimed at increasing brown bread, wholegrain cereal, fruit and vegetable intakes in adolescent girls. DESIGN Clustered randomised controlled trial. Dietary intake was assessed via three 24 h dietary recalls. SETTING Eight secondary schools in areas of low income and/or high ethnic diversity, five in London and three in the West Midlands, UK. SUBJECTS Girls aged 12-16 years participated (n 823) and were randomised by school class to receive either the tailored intervention (n 406) or a generic leaflet (n 417). RESULTS At follow-up 637 (77 %) participants completed both baseline and follow-up dietary recalls. The tailored intervention leaflet had a statistically significant effect on brown bread intake (increasing from 0.39 to 0.51 servings/d) with a smaller but significant increase in the control group also (increasing from 0.28 to 0.35 servings/d). The intervention group achieved 0.05 more servings of brown bread daily than the control group (P < 0.05), which is equivalent to 0.35 servings/week. For the other foods there were no significant effects of the tailored intervention. CONCLUSIONS The intervention group consumed approximately 0.35 more servings of brown bread weekly than the control group from baseline. Although this change between groups was statistically significant the magnitude was small. Evaluation of the intervention was disappointing but the tailored leaflet was received more positively in some respects than the control leaflet. More needs to be done to increase motivation to change dietary intake in adolescent girls.

The nutritional status of women in the first trimester of pregnancy attending an inner-city antenatal department in the UK

We have previously found high rates of poor iron and folate status in women who had delivered a low birthweight baby (LBW) in an ethnically diverse inner-city area of the UK. However, little was known of the nutritional status in the local general obstetric population. We therefore investigated biochemical measures of nutritional status in the first trimester of the first pregnancy. Routine blood samples collected at the antenatal booking clinic were analysed for haemoglobin (Hb), serum ferritin, red cell folate (RCF) (n=100) and erythrocyte transketolase activation coefficient (ETKAC) for thiamin status (n=90). We found 9% of women in our sample had a low Hb level, 10% had a low serum ferritin and only one had a low RCF. This is a substantially lower number of women with biochemical deficiencies than we found previously in women three months after delivering a LBW baby. However, 34% had low thiamin status. Thiamin status was negatively correlated with gestational age at birth (r=-0.407, p<0.001). Differences in nutritional status were observed between ethnic and socio-economic groups. Hb levels differed between ethnic (p=0.001) and socio-economic groups (p=0.02), with Africans and women in manual occupations/unwaged having the lowest Hb levels. RCF levels also differed between groups (p<0.001) with Caucasians and those in non-manual occupations having highest levels. ETKAC also differed between ethnic groups (p=0.008) with Africans having the highest level indicating a poorer status. The study highlights the need to improve nutrition particularly in ethnic minorities and low income groups who are most at risk of adverse birth outcomes such as LBW.

Maternal malnutrition in the UK and low birthweight.

Most people would associate under-nutrition with third world countries but there are also serious problems in some parts of developed countries, not so much under-nutrition, but malnutrition. London can be described as a prosperous, cultured sophisticated city with a national health service that many envy. But further down the river, not far from Tower Bridge, is Hackney and another facet of London. In Hackney 10% of live births weigh less than 2.5kg. It is a multiracial inner city area of east London with one of the highest scores of overall deprivation in the UK. The level of dependence on income support is three times the national average and the level of unemployment is as high at 40% in some wards. In fact its not just Hackney, but the United Kingdom as a whole has a high incidence of low birth weight compared to other European countries. At 7% the UK has an incidence of low birth weight similar to Romania and Albania according to the WHO figures (WHO, 1992). Furthermore, the incidence of low birth weight in this country has not changed, and may even have increased, since the early 50s. The definition of low birth weight changed in 1982 from 2.5kg and under, to less than 2.5kg. So in those terms the incidence has actually increased. This paper describes studies undertaken over the last 20 years on diet and its relationship to low birth weight. The first study in 1978 compared the diets of mothers in Hackney with a more affluent part of London, Hampstead (Doyle et al., 1982; Crawford et al., 1986). The results of this study showed that Hackney mothers had significantly lower intakes of all vitamins and minerals than the Hampstead mothers, but energy intakes in the two groups were similar. This suggests that they were eating a similar amount of food but the choice of food was different between the two areas. The mean birth weight in the Hackney mothers was 300 g (over 10 ozs) lower than in Hampstead which is a considerable difference. In Hackney, 50% of the babies weighed less than 3 kg which some paediatricians believe should be the official demarcation point for low birth weight, since that is the level at which both mortality and morbidity begin to climb.

Developing a nutrition intervention in children's centres: exploring views of parents in rural/urban settings in the UK

OBJECTIVE The present study explored parents’ requirements for healthy eating support prior to the development of a tailored intervention. DESIGN A cross-sectional study of parents attending children’s centres. SETTING Children’s centres in Cornwall (rural south-west England) and Islington (urban London borough). SUBJECTS A total of 261 parents (94.2% female) of pre-school children (aged 2–5 years) completed a questionnaire on factors influencing food choice, and preferences for and views on healthy eating support. RESULTS Parents reported that health, taste, freshness and quality were the most important factors influencing their food choices for their pre-school children. The importance of individual factors varied according to level of educational attainment. Over a third (38 %) of parents said they wanted more advice on healthy eating for children. Less educated parents showed the greatest interest in learning more about several aspects: what a ‘healthy diet’ means, how to prepare and cook healthy food, how to understand food labels, budgeting for food, examples of healthy food and snacks for children, appropriate portion sizes for children and ways to encourage children to eat well. CONCLUSIONS There was demand for healthy eating support among parents of pre-school children, especially those who are less educated, in one rural and one urban area of England