Nutrition and Food Science Children and Young People

nfs cover (i).qxd

19/09/2006

14:01

Page 1

ISSN 0034-6659

Volume 36 Number 5 2006

Nutrition & Food Science Children and young people

www.emeraldinsight.com

ISSN 0034-6659

Nutrition & Food Science

Volume 36 Number 5 2006

Children and young people Editor Dr Mabel Blades

Access this journal online___________________________

283

Editorial board ______________________________________

284

Editorial ____________________________________________

285

Gaps in the awareness of current nutrition issues as dependent on age Melanie S. Adams _________________________________________________

286

Prevalence of dieting, overweight, body image satisfaction and associated psychological problems in adolescent boys Abdulbari Bener, Abdulaziz Kamal, Ihab Tewfik and Osman Sabuncuoglu _______________________________________________

295

Generating effective change in school meals: a case study Claire Seaman and Julia Moss ______________________________________

305

Breakfast frequency and fruit and vegetable consumption in Belgian adolescents: a cross-sectional study P. Mullie, P. Clarys, D. De Ridder, P. Deriemaeker, N. Duvigneaud, M. Hebbelinck, A.R. Grivegne´e and P. Autier__________________________

Access this journal electronically The current and past volumes of this journal are available at:

www.emeraldinsight.com/0034-6659.htm You can also search more than 100 additional Emerald journals in Emerald Fulltext (www.emeraldinsight.com/ft) and Emerald Management Xtra (www.emeraldinsight.com/emx) See page following contents for full details of what your access includes.

315

CONTENTS

CONTENTS continued

Impact of household food security and nutrition programme on the nutritional status of children in Oyo state, Nigeria B.O. Lawal and A.A. Jibowo ________________________________________

327

Habitual dietary calcium intake and body weight in 7–10 year old children Amy Jennings, V. Costarelli, G.J. Davies and P.W. Dettmar _____________

337

Nutritional knowledge and dietary intakes of young professional football players Sue Murphy and Yvonne Jeanes _____________________________________

343

Probiotic acidophilus milk for infants and children S. Sarkar and A.K. Misra __________________________________________

349

Cultured milk products for lactose-intolerant recipients S. Sarkar _________________________________________________________

357

Food facts___________________________________________

365

Book reviews _______________________________________

381

Conference reports__________________________________

382

www.emeraldinsight.com/nfs.htm As a subscriber to this journal, you can benefit from instant, electronic access to this title via Emerald Fulltext or Emerald Management Xtra. Your access includes a variety of features that increase the value of your journal subscription.

Additional complimentary services available

How to access this journal electronically

E-mail alert services These services allow you to be kept up to date with the latest additions to the journal via e-mail, as soon as new material enters the database. Further information about the services available can be found at www.emeraldinsight.com/alerts

To benefit from electronic access to this journal, please contact [email protected] A set of login details will then be provided to you. Should you wish to access via IP, please provide these details in your e-mail. Once registration is completed, your institution will have instant access to all articles through the journal’s Table of Contents page at www.emeraldinsight.com/0034-6659.htm More information about the journal is also available at www.emeraldinsight.com/ nfs.htm Our liberal institution-wide licence allows everyone within your institution to access your journal electronically, making your subscription more cost-effective. Our web site has been designed to provide you with a comprehensive, simple system that needs only minimum administration. Access is available via IP authentication or username and password.

Your access includes a variety of features that add to the functionality and value of your journal subscription:

Connections An online meeting place for the research community where researchers present their own work and interests and seek other researchers for future projects. Register yourself or search our database of researchers at www.emeraldinsight.com/ connections Emerald online training services You can also access this journal online. Visit www.emeraldinsight.com/training and take an Emerald online tour to help you get the most from your subscription.

Key features of Emerald electronic journals Automatic permission to make up to 25 copies of individual articles This facility can be used for training purposes, course notes, seminars etc. This only applies to articles of which Emerald owns copyright. For further details visit www.emeraldinsight.com/ copyright Online publishing and archiving As well as current volumes of the journal, you can also gain access to past volumes on the internet via Emerald Fulltext or Emerald Management Xtra. You can browse or search these databases for relevant articles. Key readings This feature provides abstracts of related articles chosen by the journal editor, selected to provide readers with current awareness of interesting articles from other publications in the field. Non-article content Material in our journals such as product information, industry trends, company news, conferences, etc. is available online and can be accessed by users. Reference linking Direct links from the journal article references to abstracts of the most influential articles cited. Where possible, this link is to the full text of the article. E-mail an article Allows users to e-mail links to relevant and interesting articles to another computer for later use, reference or printing purposes. Structured abstracts Emerald structured abstracts provide consistent, clear and informative summaries of the content of the articles, allowing faster evaluation of papers.

Choice of access Electronic access to this journal is available via a number of channels. Our web site www.emeraldinsight.com is the recommended means of electronic access, as it provides fully searchable and value added access to the complete content of the journal. However, you can also access and search the article content of this journal through the following journal delivery services: EBSCOHost Electronic Journals Service ejournals.ebsco.com Informatics J-Gate www.j-gate.informindia.co.in Ingenta www.ingenta.com Minerva Electronic Online Services www.minerva.at OCLC FirstSearch www.oclc.org/firstsearch SilverLinker www.ovid.com SwetsWise www.swetswise.com

Emerald Customer Support For customer support and technical help contact: E-mail [email protected] Web www.emeraldinsight.com/customercharter Tel +44 (0) 1274 785278 Fax +44 (0) 1274 785204

NFS 36,5

EDITORIAL BOARD

John J.B. Anderson, PhD Professor of Nutrition, University of Carolina School of Public Health and School of Medicine, USA

284

Nutrition & Food Science Vol. 36 No. 5, 2006 p. 284 # Emerald Group Publishing Limited 0034-6659

David C. Nieman, DrPH MPH FACSM Professor, Appalachian State University, USA

Professor Winston Craig Andrews University, Berrien Springs, MI, USA

Claire Seaman, BSc, MPhil, SRD Lecturer on Food Studies, Queen Margaret College, Edinburgh, UK Christopher Strugnell, BSc, PhD, MIFST University of Ulster at Jordanstown, Northern Ireland

Marcel Hebbelinck, PhD Professor, Laboratory Human Biometry, Vrije Universiteit Brussels, Belgium

Margaret Thorogood, PhD Senior Lecturer, London School of Hygiene and Tropical Medicine, UK

Ann Reed Mangels, PhD RD FADA Nutrition Advisor, Vegetarian Resource Group, USA

Dr Wendy Wrieden Centre for Public Health Nutrition Research, Ninewells Medical School, Dundee, UK

Dr Margaret Ashwell OBE Ashwell Associates (Independent Scientific Co-ordinators & Consultants) Ashwell, UK

Editorial

Editorial

Good nutrition is important at whatever age and in this edition of Nutrition and Food Science, there is a focus on nutrition particularly of young people. At this stage, good nutrition has an impact not only on their daily well-being but also on their growth and future health. While in developing countries, enabling children to get enough food is the main problem, here in the Western countries, the whole matter is getting children to eat good food. All too often children and young people make less prudent choices with over consumption of fat and sugar and too little fruit and vegetables. Recently, I was asked to judge a Food In Schools competition for those attending secondary schools. The competition was held at the East of England Show in Peterborough. The schools had been through a number of stages before the final day’s competition. The standard was extremely high and it was excellent to see young people involved in enjoying cooking as well as doing it to such a high standard. Also I was delighted to be asked to judge a competition called Care Cook of the Year on behalf of the National Association of Care Caterers. This was open to cooks who are involved in preparing food for those they care for in residential care homes and day centres. Most of the entrants to the competition were cooking for elderly. Real attention to the food and suitability of it for the group catered for had been made. Again the standard was extremely high. These competitions and the high standard achieved by the participants show how one can tempt people of whatever age into enjoying good, nutritious and varied food.

285

Mabel Blades

E

Nutrition & Food Science Vol. 36 No. 5, 2006 p. 285 Emerald Group Publishing Limited 0034-6659

The current issue and full text archive of this journal is available at www.emeraldinsight.com/0034-6659.htm

NFS 36,5

Gaps in the awareness of current nutrition issues as dependent on age Melanie S. Adams

286

Summit Middle School, Boulder, Colorado, USA Abstract Purpose – The goal of this study is to identify important current topics in nutrition that may be poorly understood by the public. Design/methodology/approach – A questionnaire was designed to assess public awareness of a range of important findings uncovered by recent scientific research on nutrition. Responses were collected in December 2005 from 171 well-educated male and female respondents ranging from 18–70 years of age. Findings – The highly educated group of respondents surveyed with respect to their awareness of nutrition was well informed on the importance of a balanced diet, the recommendations concerning saturated fat and olive oil, the calcium content of dairy products, and the effect of diet on diabetes and cancer. Important gaps in their knowledge included a low level of awareness of the health effects of canola and corn oil, the high calcium content of several vegetables, the effect of diet on mental processes and the power of the Mediterranean diet in preventing heart attacks. In several of these latter cases, it was the group of younger participants who had the lowest level of awareness. Only about one-third of the 18–30 years old participants were well informed about canola/corn oil and the calcium content of green vegetables, respectively, vs about two-thirds in the 31–70 years old age group. Likewise, the participants of ages 18–30 were significantly less well informed about the effect of diet on cancer, intelligence and disruptive behavior than the older participants. In addition, women were found to be better informed than men on the issue of vegetables with high calcium content. Research limitations/implications – The number of male respondents was lower than that of female respondents and this may have limited the identification of additional cases where genderrelated differences in awareness exist. Originality/value – This study provides new information about current, important issues in nutrition that are poorly understood even by an educated sample audience, particularly by younger participants. This information should be used as the basis for an education program to improve public health and that should target younger people. Keywords Nutrition, Diet, Public health, Health education Paper type Research paper

Introduction Over the past few decades, research has made rapid progress in uncovering the mechanisms of how food affects all aspects of human health. However, access to the original scientific studies is limited and much of the information of the public is obtained from the mass media. This study identifies important issues in nutrition that are well documented in the original scientific literature but poorly recognized by the public. A questionnaire was designed and responses collected from 171 male and female participants ranging in age from 18–70 years.

Nutrition & Food Science Vol. 36 No. 5, 2006 pp. 286-294 Emerald Group Publishing Limited 0034-6659 DOI 10.1108/00346650610703135

E

I am grateful to Dr Barbara Demmig-Adams for her guidance during the planning of this study and writing of the manuscript, to Dr William Adams, Jr, for his advice on survey design and statistical evaluation, to Dr Volker Ebbert for making the figures and to Dr Kristine Mueh, Dr James Adams, Dr William Adams III, Ms Haydee Phelps and Mr Peter Teasdale for their help in administering the surveys.

Several questions were included for which a reasonably good public awareness was expected, such as the high calcium content of dairy products, the role of diet in diabetes and the adverse effects of excess saturated fat consumption. In addition, other issues were included for which public awareness was unknown, such as the high calcium content of various vegetables, the role of diet in mental disorders and other conditions, the value of different types of unsaturated fats and the remarkable power of the Mediterranean diet in preventing heart attacks. Methodology A questionnaire was designed to gauge awareness of a range of current issues in nutrition (see Appendix). The questionnaire included (A) demographic questions, (B) questions on different groups of dietary fats, (C) questions on overall diet composition, (D) questions on the effect of diet on a range of diseases and disorders, (E) questions on the calcium content of different food groups and (F) questions about the benefit obtained from the Mediterranean diet. The survey questions were designed to minimize guessing or arbitrary choices on part of the respondents by offering a range of answers including ‘‘haven’t seen any information on this’’. The data were collected in December 2005. Respondents included parents of the 7th and 8th Graders from two schools in the Boulder Valley School District (Summit Middle School and Centennial Middle School) as well as college students (University of Colorado and Dalton College, GA). Because 90 per cent of the parents had college degrees, surveys were collected from college students as a group younger in age but well matched in education level. Participants included a total of 49 men and 122 women with 67 participants of the ages 18–30 and 101 participants of the ages 31–70. Initial analysis of the full age profile with narrower brackets of ages 18–25 (38 per cent of participants), 26–35 (8 per cent), 36–45 (26 per cent), 46–55 (26 per cent), and 56+ (3 per cent) showed insufficient statistical power to allow the detection of significant differences among these subgroups. Because the age profile showed two natural peaks, only two groups of ages 18–30 and ages 31–70 were therefore analyzed for the final comparison. The answers from the surveys were tabulated and significant differences in the percentage of female, male, young, old and combined total participants that gave a particular answer were determined using the formula S5[(Q6P)/N]1/2, where S is the sampling error at the 95 per cent confidence level, P is the percent calculated, Q is 100–P and N is the total sample size (Babbi, 1991). Only significantly different results are shown for the two gender and age groups (Figures 1–5). Results were graphed as pie diagrams showing the percentage of participants who gave the different answers, with the best (or ‘‘correct’’) answer as based on current scientific literature emphasized in black. Results and discussion Awareness of ‘‘good’’ and ‘‘bad’’ fats The typical American diet is excessively high in saturated fat and corn oil. Vegetable oils contain two types of polyunsaturated fats, omega-6 and omega-3 fats, which should be consumed in similar proportions. Canola oil contains these two kinds of fats in similar proportions (2:1). Corn oil, however, contains them in a ratio 50:1, which can induce cancer and other chronic diseases (Simopoulos, 2004). A large percentage of the participants were aware that the level of saturated fats should be reduced in the typical American diet (Figure 1, top: saturated fat) and be replaced by oils such as olive oil (Figure 1, top: olive oil). Many participants did not know that canola oil

The awareness of current nutrition issues

287

NFS 36,5

288

Figure 1. Awareness of ‘‘good’’ and ‘‘bad’’ fats

Figure 2. Awareness of sensible diet composition

Notes: Percentages for correct answer (in black) and sampling error at 95 per cent confidence respectively for all participants were: 97.7 per cent, ±1.2 (saturated), 85.5 per cent, ±1.2 (olive), 58.5 per cent, ±2.9 (canola) and 52.0 per cent, ±3.8 (corn)

Notes: Percentages for correct answer (in black) and sampling error at 95 per cent confidence respectively for all participants were: 67.3 per cent, ±3.6 (left) and 93.6 per cent, ±1.9 (right)

consumption should not be reduced (Figure 1, bottom: canola oil) and that corn oil consumption should be reduced in the American diet (Figure 1, bottom: corn oil). However, a significantly higher percentage of older participants were aware of the correct information for canola and olive oil compared to younger people.

The awareness of current nutrition issues

289

Notes: Percentages for correct answer (in black) and sampling error at 95 per cent confidence respectively for all participants were: 94.7 per cent, ±1.7 (yogurt), 90.0 per cent, ±2.3 (cottage cheese), 21.0 per cent, ±3.1 (beans), 47.0 per cent, ±3.8 (broccoli) and 46.8 per cent, ±3.8 (kale/collard greens)

Figure 3. Awareness of foods that are good calcium sources

NFS 36,5

290

Figure 4. Awareness of diet impact on various conditions

Notes: Percentages for correct answer (in black) and sampling error at 95 per cent confidence respectively for all participants were: 97.0 per cent, ±1.3 (diabetes), 77.8 per cent, ±3.2 (cancer), 45.0 per cent, ±3.8 (intelligence), 74.9 per cent, ±3.3 (disruptive behavior) and 34.3 per cent, ±3.6 (mental disorders)

Awareness of sensible diet composition Well-designed scientific studies with many participants show that diets aimed at weight loss and weight maintenance that are very low in fat and diets low in ‘‘carbs’’ (carbohydrates) work only for a small percentage of dieters (Tsai and Wadden, 2005). The

majority of dieters abandon such diets sooner or later, due to their restrictive nature. In addition, individuals on low fat diets may be deficient in healthful fats and individuals on low ‘‘carb’’ diets (such as the Atkins diet that restricts fruits and vegetables) may suffer from vitamin deficiencies and other problems. The best option for long-term weight maintenance is to change poor dietary habits and consume a balanced diet with healthful choices. Furthermore, scientific studies have shown that consuming excessive amounts of most vitamins is equally undesirable as consuming insufficient quantities (Pryor et al., 2000; Pham and Plakogiannis, 2005). Some supplements contain excessively high concentrations of vitamins, which have been shown to cause harmful effects. There is evidence that a truly balanced diet is the best way to provide an optimal vitamin supply. While a truly balanced diet is the recommended option, it is difficult for individuals with a busy lifestyle to achieve this and a number of participants commented on that. The answer of taking a regular multivitamin was therefore counted as a ‘‘correct’’ answer as well. Two-thirds of participants knew that the most successful diet for the long-term maintenance of a healthy weight consists of healthful choices rather than low fat and/ or low ‘‘carb’’ fad diets (Figure 2, left pie diagram). A majority of the participants was furthermore aware of the fact that a balanced diet with a resulting balanced vitamin intake, is the recommended option. Only a very small percentage of the participants favored the use of high dose ‘‘megavitamins’’ (Figure 2, right pie diagram).

The awareness of current nutrition issues

291

Awareness of foods that are good calcium sources A very large percentage of participants knew that dairy products (like yogurt and cottage cheese) are a good source of calcium (Figure 3, top). However, not many respondents knew that vegetables, such as beans, broccoli and kale/collard greens, are similarly good sources of calcium as dairy products (Farnham et al., 2000; Mangels, 2003) (Figure 3, bottom). Kale and collard greens actually have more calcium than milk on an equal volume basis (Mangels, 2003). A significantly higher percentage of women were aware of the calcium content of all of these vegetables and a significantly higher percentage of the older respondents were found to have better information in the case of kale and collard greens than younger participants (Figure 3, bottom). Awareness of diet impact on various conditions All five of the conditions included in the questionnaire (cancer, diabetes, intelligence, disruptive behavior and mental disorders) are affected by dietary factors. While this is well studied for cancer and diabetes, an increasing number of studies with good controls also show a strong impact of dietary factors on mood and behavior (Bryan et al., 2004; Dani et al., 2005). A large percentage of participants were aware of the

Figure 5.

Notes: Percentages for correct answer (in black) and sampling error at 95 per cent confidence respectively for all participants were 22.2 per cent, ±3.2

Awareness of the power of the Mediterranean diet in preventing heart attacks

NFS 36,5

292

effect of diet on diabetes and cancer (Figure 4, top). In the case of cancer, it was again found that a significantly higher percentage of older participants had better information than younger respondents. This may not be surprising because older individuals are likely to worry more about getting cancer. However, a much lower percentage of participants were aware of the effect of nutrition on the other three conditions, i.e. intelligence, disruptive behavior and mental disorders (Figure 4, bottom). Once again, the older participants were better informed than the younger group in the cases of intelligence and disruptive behavior. Awareness of the power of the Mediterranean diet in preventing heart attacks A rigorously designed scientific study testing the effect of the Mediterranean diet (rich in vegetables, fruit, olive oil, seafood and lean meat) found that this diet prevented 72 per cent of second heart attacks in a large group of men (de Lorgeril et al., 1999). This outcome is much better than that of currently prescribed medications. Only a very small percentage of participants knew about the effectiveness of the Mediterranean diet (22 per cent), and 78 per cent of the participants either marked the wrong answer (33 per cent) or marked that they had not heard of this diet (45 per cent) (Figure 5). There were no significant differences in awareness among groups. In contrast, this diet and its ability to prevent heart attacks are widely acknowledged among scientists, which is demonstrated by the fact that the original study by de Lorgeril has been cited 485 times by other original peer-reviewed studies (as of January 2006) since it was published in 1999. Discussion While there is much discussion about appropriate nutrition, the present survey is unique in that it targets specific current issues that are not widely recognized by the public. Other published surveys have targeted issues that have been discussed for decades, such as the concern about excessive salt intake and cholesterol-increasing foods (Girois et al., 2001). While the highly educated group of individuals targeted in the present survey was well informed in a number of issues, even this group had important gaps in their knowledge. In a number of these cases, older participants were better informed than younger people. In the case of vegetables with high calcium content, women were better informed than men. A greater nutrition awareness of women has also been noted in other nutrition surveys (Variyam et al., 1996; Girois et al., 2001). Repetition of the present survey with a larger number of participants, and particularly a larger male group, may reveal additional instances of gender-related differences in awareness. The present results apply only to the highly educated group studied and additional work with less well educated participants may show even wider gaps of awareness in these other populations. Conclusions The highly educated group of respondents surveyed with respect to their awareness of nutrition was well informed in many issues, such as the importance of a balanced diet, the recommendations concerning saturated fat and olive oil, the calcium content of dairy products and the effect of diet on diabetes and cancer. However, even this select group showed important gaps in their knowledge, such as less awareness of the health effects of canola and corn oil, the high calcium content of several vegetables, the effect of diet on several mental processes and the power of diet in preventing heart attacks. In a number of these cases, however, women were better informed than men and older participants were better informed than younger people.

In several of the above cases where there were gaps, one may speculate that this is related to the fact that common advertisements focus on different and more profitable treatments. References Babbi, E.R. (1991), The Practice of Social Research, 6th ed., Appendix G, Wadsworth, Belmont, CA. p. A31. Bryan, J., Osendarp, S., Hughes, D., Calvaresi, E., Baghurst, K. and van Klinken, J.W. (2004), ‘‘Nutrients for cognitive development in school-aged children’’, Nutrition Reviews, Vol. 62, pp. 295–306. de Lorgeril, M., Salen, P., Martin, J.L., Monjaud, I., Delaye, J. and Mamelle, N. (1999), ‘‘Mediterranean diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction – Final report of the Lyon Diet Heart Study’’, Circulation, Vol. 99, pp. 779–85. Dani, J., Burrill, C. and Demmig-Adams, B. (2005), ‘‘The remarkable role of nutrition in learning and behaviour’’, Nutrition & Food Science, Vol. 35 No. 4, pp. 258–63. Farnham, M.W., Grusak, M.A. and Wang, M. (2000), ‘‘Calcium and magnesium concentration of inbred and hybrid broccoli heads’’, Journal of the American Society for Horticultural Science, Vol. 125, pp. 344–49. Girois, S.B., Kumanyika, S.K., Morabia, A. and Mauger, E. (2001), ‘‘A comparison of knowledge and attitudes about diet and health among 35- to 75-year-old adults in the United States and Geneva, Switzerland’’, American Journal of Public Health, Vol. 91 No. 3, pp. 418–24. Mangels, R. (2003), ‘‘Calcium in the vegan diet’’, The Vegetarian Resource Group, available at: www.vrg.org/nutrition/calcium.htm (accessed 12 November 2005). Pham, D.Q. and Plakogiannis, R. (2005), ‘‘Vitamin E supplementation in cardiovascular disease and cancer prevention: Part 1’’, Annals of Pharmacotherapy, Vol. 39, pp. 1870–8. Pryor, W.A., Stahl, W. and Rock, C.L. (2000), ‘‘Beta carotene: from biochemistry to clinical trials’’, Nutrition Reviews, Vol. 58, pp. 39–53. Simopoulos, A.P. (2004), ‘‘Omega-6/omega-3 essential fatty acid ratio and chronic diseases’’, Food Reviews International, Vol. 20, pp. 77–90. Tsai, A.G. and Wadden, T.A. (2005), ‘‘Systematic review: an evaluation of major commercial weight loss programs in the United States’’, Annals of Internal Medicine, Vol. 142, pp. 56–66. Variyam, J.N., Blaylock, J. and Smallwood, D.M. (1996), ‘‘Modelling nutrition knowledge, attitudes, and diet-disease awareness: the case of dietary fibre’’, Statistics in Medicine, Vol. 15 No. 1, pp. 23–35. Appendix A. Demographic questions (1)

gender;

(2)

age (in years);

(3)

the highest level of education obtained.

B. Questions related to dietary fats (should be reduced/should not be reduced/haven’t seen any information on this) (4)

olive oil;

(5)

animal fats;

The awareness of current nutrition issues

293

NFS 36,5

(6)

canola oil;

(7)

corn oil.

C. Questions on diet composition (8)

Based on what you have heard or read, what do you think is the best way to get your vitamins and minerals? (It is best to add a regular multi-vitamin/multi-mineral supplement to one’s diet/it is best to add vitamin/mineral supplements to one’s diet with higher amounts than suggested by the current guidelines because these are not high enough/it is enough to eat a balanced diet; no supplements are needed/none of these choices reflect my opinion/haven’t seen any information on this);

(9)

Based on what you have heard or read, which one of the following do you think would be most likely to help you reach and maintain a healthy weight? [Eat healthy choices/eat a diet low in fat/eat a diet low in ‘‘carbs’’ (carbohydrate)/eat a diet low in fat and low in ‘‘carbs’’ (carbohydrates)/none of these reflect my opinion/haven’t seen any information on this].

294

D. Questions on what food are good calcium sources (good source of calcium/not a good source of calcium/haven’t seen any information on this) (10) yogurt; (11) beans; (12) cottage cheese; (13) collard greens/kale; (14) broccoli. E. Questions on which of conditions are affected by eating habits (affected by eating habits/not affected by eating habits/haven’t seen any information in this) (15) cancer; (16) diabetes; (17) mental disorders; (18) intelligence (IQ); (19) disruptive behavior. F. Question on Mediterranean diet (20) In a large experiment, men in their mid-50s who had suffered a heart attack either continued eating the same diet as before or were put on the Mediterranean diet. Based on what you might have heard about the effect of diet on heart disease, how many second heart attacks do you think were prevented by the Mediterranean diet over the next 5 years? (10%/20%/40%/60%/80%/haven’t seen any information on this) Corresponding author Melanie S. Adams can be contacted at: [email protected]

To purchase reprints of this article please e-mail: [email protected] Or visit our web site for further details: www.emeraldinsight.com/reprints

The current issue and full text archive of this journal is available at www.emeraldinsight.com/0034-6659.htm

Prevalence of dieting, overweight, body image satisfaction and associated psychological problems in adolescent boys

Dieting, overweight and body image

295

Abdulbari Bener Department of Medical Statistics and Epidemiology, Hamad General Hospital and Hamad Medical Corporation, Doha, State of Qatar

Abdulaziz Kamal Department of Psychology, University of Qatar, State of Qatar

Ihab Tewfik School of Biosciences, University of Westminster, London, UK

Osman Sabuncuoglu Department of Child and Adolescent Psychiatry, Marmara University, Istanbul, Turkey Abstract Purpose – The aim of the present study is to examine the severity of dieting and its association with obesity, body satisfaction and psychological problems in adolescent boys. Design/methodology/approach – A representative sample of 800 boys in the age group of 14–19 in Qatar was approached during the period from October to December, 2004 and 593 boys gave consent to participate in this study, thus giving a response rate of 74.1 per cent. Self-reports were obtained from 593 teenage boys using the adolescent dieting scale (ADS), and the self-reporting questionnaire (SRQ-20) for psychopathology. Findings – Of the studied subjects, 33.1 per cent were overweight, 10.1 per cent were extreme dieters and 37.4 per cent were intermediate dieters. Among the dieters, 34 per cent were overweight. Dieting was more likely in subjects who practiced exercise and who were perceived by peers or themselves as overweight. The extreme dieters experienced more psychological problems than the intermediate dieters and non-dieters. Extreme dieters reported sleeping problems (58.3 per cent), tired all the time (53.3 per cent) and felt like crying more than usual (50 per cent). Television was the main source of information on diet (61.7 per cent). Originality/value – The present study findings provide a strong evidence for the association between frequent dieting and overweight, body image dissatisfaction and psychological problems. Keywords Diet, Obesity, Adolescents, Boys, Self-esteem, Qatar Paper type Research paper

Introduction Adolescence is a time when social demands influence the individual and when ‘‘others’’ perceptions become very significant to the individual adolescent (Hill, 1989). Capacity and competence in adolescent boys are complex issues, because adolescents have a tendency to make treatment decisions by themselves (Tan and Fegert, 2004). Nutrition & Food Science Although dieting among boys are less common when compared with girls, some Vol. 36 No. 5, 2006 studies have shown the prevalence of eating disorders among boys cannot be taken pp. 295-304 Limited too lightly (Braun et al., 1999). In complying with the demands of being socially E Emerald Group Publishing0034-6659 DOI 10.1108/00346650610703144 attractive, dieting as a method of weight control has been a common behaviour

NFS 36,5

296

particularly in Western culture and within particular groups such as adolescents (Swadi et al., 2000). While the definition of ‘‘dieting’’ includes weight reduction efforts generally considered to be healthy (e.g. increased fruit and vegetable intake and decreased fat and sugar intake), many individuals also consider ‘‘dieting’’ to include unhealthy weight control behaviours such as fasting, skipping meals and eliminating food groups (Ackard et al., 2002; Brownell and Rodin, 1994). While dieting may be viewed as a useful exercise in body weight control, the occurrence of psychiatric symptoms in association with dieting seems to be an indication that dieting is not necessarily a healthy method of weight control, at least in some to support this view as recently highlighted by Patton (Patton et al., 1997) who found that psychiatric morbidity was clearly associated with extreme dieters reported high levels of depression and anxiety. There are issues of concern over the practice of dieting among boys. First, many of the adolescent boys who dieted are of normal weight for their height, yet they use unhealthy weight control behaviours such as fasting and use appetite suppressants, rather than healthier weight loss practices such as reducing intake of fat and sweets and increasing physical activity (Ackard et al., 2002). Usually, adolescents are using unhealthy weight control measures (Neumark-Sztainer et al., 1999). While dieting efforts among average weight or underweight individuals are most often considered negative, dieting efforts among overweight individuals have been viewed more positively (Ackard et al., 2002). For example, Wing and Jeffery (1999) found that among overweight individuals, modest weight reduction (10–15 per cent of individual body weight) achieved by the combination of calorie reduction and exercise implementation was associated with positive changes in cardiovascular risk factors. Despite a large body of literature on emotional and behavioural factors associated with dieting, we are unaware of any studies that have looked at these associations independent of body mass index (BMI). Dieting as part of an eating disorder has been well documented and accepted in Western culture, but it was only recently that eating disorders began to be viewed as cross-cultural phenomena with reports of clinical eating disorders in the Arab World (Hill, 1989; Swadi et al., 2000). To our knowledge, no studies reported the prevalence of obesity or dieting behaviour among adolescent boys neither in Qatar nor in the region. The aim of the present study was to examine the severity of dieting and its association with obesity, body image satisfaction and psychological problems in adolescent boys in the State of Qatar. Methods Qatar is an independent state occupying the Qatar Peninsula, jutting into the Persian Gulf from the eastern coast of the Arabian Peninsula. On its southern side it is bordered by Saudi Arabia. Qatar has an area of 11493 km2. The land is stony and largely barren. An extremely hot, arid climate prevails. Humidity is high during the summer, but the annual rainfall is scarce. The population of Qatar is 724125 (Annual Health Report, 2003) and 30 per cent of the total population constitutes Qatari nationals. A representative sample of 800 adolescent boys aged 14–19 was included in this study. The study was conducted from October to December 2004. The population were derived from secondary and high schools in Qatar. A multistage stratified sampling design was developed. In order to secure a representative sample of the

study population, the sampling plan was stratified with proportional allocation according to stratum size. The sample size was determined with the a priori knowledge that the prevalence rate of dieting in the State of Qatar is more or less similar to UAE and Western countries; or that it may be affected by parity, heredity, climate and sociodemographic and environmental factors. Allowing an error of 2.5 per cent and level of significance (Type-1 error) of 1 per cent, it was believed that a sample size of 800 is adequate to achieve a high degree of precision in estimating the true prevalence rate of dieting in the general population. Schools were then selected according to geographical location. Of the schools selected, half of the classes were chosen (e.g. 5A, 5C, 5E…6A, 6C, 6E, etc.). In those classes, half of the students were chosen on the basis of alternate names according to the class registration list. A total of 800 boys were approached and 593 expressed their consent to participate in this study. Two hundred and seven boys were excluded from the study due to incomplete questionnaire or did not give their consent or did not want to respond to the questionnaire due to lack of time. Instruments Self-reports were obtained by using adolescent dieting scale (ADS) (Patton et al., 1997) and self-reporting questionnaire (SRQ-20) (El-Rufaie and Absood, 1994) for psychopathology. Questionnaire including the general demographic variables and dieting information was filled out by the research assistants. The anthropometrics measures of adolescent boys were measured and collected by qualified nurses. The ADS (Patton et al., 1997) The ADS consists of eight items and for each question; there are four possible answers ‘‘seldom or never, sometimes, almost and always’’. They attracted a score of 0, 1, 2 and 3 respectively. The ADS is based on a refinement of a number of other scales for measuring dietary restraint. The authors identified behaviours typical of dieting but did not include the extreme weight control strategies that are characteristics of clinical eating disorders. They identified nine behaviours, which covered three broad dieting strategies (calorie counting, reducing food quantity and meal skipping). The unidimensionality of the ADS was assessed by using a principal component analysis which showed that, for the nine item scales, there were two main components, one with an Eigen value of 5.4 and the other with a much smaller Eigen value of 1.2. However, they found that one of the items ‘‘skipping breakfast’’ has a low item correlation and therefore carried out a separate analysis without that item. The alpha coefficient for the eight items scale was 0.83 and it had two principal components with an Eigen value of 3.5 and the other component had an Eigen value of 1.0. On that basis, they considered the eight item ADS a suitable scale for measuring dieting in a non-clinical population. Three bands of dieting were in a non-clinical population. Three bands of dieting, minimal (total score 1–6), intermediate (total score 7–14) and extreme (total score more than 15) were identified using data obtained from their study. Because of the ease of administration, the feasibility of quantification of dieting and understand ability and acceptability of this questionnaire, we decided to use it in our survey. Moreover, it seems to be culture free since it inquires about specific behaviours rather than concepts, which may be influenced by cultural factors. We therefore did a translation into Arabic with back translation by a non-clinician who was fluent in both Arabic and English. We piloted the questionnaire on a small

Dieting, overweight and body image

297

NFS 36,5

298

number of adolescents who reported that the questionnaire was understandable and easy to answer. There were minimal changes in the wording following the piloting process. For the above reasons, we did not feel that a full validation study of the ADS in this culture was not necessary and was not carried out. The Arabic version of the SRQ (El-Rufaie and Absood, 1994) This is a screening instrument for identifying potential psychiatric cases in community settings and is not designed for diagnostic purposes. The original version (Harding et al., 1980) consists of 20 items designed to detect non-psychotic symptoms. Each item would attract a score of 1 for a ‘‘yes’’ response and 0 for a ‘‘no’’ response. It has been found to have a fairly good sensitivity and specificity and has been successfully used in adolescent populations (Feijo et al., 1997). El-Rufaie and Absood (1994) validated the SRQ-20 in a primary care sample in the United Arab Emirates and found it to be a valid instrument for detecting minor psychiatric morbidity. Body mass index was calculated as the weight in kilograms (1 kg subtracted to allow for clothing) divided by height squared in meters. Subjects were classified into three categories: acceptable weight (BMI,25 kg m22), overweight (BMI 25–29.9 kg m22) and obese (BMI 30+ kg m22) (Garner, 1993). Statistical methods and analysis The statistical package for social sciences (SPSS) (Norusis, 1998) was used for statistical analysis. Data were expressed as mean and standard deviation (SD) unless otherwise stated. Student-t test was used to ascertain the significance of differences between mean values of two continuous variables. Chi-square analysis was performed to test for differences in proportions of categorical variables between two or more groups. In 2 6 2 tables, the fisher’s exact text (two tailed) replaced the chi-square test if the assumptions underlying chi-square violated, namely in case of small sample size and where the expected frequency is less than 5 in any of the cells. One way analysis of variance (ANOVA) was employed for comparison of several group means and to determine the presence of significant differences between group means of continuous variables. The level p,0.05 was considered as the cutoff value for significance. Results A total of 593 of 800 enrolled school boys participated in this study, thus giving a response rate of 74.1 per cent. Table I shows the sociodemographic characteristics of the studied subjects. The mean BMI for the studied population was 23.2 (SD 3.9) (with range of 15.6–34.0). Of the total respondent population, BMI calculation showed that 196 (33.1 per cent) fell above the 25 kg m22. But, among the dieters, 34 per cent were overweight. Table II shows the adolescent dieting score and BMI by age group. Only a small minority of the adolescent boys were non-dieters (11.8 per cent). Almost 90 per cent were dieting mostly on a minimal or moderate basis. However, 10.1 per cent were extreme dieters. The prevalence of dieting did not show great variations in the two age groups of 14–16 and 17–19. Table III shows the comparison of dieting severity by ADS. Among the overweight boys, 49 per cent were dieters. Extreme dieting was higher among the subjects whose family members practiced dieting, however no significant difference was found. Dieting was most likely to be practiced among subjects who had a family history of arthritis (P50.008) and heart disease (P,0.001). Dieting was clearly associated with

Variables Age (years) 14–16 17–19 BMI (kg m22) #25 Normal .25 Overweight Education Intermediate Secondary Living condition Excellent Above average Average Below average Poor No of siblings #6 .6

Dieters N5282 n(per cent)

Non-dieters N5311 n(per cent)

119(42.2) 163(57.8)

142(45.7) 169(54.3)

NS*

186(66.0) 96(34.0)

211(67.8) 100(32.2)

NS

111(39.4) 171(60.6)

128(41.2) 183(58.8)

NS

63(22.3) 81(28.7) 43(15.2) 39(13.8) 56(19.9)

60(19.3) 82(26.4) 63(20.3) 41(13.2) 65(20.9)

NS

161(57.1) 121(42.9)

180(57.9) 131(42.1)

NS

P value

Note: *NS5Not significant

Age group 14–16 N5261 17–19 N5332

Non-dieters ADS50

Minimal dieters ADS51–6

Intermediate dieters ADS57–14

Extreme dieters ADS515–24

32(12.3) 38(11.4)

110(42.1) 131(39.5)

98(37.5) 124(37.3)

21(8.0) 39(11.7)

Dieting, overweight and body image

299

Table I. Sociodemographic characteristics of the studied subjects by gender

BMI groups (kg m22) #25

.25

171(65.5) 226(68.1)

90(34.5) 106(31.9)

exercise showing that those who diet more often also practiced exercise regularly (P50.002). Self-perception and peers perception of body weight also contributed heavily to the boys ADS score (P,0.001) in both cases. Table IV shows the association between the dieting behaviour and psychological factors in studied adolescent boys. Television and magazines were the main sources of information for the extreme dieters on dieting and have shown a significant association. About 23.3 per cent of extreme dieters got their information on dieting from school friends compared with 12.5 per cent of non-dieters and 18.9 per cent of intermediate dieters (P50.037). Television was the main source of information on diet for all subjects and again the extreme dieters were more influenced by the information through television (61.7 per cent). The self-reported questionnaires revealed that poor appetite (45 per cent) was more common among the extreme dieters. The other significant psychological problems among the extreme dieters were that sleeping problems (58.3 per cent) and feeling tired all the time (53.3 per cent), crying more than usual (50 per cent). Discussion The rate of overweight among children continues to increase in every society. Overweight and distorted body perception can both lead to serious physical and

Table II. Adolescent dieting score and BMI by age group

NFS 36,5 Variable 22

300

Table III. Comparison of dieting severity by ADS

BMI, kg m (Mean¡SD) BMI group, kg m22 #25 .25 Dieting in family Yes No Obesity in family Yes No Family history of diabetes Yes No Family history of high blood pressure Yes No Family history of Arthritis Yes No Family history of mental disorders Yes No Family history of heart diseases Yes No Dieting friends Yes No Practice exercise Yes No Satisfied with own body Yes No Peer’s perception of respondent’s figure Overweight Average Underweight Self-perception of figure Overweight Average Underweight SRQ (Mean¡SD)

Non-/minimal dieters ADS50–6

Intermediate dieters ADS57–14

Extreme dieters ADS515–24

p value

23.1¡4.0

23.4¡3.9

22.6¡3.3

NS

211(53.1) 100(51.0)

140(35.3) 82(41.8)

46(11.6) 14(7.1)

NS

155(49.7) 156(55.5)

118(37.8) 104(37.0)

39(12.5) 21(7.5)

NS

241(52.6) 70(51.9)

165(36.0) 57(42.2)

52(11.4) 8(5.9)

NS

188(51.6) 123(53.7)

137(37.6) 85(37.1)

39(10.7) 21(9.2)

NS

169(53.1) 142(51.6)

117(36.8) 105(38.2)

32(10.1) 28(10.2)

NS

75(51.7) 236(52.7)

46(31.7) 176(39.3)

24(16.6) 36(8.0)

0.008

17(42.5) 294(53.2)

15(37.5) 207(37.4)

8(20.0) 52(9.4)

NS

75(46.3) 236(54.8)

55(34.0) 167(38.7)

32(19.8) 28(6.5)

,0.001

165(51.7) 146(53.3)

121(37.9) 101(36.9)

33(10.3) 27(9.9)

NS

148(46.3) 163(59.7)

131(40.9) 91(33.3)

41(12.8) 19(7.0)

0.002

215(55.6) 96(46.6)

135(34.9) 87(42.2)

37(9.6) 23(11.2)

NS

67(40.4) 139(50.7) 105(68.6)

78(47.0) 111(40.5) 33(21.6)

21(12.7) 24(8.8) 15(9.8)

107(44.4) 123(53.2) 81(66.9) 6.8¡3.8

101(41.9) 87(37.7) 34(28.1) 6.6¡3.7

33(13.7) 21(9.1) 6(5.0) 7.4¡3.9

,0.001

,0.001 NS

psychological problems (Strauss, 1999). Specific risk factors of eating disorders are body dissatisfaction, low self-esteem, high need for social approval and history of physical abuse among adolescents (Garner, 1993). It is interesting to point out that their actions are focused on diet without paying much attention to other aspects of life style including physical activity and even psychosocial problems.

Variable Source of information on dieting School TV Magazine Radio Often has headache Has poor appetite Sleeping badly Are you easily frightened Sometimes hand shakes Feel tensed, nervous or worried Poor digestion Having trouble thinking clearly Feeling unhappy Crying more than usual Difficulty in enjoying daily activities Difficulty in making decisions Daily work is suffering Unable to play useful part in life Lost interest in things Feeling worthless person Thought of losing life in mind Feeling tired all the time Uncomfortable feeling in stomach Easily tired

Non-/minimal dieters ADS50–6 (n5311)

Intermediate dieters ADS57–14 (n5222)

Extreme dieters ADS515–24 (n560)

p value

39(12.5) 130(41.48) 123(39.5) 31(10.0) 111(35.7) 82(26.4) 146(46.9) 111(35.7) 89(28.6) 183(58.8) 67(21.5) 140(45.0) 101(32.5) 42(7.1) 93(29.9) 120(38.6) 110(35.4) 75(24.1) 106(34.1) 36(11.6) 78(25.1) 156(50.2) 97(31.2) 107(34.4)

42(18.9) 107(48.2) 93(41.9) 28(12.6) 88(39.6) 58(26.1) 84(37.8) 81(36.5) 62(27.9) 116(52.3) 49(22.1) 87(39.2) 91(41.0) 21(9.4) 77(34.7) 90(40.5) 81(36.5) 47(21.2) 77(34.7) 31(14.0) 55(24.8) 92(41.4) 56(25.2) 61(27.5)

14(23.3) 37(61.7) 27(45.0) 10(16.7) 25(41.7) 27(45.0) 35(58.3) 24(40.0) 16(26.7) 31(51.7) 22(36.7) 21(35.0) 18(30.0) 12(20.0) 22(36.7) 22(36.7) 17(28.3) 19(31.7) 15(25.0) 6(10.0) 20(33.3) 32(53.3) 16(26.7) 25(41.7)

0.037 0.014 NS NS NS 0.009 0.009 NS NS NS 0.035 NS NS 0.041 NS NS NS NS Ns NS NS NS NS NS

There are very few studies on dieting and eating behaviour conducted in other Arab countries. Two relevant studies have been recently carried out, but their main focus was on obesity. Both studies indicated that a significant proportion of males (adults and adolescents) were overweight. First, Musaiger (Musaiger et al., 2003) found that 17.1 per cent of male students were overweight and 8.4 per cent were grossly obese. More recently, a cross-sectional study (Bener and Kamal) involving a sample of 8566 secondary and high school students boys aged from 14 to19 found that 11.9 per cent of boys were at a risk of being overweight. The rate reported in our study was higher than these studies that 33.1 per cent of the adolescent boys were overweight. But, the overweight rate of Qatari adolescent boys were very similar to the rate found in a study of Fonseca (Fonseca et al., 2002) that the proportion of overweight individuals among boys (BMI greater than 90th percentile of the Brazelian population) was 23.9 per cent. Of the studied adolescent boys in the current study, 37.4 per cent were intermediate dieters and 10.1 per cent were extreme dieters which is quite higher than the rate found in an Australian study (Patton et al., 1997) that 12 per cent of boys and 38 per cent of girls were categorised as ‘‘intermediate dieters’’ and 1 per cent of boys and 7 per cent of girls were ‘‘extreme dieters’’. Despite differences in methodology, several Western studies indicated that dieting (of varying severity) is a common behaviour

Dieting, overweight and body image

301

Table IV. Association between dieting severity and psychological factors

NFS 36,5

302

even among young people of normal weight range. Wooley and Wooley (1984) estimated that 72 per cent of adolescents and young adults were dieting. A research (Xie et al., 2003) done by the Institute for Health Promotion and Disease Prevention in California documented that perceived overweight boys and girls were more likely to experience anxiety and depression than perceived normal and underweight subjects. In our study, half of the extreme dieters had significant psychological problems like crying more than usual (50 per cent), sleeping problems (58.3 per cent) and feeling tired all the time (53.3 per cent). Environmental influences particularly peer group’s perceptions and attitudes, role models and learned behaviour seem to be influential in this respect. The mass medical are believed to encourage girls to form unrealistically think body ideals (Field et al., 1999), but their impact on boys has not been investigated earlier. A study from Portugal (Fonseca et al., 1998) also reported that among boys the main factors for dieting were parental supervision and BMI. Also a report from Latin America (McArthur et al., 2001) found that the adolescents are very interested in learning more about obesity and weight loss methods. A study on body weight perception among Bahraini adolescents (Al Sendi et al., 2004) revealed a significant discrepancy between adolescents’ perception of body weight and actual BMI. There was a tendency for teenagers to underestimate their weight status, which was especially noteworthy among the overweight and obese. One third of the adolescent boys thought that their parents and their peers respectively, could consider them to be overweight or obese. Data revealed in our study that self-perception and peers perception of body weight also contributed heavily to the boys ADS score (P,0.001) in dieters. But, Steen (Steen et al., 1996) reported in their study that the obese boys perceived themselves to be less overweight and happier with their looks than obese girls. The use of problematic weight loss tactics were significantly higher among students who are involved in substance misuse reported by several studies (Garry et al., 2003; Durant et al., 1999). We have not covered these factors in our study. Weight concern develops among girls in all weight spectrum but among the boys it is strongly related to BMI (Field et al., 2001). On the contrary, our results showed that there is no association of dieting with BMI. The only factors which contribute to starting dieting among Qatari boys are self-perception and peer’s perception of their own figure. Conclusion The present study findings revealed a strong evidence for the association between frequent dieting and eating disorders, body image dissatisfaction and psychological problems in adolescent boys in Qatar. Half of the overweight boys were dieters. Extreme dieters were under stress like they felt like crying more than usual, could not sleep well and felt tired all the time. Special attention needs to be directed toward teenagers for educating them about a healthy weight, body image, nutrition and exercises using culturally appropriate materials. References Ackard, D.M., Croll, J.K. and Kearney-Cooke, A. (2002), ‘‘Dieting frequency among college females: association with disordered eating, body image, and related psychological problems’’, Journal of Psychosomatic Research, Vol. 52, pp. 129–36. Al Sendi, A.M., Shetty, P. and Musaiger, A.O. (2004), ‘‘Body weight perception among Bahraini adolescents’’, Child Care Health and Development, Vol. 30 No. 4, pp. 369–76.

Annual Health Report (2003), Hamad Medical Corporation and Ministry of Public Health. Bener, A. and Kamal, A. ‘‘The growth pattern of Qatari school children aged 6–18 years’’, Submitted to Journal of Health, Population and Nutrition. Braun, D.L., Sunday, S.R., Huang, A. and Halmi, K.A. (1999), ‘‘More males seek treatment for eating disorders’’, Int. J. Eat. Disord., Vol. 25, pp. 415–24. Brownell, K.D. and Rodin, J. (1994), ‘‘The dieting maelstrom: is it possible and advisable to lose weight?’’, Am. Psychol., Vol. 49, pp. 781–91. Durant, R.H., Smith, J.A., Kreiter, S.R. and Krowchuk, D.P. (1999), ‘‘The relationship between early age of onset of initial substance use and engaging in multiple health risk behaviors among young adolescents’’, Archives of Pediatric and Adolescent Medicine, Vol. 153, pp. 286–91. El-Rufaie, O. and Absood, G. (1994), ‘‘Validity of the self-reporting questionnaire (SRQ-20) in primary health care in the United Arab Emirates’’, International Journal of Methods in Psychiatric Research, Vol. 4, pp. 45–53. Feijo, R., Saueressig, M., Salazar, C. and Chaves, M. (1997), ‘‘Mental health screening by selfreport questionnaire among community adolescents in southern Brazil’’, Journal of Adolescent Health, Vol. 20, pp. 232–37. Field, A.E., Camargo, C.A. Jr, Taylor, C.B., Bekey, C.B. and Colditz, G.A. (1999), ‘‘Relation of peers and media influences to the development of purging behaviors among preadolescent and adolescent girls’’, Arch. Pediatr. Adolesc. Med., Vol. 153, pp. 1184–9. Field, A.E., Camargo, C.A. Jr, Taylor, B., Berkey, C.S., Roberts, S.B. and Colditz, G.A. (2001), ‘‘Peers, parent and media influences on the development of weight concerns and frequent dieting among preadolescent and adolescent girls and boys’’, Pediatrics, Vol. 107, pp. 54–60. Fonseca, H., Ireland, M. and Resnick, M.D. (2002), ‘‘Familial correlates of extreme weight control behavior among adults’’, Int. J. Eat. Disord., Vol. 32, pp. 441–8. Fonseca, V.M., Sichieri, R. and Da Veiga, G.V. (1998), ‘‘Factors associated with obesity among adolescents’’, Rev. Saude Publica, Vol. 32 No. 6, pp. 541–9. Garner, D.M. (1993), ‘‘Pathogenesis of anorexia nervosa’’, Lancet, Vol. 54, pp. 504–17. Garry, J.P., Morrissey, S.L. and Whetstone, L.M. (2003), ‘‘Substance use and weight loss tactics among middle school youth’’, Int. J. Eat. Disord., Vol. 33, pp. 55–63. Harding, T.W., De Arango, M.V., Baltazar, J., Climent, C.E., Ibrahim, H.H., Ladrido-Ignacio, L., Murthy, R.S. and Wig, N.N. (1980), ‘‘Mental disorders in primary health care: a study of their frequency and diagnosis in four developing countries’’, Psychological Medicine, Vol. 10, pp. 231–41. Hill, P. (1989), Adolescent Psychiatry, Churchill Livingstone, London. McArthur, L., Pena, M. and Holbert, D. (2001), ‘‘Effects of socioeconomic status on the obesity knowledge of adolescents form six Latin American cities’’, Int. J. Obes., Vol. 25, pp. 1262–8. Musaiger, A.O., Lloyd, O.L., Bener. A. and Al Neyadi, S.M. (2003), ‘‘Lifestyle factors associated with obesity among male university students in the United Arab Emirates’’, Nutrition and Food Science, Vol. 33 No. 4, pp. 145–7. Neumark-Sztainer, D., Sherwood, N.E., French, S.A. and Jeffery, R.W. (1999), ‘‘Weight control behaviours among adult men and women: cause for concern?’’ Obes. Res., Vol. 7, pp. 179–88. Norusis, M.J. (1998), SPSS/PC+ for Windows, Base System and Advanced Statistics User’s Guide, Release Version 11, SPSS Inc., Chicago, IL.

Dieting, overweight and body image

303

NFS 36,5

304

Patton, G.C., Carlin, J.B., Shao, Q., Hibbert, M.E., Rosier, M., Selzer, R. and Bowes, G. (1997), ‘‘Adolescent dieting: healthy weight control or borderline eating disorder?’’, Journal of Child Psychology and Psychiatry, Vol. 38, pp. 299–306. Strauss, R. (1999), ‘‘Childhood obesity’’, Curr. Probl. Pediatr., Vol. 29, pp. 5–29. Steen, S.N., Wadden, T.A., Foster, G.D. and Andersen, R.E. (1996), ‘‘Are obese adolescent boys ignoring an important health risk?’’, Int. J. Eat. Disord., Vol. 20, pp. 281–6. Swadi, H., Bener, A. and Al Darmaki, F. (2000), ‘‘Dieting among Arab girls’’, The Arab Journal of Psychiatry, Vol. 11, pp. 25–35. Tan, J.O. and Fegert, J.M. (2004), ‘‘Capacity and competence in child and adolescent psychiatry’’, Health Care Anal., Vol. 12, pp. 285–94. Wing, R.R. and Jeffery, R.W. (1995), ‘‘Effect of modest weight loss on changes in cardiovascular risk factors: are there differences between men and women or between weight loss and maintenance?’’, Int. J. Obes., Vol. 19, pp. 67–73. Wooley, S. and Wooley, O. (1984), ‘‘Should obesity be treated at all?’’, in Stunkard, A.J. and Stellar, E.J. (Eds), Eating and Its Disorders, Raven, New York. Xie, B., Liu, C., Chou, C.P., Xia, J., Spruijt, M.D., Gong, J., Li, Y., Wang, H. and Johnson, C.A. (2003), ‘‘Weight perception and psychological factors in Chinese adolescents’’, J. Adolesc. Health, Vol. 33, pp. 202–10. Corresponding author Abdulbari Bener can be contacted at: [email protected]

To purchase reprints of this article please e-mail: [email protected] Or visit our web site for further details: www.emeraldinsight.com/reprints

The current issue and full text archive of this journal is available at www.emeraldinsight.com/0034-6659.htm

Generating effective change in school meals: a case study

Generating effective change in school meals

Claire Seaman and Julia Moss Queen Margaret University College, Edinburgh, UK Abstract

305

Purpose – Obesity among primary school children is an area of current concern throughout the UK, alongside much discussion surrounding the opportunities and challenges of effecting change. School meals may contribute to obesity, tending to be high in fat and sugar and lacking in essential nutrients. The primary purpose of this study is to investigate the success of a healthy eating programme and to examine the work that had been done to identify areas where further work was required, where lessons might be learned for future campaigns and areas where further research would be useful. Design/methodology/approach – The current study uses a case study approach to examine food provision and education within a primary school in Edinburgh, which adopts a healthy eating programme based on the guidelines of Hungry for Success. Within the case study, both quantitative and qualitative methods were used, including semistructured interviews, recipe analysis and observational research. Findings – Results indicate some considerable success has been achieved and more ways in which healthy eating can be promoted within the school have been identified. The manner in which change can most effectively be implemented is explored and some indicators for future work highlighted. In addition, results indicate that slow subtle change will be more effective than well intentioned attempts to achieve the ideal in a peremptory manor and that persistence is likely to play a key role. Research limitations/implications – The study was carried out in one school where the school meals were prepared on an in-house basis. Nonetheless, looking at ways in which effective change in children’s eating habits and food choices can be achieved on a small scale provides some useful pointers for future research with schools where meals are prepared by contract caterers. Originality/value – The paper focuses on a healthy eating programme. Keywords Nutrition, Children (age groups), Primary schools, Health education, United Kingdom Paper type Case Study

Introduction In Britain, one in five children is currently estimated to be overweight and 2.5 per cent are classed as obese. Obesity among children is reported as having risen continuously for around two decades (Reilly, 2002) and currently a third of twelve year olds in Scotland are classed as overweight. In addition, recent studies of children aged between 11 and 12, established that there was confusion over what constitutes healthy eating (Health Pro, 2004). At a time when the country has never had more nutritional information, children in Britain are more likely to be overweight and to suffer the associated health and social problems. On average, children are reaching their teens a stone heavier than previous generations (Yapp, 2003). Among other factors, it has been suggested by many authors that unhealthy school meals are contributing to the problem. Menus in school canteens have been reported to regularly feature high fat, and sugary meal options (Department of Education and Skills, 2004). In Britain approximately four million school meals are prepared daily providing for 45 per cent of school children (Eves et al., 1997; current dietary advice in Nutrition & Food Science Scotland). Vol. 36 No. 5, 2006 The irony is that school meals were introduced in 1900 due to the anxiety over the pp. 305-314 Limited health of children, particularly those in poorer areas where the children were shorter E Emerald Group Publishing0034-6659 DOI 10.1108/00346650610703153 and thinner than those in more privileged areas (Alexander et al., 2001). During the

NFS 36,5

306

Boer war it was brought to the attention of the government, that the young men being recruited were, small, undernourished and unwell. There was also an absence of nutritional information. In an attempt to combat the problem, the London School Board offered cheap or free school dinners. The rational behind the idea was also that if the children were hungry it would affect their studies (Learning Curve, 2003). Nutrient standards for school meals were established by the government during the Second World War, but lapsed over time. In 1980 with the revision of the Education Act they were withdrawn formally, allowing a great change in school meal provision. There was no specific costing of meals and no statutory requirement to meet nutritional guidelines. This provided the opportunity for choice but not necessarily for the good (Adams et al., 1997; Church, 1997; Blades, 2001). The standards for school meals became very relaxed and the Local Education Authorities (LEA’s) were only obliged to provide school meals to those children entitled (Church, 1997). Recent concern has been mounting over the nutritional content of school meals, focussing primarily on studies that indicate that current school meals lack nutritional balance and contain excess fat, sugar and salt (Bunker and Burgess, 2002; DoH 1989; MAFF, 1996; Noble and Kipps, 1994; Eves et al., 1997). Attempts have been made to reintroduce national guidelines for schools, none of which have been adopted formally. In April 2001 minimal nutritional standards, using dietary reference values, based on government advice on healthy eating were introduced by the Caroline Walker Trust (Harvey, 2001). Caterers are now provided with a guide with which they can compare the nutritional content of the school meals they produce (Bunker and Burgess, 2002). In 2002 a report, ‘‘Hungry for Success – A Whole School Approach to School Meals’’ was published, providing recommendations for radical improvements in the school meals service (BNF, 2004). In addition to the problems associated with being overweight during childhood itself, school is an influential time for children in relation to moulding their dietary preferences. Healthy eating habits established in childhood are likely to influence food consumption over the lifespan and form a key part of strategies to tackle obesity in the UK. For many children the school meal is their main or in some cases, only meal of the day. A survey by the DHSS, ‘‘The Diets of British School-Children’’ revealed that around 30 per cent of a child’s energy intake is derived from school meals (Health Pro, 2004). Various bodies have become involved with schools throughout the UK in a bid to improve school meals: N The Food Standards Agency (FSA). N The School Nutrition Action Group (SNAG). N The European Network of Health Promoting Schools (ENHPS). These groups regularly carry out surveys, reports and studies into school meals in an attempt to solve current problems. Price and budget in relation to school meals are also an issue. The budget delegated to a school, can limit the food that is served (FSA, 2004). Free meals are provided for eligible pupils whose families receive certain benefits (SPEC, 2004). This development aimed to provide a meal during the day to children from less privileged backgrounds. However, the meals that are provided are not required to meet a nutritional standard. Many cafeterias are ‘‘Free Choice’’ and need to generate business. Therefore, popular options such as burgers and chips feature prominently (Health Pro, 2004; Caraher et al., 2004).

Methodology The primary methodology for this study involves a case study carried out within a primary school. Within this case study, however, the methodology that was developed in three parts to cover the span of data that it was perceived would offer a useful perspective both on the participants understanding of the school meals project and on the actual changes identified. The three categories in which data were collected were an nutritional analysis of the meals served, interviews with staff associated with food provision and a small observational study of the food choices that individuals pupils made. To explore the wide range of issues, both quantitative and qualitative methods were used, including an analysis of the nutritional content of the school meal served, providing a comparison with the guidelines published by the Caroline Walker Trust, which was carried out using Comp-Eat Software and three observational studies carried out during the serving period for lunch. In addition, semistructured depth interviews were carried out with the head of the kitchen staff, the head teacher, the member of staff who had organised the healthy eating project and a PE teacher who was also a parent of children within the school. While the choice of those individuals who were to take part in the interviews was naturally affected by the availability and willingness of the participants, it is important to note that all those interviewed had had direct contact with the project. The results obtained should therefore be viewed as the views of those staff involved in the project; the opinions of those schoolchildren who regularly ate the meals and of their parents would form a fascinating piece of supplementary research. The questions asked within the interviews varied slightly according to the focus, involvement and experience of each staff member and are listed in Table I. Three mealtimes were observed and anonymous records of the actual food choices made by children were kept to facilitate practical suggestions for future development work. Two types of observational techniques; participant and non-participant observation are in current general use (Sarantakos, 1998). During participant observations, natural science processes are studied as they happen. Researchers observe the activities and interact with the subjects (Schutt, 1999). Non-participant observations require the researcher to play a passive role in avoiding the direct influencing of events (Grix, 2001). Non-participant observations were used for this study, both for ethical reasons and to avoid distracting or influencing the children. A major concern was that if the children had known that they were being analysed, their food choices might have been affected. Three observational studies of the food choices of 180 children took place over a period of three weeks. The observations were applied to sittings of 120 primary three and four children aged between seven and nine. Each alternate child’s meal [in queuing order] was noted for analysis. A different day of each week was selected to ensure menu variety. With this type of observational study White (2002) states that it is important to blend into the background and not cause an obstruction. Therefore the observer stood to the side of the cash desk, at the best vantage point without being obtrusive. The study was repeated three times to get as much information as possible and to improve the reliability of the results. A nutritional analysis of four popular meal choices was made to allow comparisons with the Caroline Walker Trust guidelines. The foods available within the meal and the quantities provided were noted and the nutritional analysis was carried out using Comp-Eat.

Generating effective change in school meals

307

NFS 36,5

Head of Canteen

The importance of integrating a healthy eating programme. The main aims. What changes were made. Surveillance of the children’s eating habits. Guidelines. How easy it is to follow the advice provided. How lunch is organised. Waste. Should the children be educated on healthy eating earlier on in the curriculum.

Head Master

Changes in the food served over the years. Increase in obesity. Why the programme for healthy eating was introduced. Budget. Should the children be educated on healthy eating earlier on in the curriculum. The success of the project. Other reasons for healthy eating.

Project Leader

The importance of integrating a healthy eating programme. What changes have been made. Changes in the food served over the years. Nutritional background. Should the children be educated on healthy eating earlier on in the curriculum. Availability of advice. Use of support groups. Levels of physical education. Monitoring choice. Traffic light system. Budget. Children’s reactions to the programme.

PE teacher and Parent

How the programme has affected the children. Advice given by a parent. If children at p3 and p4 level are too young to make food choices. Satisfaction with the schools efforts. Availability of confectionary. Should the children be educated on healthy eating earlier on in the curriculum.

308

Table I.

Results and discussion The healthy eating programme As part of the programme the school: N Integrated healthier meals into the mainstream food service. N Reduced the amount of fast food served. N Encouraged the children to drink water throughout the day in order to aid their ability to study and to control their appetite. There have been various changes within the canteen over the last fifteen years. Initially set meals were served but due to the amount of waste, the school brought in outside caterers, providing the children with a wide choice. This was also recognised as a problem in schools by Coles and Turner (1993). However, the caterers were selling

a lot of fast food products which were not of an acceptable quality supporting the research of Ruxton et al. (1993). Three years ago the school employed an individual with experience on healthy eating and running a school canteen, to establish a basis for the provision of healthier food. A number of substantive changes have occurred, including the introduction of healthier recipes, salad bowls and fresh and dried fruit as an alternative to confectionary. Sugar free flavoured waters and fruit juices were introduced as an alternative to the more sugary beverages available previously. Within the school, it is perceived that while the kitchen is running at a minor budgetary deficit the quality of the food has greatly improved. Over the years the ambience of the canteen has also changed. Initially, due to an unfriendly atmosphere the children were being deterred from eating there. However, a change in staff and attitude has altered this ensuring that it is an inviting and friendly place to be. This has been a positive move, corresponding closely with recommendations within Hungry for Success (2002), which state that a good atmosphere in the canteen is essential. Although none of the staff actually have a background in nutrition, they have been able to follow the guidelines from ‘‘Hungry for Success’’ fairly easily. The school also used information from the Health Education Board of Scotland’s programme called, ‘‘Healthy for Life’’ which they found very useful. The project leader was also involved with the Health Promoting Schools programme. Although food such as pizza, which sounds like an unhealthy option is still served in the canteen, it was ascertained that the pizzas are made in on site. Therefore the bases are baked and not fried and can also be made with wholemeal flour providing a healthier fast food option. Chips are only served once a week, in line with current dietary advice in Scotland. The staff have devised other ways to cook potatoes which seem fairly popular, such as slicing them and cooking them with stock. Children are not allowed to use the confectionary machines provided for the senior school which is based on the same sight. This was a move to reduce the amount of crisps and sweets that they were eating previously. The school have done this by locking the machines during their play time and lunch time. However, there has been no move up to now to monitor the snacks that children bring in at break time. This is perceived as being the parent’s decision and confirms the importance of parental education. Many vending machines are now being removed from schools by the Food and Drink Federation (FDF) when requested by the school or the LEA due to dietary reasons (FDF, 2005). Another recent change with regard to confectionary within the school, was that the teachers were stopped from giving sweets as rewards at primary level. At lunch time children are not allowed to purchase any confectionary from the counters except fudge bars. They are however, able to choose a cake such as a doughnut as desert. It could be argued that a chocolate bar may be less harmful to a child nutritionally than a doughnut, although the differences are likely to be very small. Healthy eating education With regards to education on healthy eating, the children are taught all the way through the school but in more depth within primary six and seven. In primary one the children spend a lesson making up a lunch box and deciding what healthy foodstuffs it should contain. This has been successful to a point as the children have

Generating effective change in school meals

309

NFS 36,5

310

been found to discuss and in some cases even advise their parents as to what they should have in their lunchboxes. This supports the view of Bowker et al. (1998) who have focused on the importance of nutritional education and its advantages. It would beneficial to go into more depth at this point in order to make the children more aware of the food choices they are making. The school recognises the importance of parental input and is aware that there is more that could be done to encourage parents to become involved. For example, the school could advise the parents on giving the children healthy snacks for break time. Findings and discussion from the interviews The initial observation made during the headmaster, the head of the catering staff and the project leader, was very content and positive about the programme. These participants were more directly involved with the introduction of the programme which may have introduced bias but which may also have provided a useful perspective about the amount of change which had actually been achieved. The person that questioned the effectiveness of the programme was actually the physical education teacher, who is also a parent, and provides an interesting insight. Though he did not state doubts as to the effectiveness of the food improvements, he did not allow his own children to eat within the school refectory. This may suggest that he doubts the success of the healthy eating programme and is an area where future research might focus. While the numbers of people interviewed are too small to draw any firm conclusions, the importance of liaison with parents is highlighted. Findings and discussion from the observational study In general, the results from the observational study indicate that the unhealthier options on the menu or those options that appeared to be unhealthy were the most popular, notably the pizza and the hot dogs (Table II). There was a day within the three monitored when the majority of the children selected the ‘‘healthier choice’’ sausage casserole. This revealed a pattern whereby sausages were revealed as the main choice throughout the study whether they occurred in a ‘‘healthy’’ or ‘‘unhealthy’’ option. This information could be built on and the sausage selections could be made healthier, perhaps by using leaner sausages. Each day, out of the healthy options, the pasta seemed to be the most popular dish. By developing on this information, the kitchen staff could begin to infiltrate more healthy ingredients into the sauces such as more vegetables or more lean meat which would benefit the children nutritionally. A key area for future work will be the development of more and even more popular recipes that also happen to be healthy. Results indicated overwhelmingly that the salad boxes were unpopular. The school had previously considered installing a salad bar, but decided that there would be too much waste. Given the lack of enthusiasm for the salad boxes, this appears to have been a sensible decision; more work to increase the popularity of this group of foods would be required before this became a sensible option. Adding to the current salad box to make it more popular might provide a reasonable way forward, perhaps by adding cheese or pasta, as pasta in particular is such a popular option. The best alternative, however, would be to serve a small portion of salad with more of the main meals for example the burgers. The portion of salad could be slowly increased as the children became ‘‘acclimatised’’ to it. Almost all of the children accompanied their meal with a cake. The healthier options were not selected. Throughout the study only four fruit box selections were

Healthy option Day 1 Fish cakes Pasta and tomato sauce Baked potato Sandwich Salad Total Per cent Day 2 Roast beef, yorkshire pudding and stovies Sausage casserole Pasta and tomato sauce Baked potato Sandwich Salad Green split pea soup Total Per cent Day 3 Turkey and stuffing Pasta and tomato sauce Baked potato Sandwich Salad Mushroom soup Total Per cent

Unhealthy option 3 7 7 3 0

Pastry Pizza Sausage roll Burger Waffles Sausage sandwich

1 4 7 10 10 8 40 66.6

2 16 17 2 3 0 0 40 66.6

Burger Pizza Sausage roll Pie Sausage sandwich

1 7 5

3 7 4 6 0 1 21 35

Hot dog Pizza Sausage roll Pie

20 33.3

Generating effective change in school meals

311

7 20 33.3 29 2 6 2 39 65

made. In relation to the children choosing cakes as desert options the view of the school is that they are happy for the children to reward themselves with something sweet after their meal. This suggests that the school do not take into consideration the fact that there are two snack breaks per day and most of the children will have sweets or crisps provided by the parents for both breaks, thus undermining calculations on sugar and fat consumption. A way to combat this unhealthy routine could be to restrict the cakes to once or twice a week. This will also encourage the children to select the healthier options. The menu varied more for the healthier options but the unhealthy options generally stayed constant. The healthier options seemed to be based on more traditional meal choices such as casseroles. The observational study showed that what the children chose varied with the menu. Kitchen staff at the school may find it useful to investigate which are the more popular healthy options and build on this information. The unhealthier options could then be reduced gradually. This would move the healthy eating programme onto another level. As the unhealthy options tend to be very similar each day this task would be simple and effective. Findings and discussion from the Comp-Eat analysis The nutritional analysis work carried out to estimate the nutritional content of the dishes routinely provided as part of the school lunch is summarised in Table III. The results indicate that the main meals were reasonably healthy and fell more or less into

Table II. Interview schedules

NFS 36,5

312

the Caroline Walker Trust guidelines. However, the sausage casserole was found to have a high fat content. The pizza which could be perceived as an unhealthy meal actually had a lower fat content than the sausage casserole. This illustrates the contribution that can be made by nutritional analysis software to the identification of food choices that fall within the golden ideal of a healthy and popular dish! The sodium content for each savoury dish exceeded the recommended daily amount (RDA) of 5 g (CASH, 2004) and is a cause for concern. In addition, almost all of the children accompanied their meal with a cake. As doughnuts were the most popular choice, the average nutritional content of chocolate iced doughnuts were analysed against the Caroline Walker Trust guidelines in order to see what contribution they make to the average school meal. A doughnut contributes half of the recommended energy intake and almost all of the recommended fat content that a midday meal should have for a child. If a doughnut is selected as a desert this will cause all menu combinations to exceed the recommendations for fat. If the meals were combined with yoghurt or with fruit for desert they would fit in with the guidelines. Most children chose a doughnut or something similar thus exceeding the guidelines with regard to fat and protein. Booth et al. (1990) suggested that too much variety may have a negative effect on children’s food choice. Research in other countries has indicated that limiting food choice has improved dietary habits of children (current dietary advice in Scotland). In a canteen run establishment there is often a wide choice for children. An effective move for the school involved with the study may be to reduce the unhealthier options further in favour of the healthier options. It was noted that there was a great variety of choice for the children which was possibly daunting for them. From the popularity of some of the healthy dishes served at the school, improvements could be made by simply reducing the more unhealthy meals and developing the more popular healthy dishes. It has been recognised that salad boxes have not been popular. Instead of the school just reducing the amount that they produce, they should try to find new ways of introducing salad. More recipes could be developed such in a similar way suggested for the pizza in order to make them more nutritious. Pureeing more vegetables into dishes such as the pasta sauces where they will be concealed may be effective as children may not be aware that they are eating them. Conclusions and recommendations for further research Throughout this study the commitment and enthusiasm of staff within the individual school has been apparent and is likely to have been the key factor for success in this project. Staff enthusiasm, alongside parental involvement and the involvement of the

Table III. Comp-Eat nutritional analysis

Energy (Kcal) (KJ) Carbohydrate (g) Protein (g) Fat (g) Sodium (mg)

Pizza

Chicken casserole

Sausage casserole

Chocolate iced doughnut

404 1700 54.07 17.25 14.71 664

226 1115 11.38 29 12 1233

230 960 11.15 10.76 16.45 1085

250 1047 33 3 12 100

children themselves, is likely to be a key to the success of future projects and generating this atmosphere remains a key goal and a vital area for future research. Throughout the interviews it was clear that the school has found it very difficult to measure what difference the healthy eating regime is making to the diets of the school children, but there is little doubt that the changes made are positive and are likely to make a long term contribution to health and wellbeing. The enthusiasm of the children was also notable and, in itself, a very positive factor. Further research would be required to investigate the long term impact of decreasing food choices in a school canteen situation, but this is an area that would merit further research, alongside recipe modification work to establish versions of current dishes that are healthier but retain their popularity. The school in which this study was carried out has a number of advantages in terms of making change happen; it has in-house catering, facilitating trying out simple, small changes relatively quickly and funding is perhaps easier than in some areas of the UK. Nonetheless, the benefits of change and the ways in which it can most effectively be achieved are substantial and would merit further investigation. References Adams, A., Griffiths, H., Mock, J. and Snowdon, L. (1997), ‘‘Nutritional analysis of mid-day meals provided for 5–11 year old schoolchildren’’, British Food Journal, Vol. 99 No. 1, pp. 12–19. Alexander, E., Colquhoun, A. and Lyon, P. (2001), ‘‘Feeding minds and bodies: the Edwardian context of school meals’’, Nutrition & Food Science, Vol. 31 No. 3, pp. 117–25. Blades, M. (2001), ‘‘Catering for young people in schools’’, Nutrition & Food Science, Vol. 31 No. 4, pp. 189–93. BNF (2003), ‘‘Nutritional standards for school lunches’’, BNF Healthy Schools, available at: www.nutrition.org.uk (accessed 6 March 2005). Booth, L.P., Neale, R.J. and Tilston, C.H. (1990), ‘‘The consumer survey of school meals’’, British Food Journal, Vol. 92 No. 6, pp. 22–31. Bowker, S., Crosswaite, C., Mcguffin, S. and Tudor-Smith, C. (1998), ‘‘The healthy option – a review of activity on food and nutrition by UK schools involved in the European network of health promoting schools’’, Health Education, Vol. 98 No. 4, pp. 135–41. Bunker, V.W. and Burgess, A.L. (2002), ‘‘An investigation of school meals eaten by primary schoolchildren’’, British Food Journal, Vol. 104 No. 9, pp. 705–12. Caraher, M., Baker, H. and Burns, M. (2004), ‘‘Children’s views of cooking and food preparation’’, British Food Journal, Vol. 106 No. 4, pp. 255–75. Caroline Walker Trust (1992), Nutritional Guidelines for School Meals, Report of an Expert Working Group, The Caroline Walker Trust, London. CASH (2004), ‘‘Salt and children information’’, Consensus Action on Salt and Health, available at: www.hyp.ac.uk (accessed 29 March 2004). Church, S. (1997), ‘‘School food- turning the tide’’, Nutrition & Food Science, Vol. 97 No. 1, pp. 20–2. Cole, A. and Turner, S. (1993), Catering for Healthy Eating in Schools, Health Education Authority, London. Department of Education and Skills (2004), ‘‘Food in schools- a commitment to healthy choice’’, Department of Education and Skills, available at: www.dfes.gov.uk (accessed 19 October 2004).

Generating effective change in school meals

313

NFS 36,5

314

DoH (1989), Diets of British Schoolchildren, Report on Health and Social Subjects No. 36, Department of Health, HMSO, London. Eves, A., Corney, M., Kipps, M., Noble, C. and Lumbers, M. (1997), ‘‘Primary children’s school meal choices- nutritional implication’’, Hygiene and Nutrition in Foodservice and Catering, Vol. 1, pp. 245–57. FDF (2005), ‘‘Food and health manifesto’’, Food and Drink Federation, available at: www.fdf.org.uk. FSA (2004), ‘‘School meals research project’’, Food Standards Agency, available at: www.food.gov.uk (accessed 19 October 2004). Grix, J. (2001), Demystifying Postgraduate Research from MA to PhD, The University of Birmingham Press, Birmingham. Harvey, J. (2001), ‘‘Food in schools: the chips are down’’, British Nutrition Foundation, Nutrition Bulletin, Vol. 26, pp. 301–3. Health Pro (2004), ‘‘Diet or disease? The case for school meals guidelines’’, School Meals Guide, available at: www.healthpro.org.uk (accessed 10 October 2004). Hungry for Success (2002), ‘‘A whole school approach to school meals in Scotland’’, Scottish Executive, available at: www.scotland.gov.uk. Learning Curve (2003), ‘‘School dinners. Why were school dinners brought in?’’, Learning Curve, available at: www.learningcurve.pro.gov.uk (8 November 2004). MAFF (1996), National Food Survey 1995, Ministry of Agriculture, Fisheries and Food HMSO, London. Noble, C. and Kipps, M. (1994), ‘‘School meals and the 1980 Education Act; was the professional concern justified?’’, Hygiene and Nutrition in Food Service and Catering, Vol. 1 No. 1, pp. 21–32. Reilly, J. (2002), ‘‘Childhood obesity at ‘epidemic levels’’’, Guardian Unlimited, Tuesday 17 September, www.society.guardian.co.uk (accessed 8 November 2003). Ruxton, C.H.S., Kirk, T.R., Belton, N.R. and Holmes, M.A.M. (1993), ‘‘School meals’’, British Food Journal, Vol. 95 No. 8, pp. 9–12. Sarantakos, S. (1998), Social Research, 2nd ed., London, Macmillan Press Ltd. Schutt, R.K. (1999), The Process and Practice of Research, 2nd ed., London, Sage Publications Ltd. SPEC (2004), ‘‘Education committee’s starter paper on school meals bill’’, available at: www.govanlc.com (accessed 11 October 2004). White, B. (2002), Writing your MBA Dissertation, Bindles Ltd, London. Yapp, E.J. (2003), available at: www.eatrightnebraska.org

Corresponding author Claire Seaman can be contacted at: [email protected]

To purchase reprints of this article please e-mail: [email protected] Or visit our web site for further details: www.emeraldinsight.com/reprints

The current issue and full text archive of this journal is available at www.emeraldinsight.com/0034-6659.htm

Breakfast frequency and fruit and vegetable consumption in Belgian adolescents A cross-sectional study

Fruit and vegetable consumption

315

P. Mullie, P. Clarys, D. De Ridder, P. Deriemaeker, N. Duvigneaud and M. Hebbelinck Faculty of Physical Education and Physiotherapy, Department of Human Biometry and Biomechanics, Vrije Universiteit Brussel, Belgium

A.R. Grivegne´e and P. Autier Unit of Epidemiology and Prevention, Jules Bordet Institute, Brussels, Belgium Abstract Purpose – Several cross-sectional studies reported that breakfast skipping and a poor consumption of fruits and vegetables are associated with overweight and obesity-related morbidities. In this respect healthy eating habits such as regular breakfast and a sufficient intake of fruit and vegetables are two important items to prevent childhood and adolescent obesity. The purpose of this study is to determine the breakfast frequency and the fruit and vegetable consumption in Belgian adolescents. Design/methodology/approach – A cross-sectional study using pupils contacted by nurses in schools during an information session about female hygiene. On that occasion all pupils (boys and girls) completed a questionnaire concerning their eating habits. Subjects were boys (n51390) and girls (n53610) between 12 and 15 years of age from the main three educational programmes (general, technical and occupational programme). Findings – Socio-economic status significantly influenced breakfast frequency with differences between the highest educational programme (general) and the lower technical- and occupational programmes. The use of daily breakfast was respectively 67 versus 49 and 48 per cent for the boys and 60 versus 42 and 39 per cent for the girls). For both sexes breakfast frequency decreased when comparing age groups from 12 with 15 years of age respectively from 67 to 55 per cent for the boys and from 61 to 47 per cent for the girls. Half of the subjects who declared to have overweight (selfimage) did not take breakfast at a regular base. Twenty six per cent of the boys of the French speaking part and 19 per cent of the boys of the Flemish speaking part of Belgium declared to take only one or less than one portion of fruit and/or vegetables a day. For the girls the reported intake of one or less than one portion of fruit and/or vegetables was respectively 20 and 16 per cent. Only 13 per cent of the French speaking boys and 10 per cent of the Flemish speaking boys reported an intake of four or more fruits and/or vegetables a day. The percentage of girls reaching an intake of four or more a day was 15 per cent for the two language regions. Fruit and/or vegetable intake was influenced significantly by the educational programme and by the educational level of the mother. In conclusion, healthy eating habits among girls and boys in Belgium (as estimated by breakfast frequency and fruit and/or vegetable intake) are rather poor. These habits are influenced by age, educational programme, self-image and educational level of the mother. Originality/value – In the light of these findings action should be taken to improve the eating habits among Belgian children to prevent childhood obesity. Keywords Diet, Nutrition, Adolescents, Fruits, Vegetables, Belgium Paper type Research paper

The authors would like to thank the nurses for their participation. They would also like to thank Martine Mullie-Devos who coded and entered the records in the database. This research was E made possible due to the unconditional financial support of Proctor and Gamble, Belgium.

Nutrition & Food Science Vol. 36 No. 5, 2006 pp. 315-326 Emerald Group Publishing Limited 0034-6659 DOI 10.1108/00346650610703162

NFS 36,5

316

Background As several other behaviours, healthy eating habits at younger age may be an important factor for healthy eating habits in later live. Regular breakfast and a sufficient intake of fruit and vegetables are two important items of a healthy eating pattern to prevent childhood obesity. The regular intake of breakfast increases the possibility of a balanced diet improving the overall nutritional status and the nutrient density, especially during growth stages (Nicklas et al., 2004). Lack of regular breakfast influences cognition and learning in a negative way (Pollitt and Mathews, 1998). Skipping breakfast has also been associated with poor eating habits and multiple snacking during the reminder of the day. Skipping breakfast increased the risk for overweight in adolescents (Berkey et al., 2003; Keski-Rahkonen et al., 2003). Reported reasons for poor breakfast habits are stress, lack of time, lack of parental control (outdoor working or divorced parents), or it may be a part of the individualisation process (Nicklas et al., 2004; Pollitt and Mathews,1998; Berkey et al., 2003; Keski-Rahkonen et al., 2003). Moreover, breakfast skipping in adolescents has been associated with several health compromising behaviours and unhealthy lifestyles (Keski-Rahkonen et al., 2003). The health aspects of daily fruit and vegetable intake are sustained by several epidemiological studies. Fruit and vegetables may protect against excessive weight gain because of their low energy density, high fiber content and low glycemic index. In addition, poor consumption of fruit and vegetable has been associated with obesityrelated morbidities (Bowman et al., 2004). According to the study of Epstein et al. (2001) increasing fruit and vegetable intake should help to decrease the consumption of high-fat and high-sugar foods among obese parents and their children. By consequence, increasing the consumption of fruit and vegetable may be a useful approach for nutritional change in obese individuals. It was estimated that a daily intake of more than 400 g of fruit and vegetables may decrease cancer incidence by 20 per cent (World Cancer Research Fund, 1997). There is also epidemiological evidence that sufficient intake of fruit and vegetables protects against cardiovascular and other prosperity diseases (World Cancer Research Fund, 1997). Again, an intake of over 400 g a day decreases the risk for cardiovascular diseases between 20 and 40 per cent. In a recent study of Tylavsky et al. (2004), three or more servings of fruit and vegetables a day resulted in a better bone mineral density and a lower urinary calcium output in early pubertal girls compared with girls with a low fruit and vegetables consumption. However, these well documented positive health outcomes of regular fruit and vegetable consumption do not lead to a sufficient intake in the major part of the population. Different studies showed that the consumption of fruit and vegetables is low among adolescents. In the Unites States less than 20 per cent of the children between 2 and 18 years eat the recommended 5 portions of fruit and vegetables a day (Krebs-Smith et al., 1996). The consumption of fruit and vegetables is influenced by several social and environmental factors. The study of Boynton-Jarett et al. (2003) for example suggests that television viewing may contribute to a decline in fruit and vegetable consumption among adolescents. Consumption of fruit and vegetables was more likely as the education level of the responsible adult increased (Lowry et al., 1996). Especially maternal education is considered as an important determinant of dietary intake (North and Emmett, 2000). The aim of this study was to evaluate the breakfast frequency and the fruit and vegetable intake in adolescents between 12 and 15 years. It was equally the aim to

evaluate these two aspects of healthy eating habits in function of age, gender, educational programme, education of the mother and self image of the adolescent. The results of this study may help to give direction to health education projects for adolescents.

Fruit and vegetable consumption

Methods Subjects/setting Subjects were girls (n53,610) and boys (n51,390) of different educational programmes (general, technical, and occupational level) aged between 12 and 15 years. Between September 1999 and May 2000, pupils were contacted in the school setting during an information session about female hygiene. School directions over the country (the French and Flemish region) could invite a team of nurses to give these information sessions for female adolescents between 12 and 15 years. During this 1 hour session the girls completed a short questionnaire concerning their eating habits, living environment and their self image with regard to their body weight. During the same hour, boys completed the same questionnaire in a separate classroom under supervision of a teacher. Since not all schools/teachers agreed to participate in this procedure the group of questioned boys was smaller compared with the group of the girls.

317

Measures A closed questionnaire was developed to assess breakfast frequency, fruit and vegetable consumption, self-image in relation to body weight, educational programme of the respondent and educational level of the mother. Subjects could report breakfast frequency during a 1 week period ranging from never over once a week (1) to all days of the week (7). No distinction was made between week and weekend days. Breakfast was defined as all food used between 5 and 10 am (without inclusion of drinks) (Siega-Riz et al., 1998). Daily fruit and vegetable intake was assessed by the use of portions a day. One portion of fruit was defined as a medium sized apple while a portion of vegetables was defined as a quarter of a plate. Possibilities for daily fruit portions ranged from none with half of a portion interval to 4 portions. For vegetable intake answer possibilities ranged from none to ,1, 1, 1.5, 2 or more than 2 portions. Intake of fruit juice, potatoes and potatoes derived products (French fries, chips) was not considered as fruit or vegetables (Cullen et al., 2000). Self-image concerning body weight was reported using the following classification: too thin, thin, satisfied, thick, too thick. Answering possibilities for educational programme were from high to low level: general, technical or occupational programme. The following levels were possible for the educational level of the mother: lower grade (up to 12 years), higher grade (up to 18 years), non university higher education, university degree. The subjects indicated their living environment (town versus rural), time to reach the school (in 10 minute intervals) and mode of transportation (bus, train, car, bike, foot). For all questions the option ‘‘I do not know’’ was a possible answer. The questionnaire was designed in two languages (French and Dutch). After a validation try-out on 200 pupils, corrections were made to improve the comprehensibility. The questionnaire was not validated against other research methods.

NFS 36,5

318

Statistics The fruit and vegetable consumption and breakfast frequency were analysed using the Mantael–Haenstzel x2 for trends. Influence of independent variables was assessed using multilinear regression. The level of significance was set at 0.05. Results Table I gives an overview of the subjects and the different groups (sex, age, region and education programme) used for the analysis. The data collection procedure (on invitation with the target age for the information session at the onset of girl’s puberty) provoked an uneven distribution between girls and boys and between the different age groups. More girls (n53,610) than boys (n51,390) completed the questionnaire. For both sexes an overrepresentation was noticed for the age group of 13 years: 57.3 per cent for the girls (n52,069) and 56.1 per cent (n5780) for the boys. More subjects from the French speaking region (62 per cent) completed the questionnaire compared with the Flemish speaking region (38 per cent). There was an overrepresentation of pupils from the general programme: three out of four respondents, and this for both sexes, followed general education. The representation of the girls was comparable for technical (12.7 per cent) and occupational programme (11.4 per cent) while there was an under representation for the boys from the occupational programme (5.0 per cent) compared with the technical programme (15 per cent). Breakfast frequency was divided into four categories: never, one to four times a week, five to six times a week and every day. Fruit and vegetable portions were summed and subjects were divided in three categories: 0 to 1 portion a day; 1.5 tot 3.5 portions a day and more than 4 portions a day. Data concerning breakfast frequency are represented in Tables II and III. Significantly (p , 0.05) less girls consumed breakfast compared with the boys. The latter was independent of the language region. Breakfast frequency for both sexes differed when comparing the two language regions. Significantly (p , 0.05) more girls and boys from the Flemish speaking region (respectively 59.9 and 71.8 per cent) consumed breakfast compared with their counterparts in the French speaking region (respectively 52.6 and 58.9 per cent).

Male adolescents n Per cent

Table I. Distribution of the 5000 male and female adolescents

Total group Regions Flemish speaking French speaking Age 12 years 13 years 14 years 15 years School programme General Technical Occupational

Female adolescents n Per cent

1,390

100.0

3,610

100.0

528 862

38.0 62.0

1,353 2,257

37.5 62.5

157 780 319 134

11.3 56.1 22.9 9.6

326 2,069 721 494

9.0 57.3 20.0 13.7

1.108 213 69

79.7 15.3 5.0

2,742 457 411

76.0 12.7 11.4

One to four Five to six Never breakfast(s) breakfasts Every day Do not a week a breakfast know breakfast a week n per cent n per cent n per cent n per cent n per cent Region – male Flemish speaking French speaking Region – female Flemish speaking French speaking Age – male 12 years 13 years 14 years 15 years Age – female 12 years 13 years 14 years 15 years Self-image – male To thin + thin Good Overweight + obesity Self-image – female To thin + thin Good Overweight + obesity School programme – male General Technical Occupational School programme – female General Technical Occupational Travel time to school 10 to 20 min 30 to 40 min 50 and more min Education mother Lesser than six years Six years Twelve years Higher non-university University Unknown

16 55

3.0 6.4

59 154

11.2 17.9

65 105

12.3 379 12.2 508

71.8 58.9

9 40

1.7 4.6

57 179

4.2 7.9

261 521

19.3 23.1

170 257

12.6 811 11.4 1187

59.9 52.6

54 113

4.0 5.0

6 29 26 10

3.8 3.7 8.2 7.5

10 107 72 24

6.4 13.7 22.6 17.9

18 96 41 15

11.5 111 12.3 519 12.9 174 11.2 83

70.7 66.5 54.5 61.9

12 29 6 2

7.6 3.7 1.9 1.5

6 107 50 73

1.8 5.2 6.9 14.8

52 362 211 157

16.0 17.5 29.3 31.8

43 246 82 56

13.2 213 11.9 1.262 11.4 340 11.3 183

65.3 61.0 47.2 37.0

12 92 38 25

3.7 4.4 5.3 5.1

4 40 27

2.5 4.2 10.1

17 143 53

10.5 14.9 19.9

16 107 47

9.9 122 11.1 635 17.6 130

75.3 66.1 48.7

3 36 10

1.9 3.7 3.7

21 80 135

6.5 4.4 9.3

48 325 409

15.0 17.7 28.1

35 216 176

10.9 201 62.6 11.8 1.138 62.1 12.1 659 45.2

16 73 78

5.0 4.0 5.4

45 18 8

4.1 8.5 11.6

152 41 20

13.7 19.2 29.0

129 35 6

11.6 749 16.4 105 8.7 33

67.6 49.3 47.8

33 14 2

3.0 6.6 2.9

137 48 51

5.0 10.5 12.4

508 140 134

18.5 30.6 32.6

337 55 35

12.3 1.644 60.0 12.0 193 42.2 8.5 161 39.2

116 21 30

4.2 4.6 7.3

204 73 30

5.5 7.8 9.4

726 202 67

19.4 21.5 20.9

456 113 28

12.2 2.202 58.9 12.0 504 53.6 8.8 179 55.9

151 49 16

4.0 5.2 5.0

13 19 81 23 36 135

24.5 8.9 6.8 4.5 4.8 5.9

14 54 272 77 131 447

26.4 25.4 22.9 15.2 17.4 19.6

6 28 151 62 87 263

11.3 13.1 12.7 12.3 11.5 11.5

5 4 42 19 26 120

9.4 1.9 3.5 3.8 3.4 5.2

15 108 642 325 474 1.321

28.3 50.7 54.0 64.2 62.9 57.8

The use of a daily breakfast decreased as a function of age and this for both sexes. When comparing age 13 with age 14 percentages decreased from 61.0 to 47.2 per cent for the girls and from 66.5 to 54.5 per cent for the boys. Over 45 per cent of the female adolescents of 15 years of age had a breakfast frequency of four times or less a week.

Fruit and vegetable consumption

319

Table II. Breakfast frequency in function of gender, region, age and self-image of 5,000 male and female adolescents

NFS 36,5

320

Table III. Multilinear regression analysis of the independent variables gender, age, region, school programme, self-image and education of the mother and the dependant variable breakfast frequency

Variable Sex Male Female Age 12 years 13 years 14 years 15 years Region Flemish speaking French speaking School programme General Technical Occupational Self-image To thin Thin Good Overweight Obesity Education mother Lesser than six years Six years Twelve years Higher non-university University

Coefficient

SE

p value

95% Confidence interval

Ref. 20.186

0.072

0.01

20.330 to 20.042

Ref. 20.103 20.634 20.788

0.113 0.127 0.146

0.36 , 0.0001 , 0.0001

20.329 to 0.123 20.888 to 20.380 21.080 to 20.496

Ref. 20.649

0.069

, 0.0001

20.787 to 20.511

Ref. 20.759 20.989

0.102 0.121

, 0.0001 , 0.0001

20.963 to 20.555 21.231 to 20.747

Ref. 0.380 0.168 20.408 21.038

0.238 0.212 0.217 0.231

0.11 0.43 0.06 , 0.0001

20.096 20.256 20.842 21.500

to to to to

Ref. 0.924 1.125 1.380 1.331

0.352 0.325 0.335 0.330

0.008 0.0005 , 0.0001 , 0.0001

0.220 0.475 0.710 0.671

1.628 1.775 2.050 1.991

to to to to

0.856 0.592 0.026 20.576

For girls and boys, breakfast frequency was influenced by the self-image of the respondents. Lower breakfast frequencies were noticed for adolescents reporting thick or too thick for their self-image compared with those reporting to be satisfied of their self-image and those reporting to be thin or too thin. For the adolescents from the categories thick or too thick less than 50 per cent consumed daily breakfast. The educational programme had a significant impact on the breakfast frequency. The pupils from the general education programme consumed more regularly breakfast compared with pupils from the technical and occupational programme: 60.0 per cent of the girls and 67.6 per cent of the boys from the general education level consume breakfast every day compared with respectively 47.8 and 49.3 per cent for the technical programme and 39.2 and 42.5 per cent for the occupational programme. Time to reach the school in the morning did not influence the breakfast frequency. Educational level of the mother significantly (p , 0.05) influenced the breakfast frequency with breakfast frequency increasing as a function of the educational level of the mother. Only 28.3 of the pupils reporting their mother to have the lowest educational level consumed breakfast every day compared with 62.9 per cent of the pupils of which their mother obtained a university degree. Results for fruit and vegetable consumption are represented in Table IV. Only a very low percentage of girls and boys reached the recommended intake of fruit and vegetables. More girls than boys reached the recommended intake: for the girls respectively 15 per cent from the Flemish speaking region and 14.6 per cent from the

0 to 1 portion a day n per cent Region – male Flanders 101 19.1 Wallonia 227 26.3 Region – female Flanders 216 16.0 Wallonia 439 19.5 Age – male 12 years 38 24.2 13 years 158 20.3 14 years 94 29.5 15 years 38 28.4 Age – female 12 years 55 16.9 13 years 315 15.2 14 years 142 19.7 15 years 143 28.9 Education – male – Flemish speaking General Education School 72 17.3 Technical Education School 23 27.7 Professional Education School 6 21.4 Education – male – French speaking General Education School 150 21.7 Technical Education School 46 42.6 Professional Education School 31 49.2 Education – female – Flemish speaking General Education School 93 11.6 Technical Education School 47 17.5 Professional Education School 76 26.8 Education – female – French speaking General Education School 338 17.4 Technical Education School 47 31.1 Professional Education School 54 32.7 Education mother – male – Flemish speaking Unknown 56 22.7 Six years or lesser 6 22.2 12 years 23 19.5 More than 12 years 16 11.8 Education mother – male – French speaking Unknown 123 32.5 Six years or lesser 13 25.5 Twelve years 41 21.5 More than 12 years 50 20.7 Education mother – female – Flemish speaking Unknown 129 19.1 Six years or lesser 11 17.2 12 years 46 13.9 More than 12 years 30 10.7 Education mother – female – French speaking Unknown 220 22.4 Six years or lesser 25 20.2 12 years 108 19.7 More than 12 years 86 14.3

1.5 to 3.5 4 and more portions a day portions a day x2 for trend n per cent n per cent p value 374 521

70.8 60.4

53 114

10.0 13.2

0.21

934 1.489

69.0 66.0

203 329

15.0 14.6

0.0468

106 523 183 83

67.5 67.1 57.4 61.9

13 99 42 13

8.2 12.7 13.2 9.7

Ref. 0.092 0.95 0.68

216 1.450 466 291

66.3 70.1 64.6 58.9

55 304 113 60

16.8 14.6 15.7 12.2

Ref. 0.872 0.307 0.0001

307 48 19

73.6 57.8 67.9

38 12 3

9.1 14.5 10.7

Ref. 0.42 0.797

444 56 21

64.3 51.9 33.3

97 6 11

14.0 5.6 17.5

Ref. 0.001 0.0028

577 182 175

72.0 67.9 61.6

131 39 33

16.4 14.6 11.6

Ref. 0.042 0.0001

67.5 54.3 58.8

293 22 14

15.1 14.6 10.5

Ref. 0.0035 0.0001

174 14 86 100

70.4 51.9 72.9 73.5

17 7 9 20

6.9 25.9 7.6 14.7

Ref. 0.077 0.50 0.00086

211 33 126 151

55.7 64.7 66.0 62.7

45 5 24 40

11.9 9.8 12.6 16.6

Ref. 0.60 0.033 0.0015

462 44 233 195

68.2 68.8 70.4 69.4

86 9 52 56

12.7 14.1 15.7 19.9

Ref. 0.66 0.029 0.00019

635 87 351 416

64.6 70.2 64.1 69.1

128 12 89 100

13.0 9.7 16.2 16.6

Ref. 0.84 0.062 0.0001

1.310 82 97

Fruit and vegetable consumption

321

Table IV. Fruit and vegetable consumption in function of gender, region, age and school programme of 5,000 male and female adolescents

NFS 36,5

322

French speaking region versus 10.0 per cent for the Flemish speaking region and 13.2 per cent for the French speaking region for the boys. Discrepancies between the language regions were less pronounced compared with the results of the breakfast frequency. Fruit and vegetable consumption decreased as a function of age. This trend was significant (p , 0.05) for the girls but not for the boys. The girls reaching the recommended intake decreased from 16.8 per cent at the age of 12 years to 12.2 per cent at the age of 15 years while the number of girls reporting an intake between 0 and 1 portion a day increased from 16.9 to 28.9 per cent over that age period. At the age of 15 years, 28.4 per cent of the boys reported an intake between 0 and 1 portion of fruit and vegetables a day while only 9.7 per cent of the boys reached the recommended intake at that age. The educational programme of the respondents influenced the fruit and vegetable consumption with lowest intakes for the lowest educational programme. The latter was significant (p , 0.05) for the girls and the boys in the French speaking region and for the girls in the Flemish speaking region. Educational level of the mother influenced the fruit and vegetable intake. The number of pupils reporting an intake from 0 to 1 portion a day decreased with increasing educational level of the mother, while an intake of 4 and more portions a day increased with increasing educational level of the mother. These trends were significant (p , 0.05) for the girls and boys of the Flemish speaking region and for the boys of the French speaking region. Discussion The method used for data collection (collection during information sessions about female hygiene) provoked an uneven distribution between girls and boys, with more girls than boys in the analysis. Due to the uneven distribution of participants and because of the distribution in several categories (age, language region, education programme, educational level of the mother, time used for travelling to school), some categories are underrepresented. However, our results on breakfast frequency and fruit and vegetable intake corroborate the findings of several other studies carried out on adolescents in affluent countries (Keski-Rahkonen et al., 2003; Frost-Anderson et al., 1997; Gleason, 1995; Hoglund et al., 1998; Skinner et al., 1985; Krebs-Smith and Kantor, 2001). They equally shed some light on the particular situation in Belgium as several inequalities between the two main language regions were detected. National statistics point to a weaker health and socio-economic status in the French compared with the Flemish speaking region of Belgium (Center for Operational Research in Public Health, 1997a). Our study indicates that these differences in health and socio-economic status result already at young age in poorer nutritional habits for the adolescents from the French speaking region. A study carried out among 7600 Swedish youngsters of 15 years of age revealed that 27 per cent of the girls and 17 per cent of the boys never consumed breakfast (Skinner et al., 1985). Prevalence of no breakfast at all for the group of 15 years of age was lower in our study with a prevalence of 14.8 per cent for the girls and 7.5 per cent for the boys. Considering all age groups we found that 4.2 per cent of the girls of the Flemish speaking region never took breakfast versus 7.9 per cent of the French speaking region. Percentages for boys were respectively 3 per cent for the Flemish region and 6.4 per cent for the French region.

The results obtained by De Henauw et al. (1997) on Flemish primary school children are in good agreement with our study. Data on breakfast frequency were obtained with the 24 h food recall method on 1.321 Flemish children between 6 and 12 years old. They observed that 4.4 per cent of the children did not take breakfast or less than 420 kJ during breakfast. In our study the prevalence of children taking no breakfast at all at 12 years of age was 1.8 per cent for the girls and 3.8 per cent for the boys. Our study extends the data obtained by De Henauw et al. (1997) towards older adolescents. The data indicate a further increase of the breakfast skippers up to 15 years (respectively 14.8 per cent for the girls and 7.5 per cent for the boys). The increasing trend of skipping breakfast in function of age was equally reported by Frost-Anderson et al. (1997). In their study 9 per cent of the girls and 5 per cent of the boys did take less than two times breakfast a week. These percentages increased to respectively 12 and 15 per cent at the age of 18. In our study the critical age for a significant decrease in breakfast frequency was between 13 and 14 years of age. According to Morgan et al. (1986) breakfast frequency decreases significantly during puberty. The latter was noticed especially for girls fearing an increase in body mass. According to Keski-Rahkonen et al. (2003) dieting and body shape ideals are the strongest determinants for the eating pattern amongst teenage girls. Our results indicate indeed a decreased breakfast frequency at that age, but also as a function of the selfimage of their body: subjects with a self-image related with overweight skipped breakfast more frequently compared with subjects classifying their self-image concerning body weight as normal or as thin and too thin. Moreover, several crosssectional studies have consistently reported that skipping breakfast tended to increase snacking and the risk of overweight among children and adolescents. In contrast, the longitudinal study of Berkey et al. (2003) suggested that overweight children who never ate breakfast had lower daily energy intakes and may lose body fat. On the other hand, normal weighted children who never ate breakfast tended to gain weight. In any case, skipping breakfast is not an adequate method to reduce energy intake given its adverse effects on academic performance (Wyon et al., 1997) and general health. Ortega et al. (1998) demonstrated that breakfast frequency among children increased during holidays compared with school days, pointing to the possible influence of stress and lack of time as possible reasons for skipping breakfast. The finding in our study that time to school does not influence the breakfast frequency is in contradiction with the stress hypothesis as postulated by Ortega et al. (1998). Fruit and vegetable consumption was evaluated in the study of Paulus et al. (2001). They studied eating habits in 1,526 adolescents between 12 and 17 years of age living in the province of Luxemburg, a part of the French speaking region of Belgium. Using semi-quantitative food frequency questionnaires they revealed that 59 per cent of the respondents did not consume vegetables on daily basis while 17 per cent of them reported to eat only one serving of vegetables a week. Similar findings were reported for fruit intake: 54 per cent reported an intake of one portion of fruit per day while 10 per cent of the respondents consumed only 1 portion of fruit per week. In their study differences in fruit and vegetable intake were more pronounced when comparing girls and boys. Sixty one per cent of the girls reported a daily intake of at least 1 portion of fruit whilst 46 per cent of the girls reported an intake of minimum 1 portion of vegetables a day, this was respectively 47 and 35 per cent for the boys. However, when considering the recommended intake we also found a better profile for the girls compared with the boys. Of the girls 15 per cent from the Flemish speaking

Fruit and vegetable consumption

323

NFS 36,5

324

region and 14.6 per cent of the French speaking region reached the recommended intake compared with respectively 10 and 13.2 per cent of the boys. Other similarities between the study of Paulus et al. (2001) and ours were the decreasing trend of the daily intake of fruit and vegetables in function of age as well as the influence of the educational programme of the respondents. The study of Lien et al. (2001), carried out on 885 Nordic subjects between 15 and 21 years also indicated a decrease of fruit and vegetable consumption as a function of age. Their sample is indeed somewhat older compared with ours, but their results are alarming since they indicate a continuous decrease also after the age of 15. Indeed, they reported a decrease in the consumption of 1 portion of fruit from 59 per cent at 14 years of age to 29 per cent at 21 years of age for the girls and a decrease from 53 to 20 per cent for the boys. In our study, at the age of 15, one out of three female and male adolescents (respectively 28.9 and 28.4 per cent) declared to eat 1 or less than 1 portion of fruit and vegetables a day. The fruit and vegetable consumption among most Belgian adolescents is insufficient and should be encouraged to protect against weight gain and obesity-related morbidities such as cardiovascular disease and diabetes. Conclusions Our results indicate alarming trends for unhealthy eating habits such as skipping daily breakfast and insufficient intake of fruit and vegetables. These unhealthy eating habits increase the risk of overweight and obesity among adolescents. Breakfast intake has been identified as an important factor in nutritional well-being, especially during growth (Berkey et al., 2003).The downward trend in these eating habits as a function of age should receive uttermost attention. In the light of these findings action should be taken to improve the eating habits among Belgian children to prevent childhood obesity. From a public health perspective, improved understanding of the determinants of adolescents dietary behaviors is critical for the promotion of healthy dietary habits. In our study fruit and vegetable consumption was not different when comparing girls and boys while breakfast frequency was significantly higher for the boys compared with the girls. The latter finding may be an indication that healthy nutritional habits are not always interrelated. Again, this should be taken into account when designing health promotion campaigns. The type of educational programme followed by the adolescent and the educational level of the mother were found to be strong determinants for healthy eating habits. Our study indicated also different healthy eating patterns as a function of the language region (the French versus the Flemish speaking region). As mentioned by Keski-Rahkonen et al. (2003), breakfast skippers tend to have more health compromising behaviors and unhealthy lifestyles compared with the regular breakfast eaters. Their family study indicates equally that parental breakfast eating was the most significant factor associated with adolescent breakfast eating. Hence they advice to address breakfast endorsing progammes to the entire family with sufficient attention for the influence of peers and other health behaviours related with regular breakfast eating. References Berkey, C.S., Rockett, H.R., Gillman, M.W., Field, A.E. and Colditz, G.A. (2003), ‘‘Longitudinal study of skipping breakfast and weight change in adolescents’’, Int. J. Obe.s Relat. Metab. Disord., Vol. 27 No. 10, pp. 1258–66.

Bowman S.A., Gortmaker, S.L., Ebbeling C.B., Pereira, M.A. and Ludwig D. S. (2004), ‘‘Effects of fast-food consumption on energy intake and diet quality among children in a national household survey’’, Pediatrics, Vol. 113 No. 1, pp. 112–18. Boynton-Jarrett, R., Thomas, T.N., Peterson, P.E., Wiecha, J., Sobol, A.M. and Gortmaker, S.L. (2003), ‘‘Impact of Television viewing patterns on fruit and vegetable consumption among adolescents’’, Pediatrics, Vol. 112, pp. 1321–6. Center for Operational Research in Public Health (1997), ‘‘Overlijden en oorzaakspecifiek overlijden in de Vlaamse Gemeenschap 1989–1991’’ (‘‘Deaths and causes of Death in the Flemish Community 1989–1991’’), Center for Operational Research in Public Health, Brussels, Belgium. Cullen, K.W., Eagan, J., Baranowki, T., Owens, E. and De Moor, C. (2000), ‘‘Effect of a la carte and snack bar foods at school on children’s lunchtime intake of fruits and vegetables’’, J. Am. Diet Assoc., Vol. 100, pp. 1482–6. De Henauw, S., Wilms, L., Mertens, J., Standaert, B. and De Backer, G. (1997), ‘‘Overall and mealspecific macronutrient intake in Belgian primary school children’’, Ann. Nutr. Metab., Vol. 41 No. 2, pp. 89–97. Epstein L.H., Gordy, C.C., Raynor H.A., Beddome, M., Kilanowski C.K. and Paluch, R. (2001), ‘‘Increasing fruit and vegetable intake and decreasing fat and sugar intake in families at risk for childhood obesity’’, Obesity Research, Vol. 9 No. 3, pp. 171–8. Frost-Anderson, L., Nes, M. and Bjorneboe, G.E. (1997), ‘‘Food habits among 13-year-old Norwegian adolescents’’, Scand. J. Nutr., Vol. 41, pp. 150–4. Gleason, P.M. (1995), Participation in the National School Lunch Program and the School Breakfast Program’’, Am., J. Clin. Nutr., Vol. 61, pp. 213S–20S. Hoglund, D., Samuelson, G. and Mark, A. (1998), ‘‘Food habits in Swedish adolescents in relation to socioeconomic conditions’’, Eur. J. Clin. Nutr., Vol. 52, pp. 784–9. Keski-Rahkonen, A., Kaprio, J., Rissanen, A. and Virkkunen-Rose R. J. (2003), ‘‘Breakfast skipping and health-compromising behaviors in adolescents and adults’’, Eur. J. Clin. Nutr., Vol. 57, pp. 842–53. Krebs-Smith, S.M., Cook, A., Subar, A.F., Cleveland, L., Friday, J. and Kahle, L.L. (1996), ‘‘Fruit and vegetable intakes of children and adolescents in the United States’’, Arch. Pediatr. Adolesc. Med., Vol. 150, pp. 81–6. Krebs-Smith, S.M. and Kantor, L. (2001), ‘‘Choose a variety of fruits and vegetables daily: understanding the complexities’’, J. Nutr., Vol. 131, pp. 487S–501S. Lien, N., Lytle, L.A. and Klepp, K.I. (2001), ‘‘Stability in consumption of fruit, vegetables and sugary foods in a cohort from age 14 to age 21’’, Prev. Med., Vol. 33, pp. 217–26. Lowry, R., Kann, L., Collins, J.L. and Kolbe, L.J. (1996), ‘‘The effect of socio-economic status on chronic disease risk behaviors among US adolescents’’, JAMA, Vol. 276, pp. 792–7. Morgan, K.J., Zabik, M.E. and Stampley, G.L. (1986), ‘‘Breakfast consumption patterns of US children and adolescents’’, Nutr. Res., Vol. 6, pp. 635–46. Nicklas, T.A., O’Niel, C. and Meyers, L. (2004), ‘‘The importance of breakfast consumption to nutrition of children, adolescents, and young adults’’, Nutr. Today, Vol. 39, pp. 30–9. North, K. and Emmett, P. (2000), ‘‘Multivariate analysis of diet among three-year-old children and associations with socio-demographic characteristics’’, The Avon Longitudinal Study of Pregnancy and Childhood (ALSPAC) Study Team, Eur. J. Clin. Nutr., Vol. 54, pp. 73–80. Ortega, R.M., Requejo, A.M., Lopez-Sobaler, A.M., Andres, P., Quintas, M.E., Navia, B., Izquierdo, M. and Rivas, T. (1998), ‘‘The importance of breakfast in meeting daily recommended calcium intake in a group of schoolchildren’’, J. Am. Coll. Nutr., Vol. 17, pp. 19–24.

Fruit and vegetable consumption

325

NFS 36,5

326

Paulus, D., Saint-Remy, A. and Jeanjean, M. (2001), ‘‘Dietary habits during adolescence - results of the Belgian Adolux Study’’, Eur. J. Clin. Nutr., Vol. 55, pp. 130–6. Pollitt, E. and Mathews, R. (1998), ‘‘Breakfast and cognition: an integrative summary’’, Am. J. Clin. Nutr., Vol. 67, pp. 804S–13S. Rimm, E.B. (2002), ‘‘Fruit and vegetables - building a solid foundation’’, Am. J. Clin. Nutr., Vol. 76, pp. 1–2. Siega-Riz, A.M., Popkin, B.M. and Carson, T. (1998), ‘‘Trends in breakfast consumption for children in the Unites States from 1965–1991’’, Am. J. Clin. Nutr., Vol. 67, pp. 748S–56S. Skinner, J.D., Salvetti, N.N., Ezell, J.M., Penfield, M.P. and Costello, C.A. (1985), ‘‘Appalachian adolescents’ eating patterns and nutrient intakes’’, J. Am. Diet. Assoc., Vol. 85, pp. 1093–9. Tylavsky, F.A., Holliday, K., Danish, R., Womack, C., Norwood, J. and Carbone, L. (2004), ‘‘Fruit and vegetable intakes are an independent predictor of bone size in early pubertal children’’, Am. J. Clin. Nutr., Vol. 79 No. 2, pp. 311–7. World Cancer Research Fund (1997), Food, Nutrition and the Prevention of Cancer: A Global Pperspective, American Institute for Cancer Research, Washington, DC. Wyon, D.P., Abrahamsson L., Jartelius, M. and Fletcher R. J. (1997), ‘‘An experimental stuty of the effects of energy intake at breakfast on the test performance of 10-year-old children in school’’, Int. J. Food. Sci. Nutr., Vol. 48, pp. 5–12. Corresponding author P. Mullie can be contacted at: [email protected]

To purchase reprints of this article please e-mail: [email protected] Or visit our web site for further details: www.emeraldinsight.com/reprints

The current issue and full text archive of this journal is available at www.emeraldinsight.com/0034-6659.htm

Impact of household food security and nutrition programme on the nutritional status of children in Oyo state, Nigeria

Food security and nutrition programme

327

B.O. Lawal Farming Systems Research and Extension Programme, Institute of Agricultural Research and Training, Obafemi Awolowo University, Ibadan, Nigeria

A.A. Jibowo Department of Agricultural Extension and Rural Sociology, Obafemi Awolowo University, Ile-Ife, Nigeria Abstract Purpose – The purpose of this paper is to assess the impact of household food security and nutrition programme (HFSN) on the nutritional status of children (0–5 years) in Oyo state, Nigeria. Design/methodology/approach – Pre-tested structured and unstructured questionnaires were used to elicit information from 201 programme and 201 non-programme women participants. The participants who are farmers were selected using systematic random sampling technique from each of the six local government areas covered by the programme, while non-participants were selected using simple random sampling technique. Also, anthropometry technique was used to assess the nutritional status of the children of both groups. Descriptive statistics such as frequency counts, percentages and means were used to describe the findings while analysis of variance (ANOVA) was used to determine the significant difference in the nutritional status of the children of the two groups. Findings – The results show that the women farmers who participated in programme activities possessed some personal and household characteristics which influenced the nutritional status of the children. The participants utilized most of the prograrmme recommendations and significant differences existed in the weight for age and height for age indices of their children. Originality/value – The results indicate the need for constant surveillance and collaborative effort of the health, agricultural extension and education departments in providing women farmers with the education and training needed to reduce the incidence of malnutrition and food insecurity. Keywords Nutrition, Diet, Children (age groups), Health education, Nigeria Paper type Research paper

Introduction Nigeria is still faced with the problem of equating the supply of food with the everincreasing demand for it four decades after attaining her independence. Increasing malnutrition and household food insecurity are related human welfare problems heightened in the last few decades by economic recession (Akinyele, 1993). This led to poverty, which became real in many households with effects on women and children. These effects are visible in the living conditions of the people especially those residing in rural and peri-urban areas. Such conditions cause high levels of mortality and morbidity and spread of ill health and malnutrition. Malnutrition is a serious problem, causing morbidity and mortality among young Nutrition & Food Science children and women of childbearing age. It has also been recognized that malnutrition Vol. 36 No. 5, 2006 is a consequence of poverty and low food production, and it is also increasingly clear pp. 327-336 Limited that poverty is one of the causes of malnutrition. About 200 million children under the E Emerald Group Publishing0034-6659 DOI 10.1108/00346650610703171 age of five, that is about 40 per cent of all children in the developing world, lack

NFS 36,5

328

sufficient nutrition to lead full and active lives (FGN/UNICEF, 1991). The Nigerian demographic and health survey (FOS, 1992) showed that in 1990, 43 per cent of Nigerian children under the age of five years were stunted, an indication of the prevalence of malnutrition and chronic household food security; while 36 per cent were underweight and 9 per cent wasted. Also, nutritional surveys conducted in Nigeria (Adelekan et al., 1997; Abidoye and Ihebuzor, 2001) reveal high prevalence of malnutrition among the same group of children in Nigeria. This problem of malnutrition had led to embarking on strategies of direct intervention in form of agricultural and rural development programmes to alleviate the problem. Notable among them is UNICEF/FGN intervention programme on household food security and nutrition. The aim of the programme is to increase the availability of staple foods throughout the year and also to promote the nutritional well-being of household members especially women and children. UNICEF recognized the fact that women are the driving force in achieving project effectiveness and reducing poverty and also the key to addressing the household food security and nutrition goals. The need to enhance food security and nutrition at the household level has led to the development of improved technologies in the area of farming, livestock production, time and labour saving devices, improved feeding practices and child care which are being promoted among households in Nigeria especially through nutritional education. To understand the present situation therefore, this study embarked on the assessment of the impact of the household food security and nutrition programme on the nutritional status of children in the target area. Objectives of the paper The general objective of the paper is to assess the effect of household food security and nutrition programme on the nutritional status of the children in the study area. The specific objectives are to: N Identify the personal and household characteristics of women in the study area; N Determine the utilization of the various household food security and nutrition Programme’ recommendations by the women; N Assess the nutritional status of children (0–5 years) in the study area; N Assess the impact of the programme on the nutritional status of children. Methodology The study was carried out in Oyo state, which is one of the states in the South Western Nigeria. The state is predominantly agrarian with about 70 per cent rural population. The land area covers a vast landmass of 32,249.1 square kilometers out of which 27,107.93 km2 is cultivable (OYSADEP, 2001). The programme of intervention covered the four agricultural zones to which the state was divided. These are Ibadan/Ibarapa, Oyo, Ogbomoso and Saki. The programme however covered six local government areas (LGAs) in all the four zones. These LGAs were purposively selected for the study. Systematic sampling procedure with a random starting was employed to select the sampled households from the list of participant households. For non-programme communities non-participants were selected through random sampling technique from communities similar to the programme areas in ecology and socio-economic background. The main target in each

selected household was a mother having at least one child below the age of six. The sample size of 201 participants and 201 non-participants were selected for the study. Pre-tested structured interview schedule was used to collect information from women farmers on the personal, socio-economic, household related characteristics and utilization of improved recommendations introduced through the programme. Anthropometric measurements were taken for all the children. Height and weight of children of the respondents were measured using standard anthropometric techniques as described by WHO (1983). The data collected were analysed using Epi info (CDC, Atlanta), release 6.0 and Z-score was calculated and compared with WHO/ NCHS reference data. The three indices of nutritional status used for the analysis were height for age, weight for height and weight for age. Frequencies, percentages and means were used to quantify the data generated while analysis of variance (anova) was used to determine the significant difference between the nutritional status of children in the two groups selected for the study. Results and discussion Personal and socio-economic characteristics of women farmers The data in Table I reveal that more than half (51.5 per cent) of participants and 47 per cent of non-participants were between the age category of 30 and 39. The mean age of women participants was 35.79 while that of non-participants was 35.08. All the women farmers interviewed were married and the vast majority of them were currently living with their husbands. More than half of the participants (59 per cent) and non-participants (53 per cent) had between five and eight children. This is an indication that farmers in the study area had relatively large number of children with whom they would readily augment their farm labour (Table I). Forty-five per cent of the participants spent between 1 and 6 years in school while 42.3 per cent of non-participants spent same number of years in school. More than onequarter (29.4 per cent) and 52.0 per cent of participants and non-participants respectively had no formal education. This shows a higher level of education among participants as compared with non-participants. Education must therefore have given the participants a higher propensity to participate in the programme directed towards improving the nutrition and health status of their children as well as agricultural development within the households. Farming was the major occupation of 43 per cent of participants and 60.8 per cent of non-participants (Table I). The finding corroborates other findings (Siyanbola, 1995; Odebode and Akinbile, 2000) that rural women are actively involved in farming activities. The data on farm size show that 46.8 per cent of participants and 54.7 per cent of non-participants cultivated between 1 and 1.99 hectares of land (Table I). More than half (53.4 per cent) of the participants and 48.2 per cent of the non-participants had income of between N20,001 and N40,000; while 36.3 per cent and 20 per cent of participants and non-participants respectively earned more than N40,000 annually. The relatively poor financial status of most women farmers may however discourage the use of innovations especially those, which are expensive to adopt. Majority (82.7 per cent and 76.0 cent) of the participants were members of the religious societies and women groups respectively. On the other hand, 52.7 per cent and 8.1 per cent of the non-participants were members of the religious and women groups respectively. The belongingness of most participants to social organizations may have positive impact on their willingness to accept change as a result of group influence.

Food security and nutrition programme

329

NFS 36,5

Household characteristics of women farmers The data on Table II show the household related characteristics of women. The majority of the participants (68.1 per cent) and 54.9 per cent of the non-participants were first and only wife of the household head. However, 15.1 percent of the participants and 24.6 per cent of the non-participants were household heads. Majority

330 Personal/socio-economic characteristics

Table I. Percentage distribution of respondents by personal and socio-economic characteristics

Age (years) 20–29 30–39 40–49 Mean Marital status Married and living with husband Widowed Separated Divorced Religion Christianity Islam Traditional Total number of children 1–4 5–8 .8 Mean Years of schooling None 1–6 7–12 . 12 Mean Major occupation Farming Trading Agro-processing Artisan Civil servant Size of farm land cultivated (hectare) ,1 1–1.99 2–2.99 >3 Mean Annual income (in naira) 0–20,000 20,001–40,000 40,001–60,000 60,001–80,000 . 80,000 Mean

Participant (n 5 210)

Non-participants (n 5 210)

16.7 51.5 31.8 35.79

20.3 47.0 32.7 35.08

87.9 5.0 4.9 2.2

71.3 15.6 2.7 2.5

55.1 43.5 1.4

59.0 40.0 1.0

40.4 59.1 0.5 6

42.9 53.4 3.7 7

29.4 45.4 20.0 5.2 5.2

52.0 42.3 5.7 – 3.8

42.7 37.2 9.6 4.4 6.1

60.8 13.7 16.6 6.8 2.1

34.5 46.8 13.2 11.5 1.86

22.2 54.7 20.2 10.4 1.32

10.3 53.4 24.9 6.3 5.1 46,850.75

34.8 48.2 16.6 0.4 – 30,919.40 (continued)

Personal/socio-economic characteristics Size of farm land cultivated (hectare) ,1 1–1.99 2–2.99 >3 Mean Social organizations Religious organization Cooperative organisations Women groups Community development associations Political organisations Village council

Participant (n 5 210)

Non-participants (n 5 210)

34.5 46.8 13.2 11.5 1.86

22.2 54.7 20.2 10.4 1.32

82.7 72.1 76.0 28.9 15.9 6.7

52.7 46.5 8.1 18.1 4.7 8.1

Source: Field survey, 2001

of the participants (71.6 per cent) and non-participants (72.9 per cent) had between seven and 12 household members. The mean household size for the participants and non-participants was 8.31 and 8.58 respectively. This is in support of other findings indicating large household size of rural households (Ojolo, 1995; Siyanbola, 1995; Fasorannti, 1999). There was a slight difference in the years of schooling spent by household head between the two groups. Seventy-two per cent of participants’ household heads were literates and had attained primary, secondary or tertiary education, while a lesser percentage (56.1 per cent) of the non-participants household heads were represented in the same category (Table II). The mean years of schooling were 7.09 and 4.21 for participants’ and non-participants’ household head. Improved level of education within a household is advantageous for encouraging people to bring about change. Data in Table II further show that 33.0 per cent and 31.0 per cent of participants and non-participants sourced drinking water from dug wells. It is worth noting that none of the two groups had access to public tap. This has implications for child and family health, as access to clean safe water may not be met. Also, majority of participants (57 per cent) and non-participants (79.9 per cent) failed to treat their water before drinking. However, 8.7 per cent and 2.3 per cent of the participants and nonparticipants respectively, do boil their water before drinking. A very small proportion of the households used the most sanitary means of human waste disposal. The bush was therefore the most commonly used means among the non-participants (66.2 per cent) while less than half (33.3 per cent) of participants resorted to the bush. FG/ UNICEF (1994) and Maxiya-Dixon et al. (2004) also revealed similar unhygienic conditions at the household level which are pre-conditions for diarrhoea diseases in young children. Also, majority of the participants (60.5 per cent) and 22 per cent of the non-participants utilized health services on a regular basis. Household food security status of the respondents revealed that while 12.8 per cent and 16.2 per cent of the participants and the non-participants were food secure, 9.9 per cent of participants and 56.4 per cent of non-participants were food insecure. However, 77.2 per cent of the participants and less than one-third (27.3 per cent) of the non-participants were moderately food secure.

Food security and nutrition programme

331

Table I.

NFS 36,5

332

Table II. Percentage distribution of respondents by household characteristics

Household related characteristics Women status Household head 1st/only wife 2nd wife 3rd wife Household size 1–6 7–12 > 13 Mean Years of schooling of household head 0 1–6 7–12 13–18 Mean Sources of drinking water Well Stream Borehole Water treatment No treatment Addition of Alum Filteration Boiling Waste disposal Bush Ordinary pit latrine VIP Water closet Use of health services Regularly Occasionally Not at all Household food security status Food insecure Moderate Food secure/adequate

Participant

Non-participant

15.1 68.1 16.4 0.4

24.6 54.9 18.2 2.3

20.2 71.6 8.2 8.31

16.2 72.9 10.9 8.58

28.0 31.3 30.1 10.6 7.09

43.9 32.3 17.4 6.4 4.21

63.5 3.5 33.0

51.2 17.7 31.1

57.0 14.7 19.6 8.7

79.9 12.1 5.7 2.3

33.3 54.2 8.4 4.1

66.2 31.7 2.1 –

60.5 39.1 0.4

22.2 69.6 8.2

9.9 77.2 12.8

56.4 27.3 16.2

Source: Field survey, 2001

Utilization of HFSN recommendations by women farmers Among the improved seeds/seedlings introduced, cassava cuttings and maize seeds were the major ones presently being utilized by majority of the participants (Table III). The percentage for the two crops was 72 per cent. There was a poor utilization of fertilizer by women for most of their crop production. However, majority (77.5 per cent) of the women indicated they have utilized them before. Only 1.0 per cent of the women farmers indicated their present usage of fertilizer. There was also poor utilization of improved livestock breeds (5.5 per cent) and feeding of livestock with crop residue (34.1 per cent). Out of all the processing equipment, cassava processing machine, melon sheller and maize hand sheller were well utilized by more than half of the

Recommendations Maize Cassava Oil palm Citrus Mango Soybeans Fertilizer Improved livestock breeds Crop residue Cassava processing Palm oil processing Melon hand sheller Maize sheller Exclusive breastfeeding Continued breastfeeding Gardening Soymilk Soyflour Soy-ogi Growth monitoring Iodized salt Vitamin A Iron

Presently using

n 5 201 Have used before

Never used

145(72) 145(72) 8(4.0) 7(3.5) 17(8.5) 38(18.9) 2(1.0) 11(5.5) 69(34.1) 160(79.6) 18(9.5) 115(57.3) 112(55.7) 91(45.4) 173(86.1) 124(61.7) 147(73.1) 83(41.3) 134(66.7) 148(73.6) 182(90.5) 85(42.3) 36(17.9)

48(24.1) 47(23.4) 85(42.3) 82(40.7) 74(36.8) 96(48.1) 156(77.6) 13(6.5) 23(11.2) 17(8.5) 23(11.4) 17(8.3) 14(7.0) 62(30.8) 23(11.4) 19(9.5) 37(18.4) 43(21.4) 45(22.3) 47(23.4) 17(8.4) 115(57.2) 164(81.6)

8(4.0) 9(4.6) 108(53.7) 112(55.7) 110(54.7) 67(33.3) 43(21.4) 177(88.0) 110(54.7) 24(11.9) 160(80.1) 69(34.4) 75(37.3) 48(23.8) 5(2.5) 58(28.8) 17(8.5) 75(37.3) 22(11.0) 6(3.0) 2(1.1) 1(0.5) 1(0.5)

Note: Percentages in parentheses Source: Field survey, 2001

women in the state. The percentage of women who indicated their present usage is 79.6 per cent, 57.3 per cent and 55.7 per cent respectively. Majority (86.1 per cent) of the women still practice continued breastfeeding while less than half (45.4 per cent) of the women currently breastfeed their children exclusively. Majority (61.7 per cent) of the women presently utilize gardening for nutrition due to availability of space in their background to practice it. The most currently utilized of all soybean products are soymilk and soy-ogi with the percentage of 73.1 per cent and 66.9 per cent respectively; 73.9 per cent and 90.7 per cent of the women were currently utilizing growth-monitoring technique and iodized salt. The frequencies and percentages of respondents who had used each recommended practice before but discontinued are shown in Table III. The reasons adduced for discontinuance of the various recommendations by women farmers include non-availability of input/recommendations (77 per cent), poor germination of seeds/seedlings (37.8 per cent), late arrival of inputs (37.8 per cent), lack of time for preparation (36.1 per cent) and lack of access to enough information (27.5 per cent). Nutritional status of children in study area The height for age (HAZ) index show that 35.3 per cent of the participants’ children and 58.7 per cent of non-participants’ children fell below minus two standard deviations (22SD) from the median of the reference population for the height for age index (Table IV). This implies that about three in every ten children were stunted

Food security and nutrition programme

333

Table III. Distribution of participants by utilization of various introduced recommendations

NFS 36,5

334

in the study population for the participants’ communities while six in every ten children were stunted in the non-participants’ communities. In relation to weight for height (WAZ) index, 5.5 per cent of the participants’ children and 7.5 per cent of the non-participants’ children suffer from wasting. This implies that a small percentage of the children from both participants and non-participants’ suffered recent undernutrition. Children below two standard deviation (22SD) from the mean of the reference population are classified as being underweight. A similar pattern as reported for height for age and weight for height is observed in weight for age. Children of nonparticipants were more underweight (33.8 per cent) and therefore fell in the very high prevalence reference value. However, only 14.9 per cent of the participants’ children were underweight and fell in the medium prevalence reference value. Relationship between the nutritional status of the participants and the non-participants The result of the analysis of variance (ANOVA) is presented in Table V. The table shows that there was a significant difference in the weight for age and height for age indices of the children of participants and non-participants (F 5 9.29 and 6.52 respectively). The result indicates that participants’ children were nutritionally better in terms of prevalence of undernutrition and stunting. The difference could be entrenched in the effect of the programme. Participants were exposed to the programme and utilized the various recommendations over the years, which had resulted into better nutrition. Conclusions and recommendations It is evident from the findings of this study that women farmer participants possessed some characteristics, which influenced the nutritional status of the children. Women farmers who had formal education were more among the participants than the nonparticipants. The majority of participants and non-participants were between the age

Table IV.

Type of malnutrition

Prevalence of malnutrition in children (0–5 years) of participants and nonparticipants

Stunting (HAZ) Wasting (WHZ) Underweight (WAZ)

WHZ

Test of difference between nutritional status of children in two groups

71 11 30

Non-participant Frequency Percentage

35.3 5.5 14.9

118 15 68

58.7 7.5 33.8

Source: Field survey, 2001

Variable

Table V.

Participant Frequency Percentage

WAZ HAZ

Group Participants Non-participants Participants Non-participants Participants Non-participants

Note: *Significant at p , 0.05

Number of case

Mean score

F value

p value

201 201 201 201 201 201

0.56 3.01 9.96 1.07 22.2 3.41

0.186

0.667

9.29

0.002*

6.52

0.011*

category of 30 and 39 and were living with their spouses. The average number of children was six for participants and seven for non-participants. Women farmer participants however had higher years of formal schooling than the non-participants. Participants earned higher incomes, and were members of more social organizations than non-participants. Majority of participant household heads were literate and had attained primary, secondary or tertiary education while lesser percentages of nonparticipant household heads were represented in the same category. Majority of the participants sourced water from wells while majority of non-participants failed to treat their water before drinking. Also, majority of non-participants and lesser percentage of the participants made use of the bush for human waste disposal. Participants utilized health services on a more regular basis than non-participants and most of the participants were more food secured than the non-participants. A substantial percentage of participants utilized improved cassava cuttings and improved maize varieties while improved livestock were poorly utilized. Although, the nutritional status of participants’ children were better than that of non-participants’ in terms of height for age, weight for height and weight for age indices, protein energy malnutrition is still a major problem of public health importance in the study area. The study therefore recommended that incidence of malnutrition could be reduced through constant surveillance from the agricultural and health workers. Agricultural workers attached to rural areas should be equipped with simple anthropometric tools to assess the children under the age of five. This will go a long way in identifying early and correcting malnutrition. Also, there is need for health, extension and educational departments to work together in providing women farmers with education and training to support their roles in household food security and nutrition management and be encouraged to utilize such recommendations. Government must ensure that there is adequate provision of potable water and sanitary means of human waste disposal in rural areas. This will go a long way in reducing the incidence of water borne diseases and improve the nutritional status of the people. There is need for women farmers to be educated on socio-economic and household characteristics which are likely to affect the nutritional status of children and other household members in general. References Abidoye, R.O. and Ihebuzor, N.N. (2001), ‘‘Assessment of nutritional status using anthropometric methods on 1–4 year old children in an urban Ghetto in Lagos, Nigeria’’, Journal of Nutrition and Health, Vol. 15, pp. 29–39. Adelekan, D.A., Fatusi, A.O., Fakunle, J.B., Olotu C.T., Olukoga, I.A., Jinadu, M.K. and Ojofeitimi, E.O. (1997), ‘‘Prevalence of malnutrition and vitamin A deficiency in Nigerian preschool children subsisting on high intakes of carotenes’’, Journal of Nutrition and Health, Vol. 2, pp. 17–24. Akinyele, I.O. (1993), ‘‘Give us this day our daily bread: an inaugural lecture from the faculty of basic medical sciences’’, University of Ibadan, Ibadan, Nigeria, pp. 4–16. Fasorannti, O. (1999), ‘‘Impact of agricultural development programme on rural communities in Ondo state’’, unpublished PhD thesis, Obafemi Awolowo University, Ile-Ife, Nigeria. Federal Office of Statistics (FOS, Nigeria) (1992), ‘‘Nigeria demographic and health survey 1990’’, Columbia, Maryland, Federal Office of Statistics and Macro International Inc., USA, pp. 107–112. FGN/UNICEF, (1991), Master Plan of Operation for the 1991–95 Programme of Cooperation, UNICEF, Lagos, Nigeria, pp. 1–25.

Food security and nutrition programme

335

NFS 36,5

336

FGN/UNICEF, (1994), The Nutritional Status of Women and Children in Nigeria, UNICEF, Lagos, Nigeria, p. 111. Maxiya-Dixon, B., Akinyele, I.O., Oguntona, E.B., Nokoe, S., Sanusi, R.A. and Harris, E. (2004), ‘‘Nigeria food consumption and nutrition survey 2001–2003’’, International Institute of Tropical Agriculture, Ibadan, Nigeria, p. 75. Odebode, S.O. and Akinbile, L.A. (2000), ‘‘Improved agricultural technology for poverty alleviation among rural women in Oyo state’’, in Olowu, T. (Ed.), Agricultural Extension and Poverty Alleviation in Nigeria, Proceedings of the Sixth Annual National Conference of the Agricultural Extension Society of Nigeria, pp. 65–73. Ojolo, B.O. (1995), ‘‘The organization and management of rural women cooperative in Osun state’’, Unpublished MSc thesis, Obafemi Awolowo University, Ile-Ife, Nigeria, p. 46. OYSADEP (2001), ‘‘A report of village listing survey in Oyo state’’, Planning, Monitoring, and Evaluation Department, Oyo Sstate Agricultural Development Programme, Nigeria, pp. 1–15. Siyanbola, A.T. (1995), ‘‘Participation of women in agricultural and rural development projects in Osun state of Nigeria’’, unpublished PhD thesis, Obafemi Awolowo University, Ile-Ife, Nigeria, p. 46. World Health Organization (1983), ‘‘Measuring change in nutritional status’’, Guidelines for Assessing the Nutritional Impact of Supplementary Feeding Programmes for Vulnerable Groups, WHO, Geneva, pp. 1–18. Corresponding author B.O. Lawal can be contacted at: [email protected]

To purchase reprints of this article please e-mail: [email protected] Or visit our web site for further details: www.emeraldinsight.com/reprints

The current issue and full text archive of this journal is available at www.emeraldinsight.com/0034-6659.htm

Habitual dietary calcium intake and body weight in 7–10 year old children Amy Jennings, V. Costarelli and G.J. Davies

Calcium and body weight in children

337

Academy of Sport, Physical Activity and Wellbeing, London South Bank University, London, UK

P.W. Dettmar Reckitt Benckiser Healthcare Ltd, Hull, UK Abstract Purpose – Several recent observational studies detected inverse associations between dietary calcium intake and body weight. It was demonstrated that low calcium diets lead to an increase in intracellular calcium concentrations, which in turn act to promote body fat deposition, reduce lipolysis and reduce thermogenesis. Most of the studies have been conducted on adults, however, it was recently demonstrated that longitudinal calcium intake is negatively associated with children’s body fat levels. The purpose of the current study is to investigate possible associations between habitual calcium intake and body weight in a group of 7–10 years old children. Design/methodology/approach – Eighty-five children, 21 boys and 64 girls (mean age: 9.2¡0.9) were recruited from 12 primary schools in the London area. Dietary intake was measured using the 7-day weighed inventory method. Body weight and height measurements were also recorded. Findings – Data suggested that girls have significantly lower intakes of calcium than boys and that 48 per cent of boys and 38 per cent of girls were overweight (above the 91st centile). However, there were no significant correlations between body weight or body mass index (BMI) and habitual intake of dietary calcium in this age group, which is in contrast with the results of similar studies conducted in adults. Originality/value – One explanation could be that the possible effect of calcium on adiposity and body weight is more pronounced in adulthood than in childhood. It is important for future studies to measure levels of body fat in children together with body weight in conjunction with calcium intake in order to elucidate the original hypothesis. Keywords Diet, Children (age groups), United Kingdom Paper type Research paper

Introduction Obesity in children has reached epidemic proportions (Matayka, 2004). Ultimately energy imbalance is the reason for excessive weight gain, whether the main cause is consumption of a high-energy diet, lack of physical activity or genetics. Dietary calcium has been shown to play a pivotal role in the regulation of energy metabolism (Teegarden, 2003) and several observational studies have detected inverse associations between dietary calcium intake and body weight (Davies et al., 2000). Most of these studies have been conducted with adults; however, Skinner et al. have recently demonstrated that longitudinal calcium intake is negatively associated with children’s body fat levels (Skinner et al., 2003). Another recent study which was set out to investigate risk of prepubertal bone fractures and milk intake, suggested that children who avoid milk, are more likely to be of heavier weight than children who do not avoid milk (Goulding et al., 2004). The authors thank all of the children and their guardians for generously volunteering to participate in the study and the schools for their contribution. Also Reckitt Benckiser Healthcare E for their financial assistance.

Nutrition & Food Science Vol. 36 No. 5, 2006 pp. 337-342 Emerald Group Publishing Limited 0034-6659 DOI 10.1108/00346650610703180

NFS 36,5

338

It has been reported that increasing dietary calcium significantly augments weight and fat loss in the absence of caloric restriction in obese adults with dairy products exerting a substantially greater effect (Zemel et al., 2004). The idea of dietary calcium having an anti obesity effect was derived from studies investigating the mechanism of agouti, the first obesity gene to be cloned, which is found in human adiposities. It has been demonstrated that agouti protein stimulates calcium influx in human adiposities promoting the process of fat formation and lipogenesis and inhibiting fat breakdown. It was also shown that increasing 1,25-dihydroxy vitamin D in response to lowcalcium diets stimulates adipocyte Ca2+ influx and as a consequence, stimulates lipogenesis, suppresses lipolysis and increases lipid accumulation, whereas increasing dietary calcium inhibits these effects and markedly accelerates fat loss in mice subjected to caloric restriction (Zemel, 2003). It was also reported that parathyroid hormone positively correlates with body mass index (BMI) and levels of 1,25dihydroxy vitamin D are significantly lower in obese individuals compared to non-obese individuals (Parikh et al., 2004). Papakonstantinou et al. (2003) conducted a study that investigated which aspect of energy balance was responsible for the decrease in body fat content of rats fed a highcalcium and high-dairy protein diet. They concluded that a high-calcium diet decreases body weight and fat content due to a lower digestible energy intake caused by increased fecal lipid and a non-significant reduction in gross energy intake. There is sufficient data from controlled animal studies to demonstrate a beneficial role for dietary calcium in regulating weight during energy restriction (Shi et al., 2001). Increasing evidence suggests that calcium from dairy sources has a greater antiobesity effect than tablet supplementation and calcium enriched foods (Zemel, 2003). Notably, dairy sources of calcium exert a significantly greater anti-obesity effect than supplemental sources in each of these studies, possibly due to the effects of other bioactive compounds on adipocyte metabolism, such as the angiotensin converting enzyme inhibitor found in milk, indicating an important role for dairy products in the control of obesity. Melanson et al. (2003) carried out a trial investigating a relationship between calcium and fat oxidation in 35 obese individuals who were moderately active. Habitual calcium intake was self-reported and each subject completed a 24 hour stay in a whole room calorimeter. It was found that subjects with high intakes of dietary calcium had higher rates of fat oxidation (Melanson et al., 2003). Data from six observational studies and three controlled trials in which calcium intake was the independent variable have been reanalyzed by Heaney et al., 2002, to evaluate the effect of calcium intake on body weight and body fat. A consistent effect of higher calcium intakes, expressed as lower body fat and/or body weight, and reduced weight gain at midlife, was found. The above review has also shown that studies relating nutrient intake to body composition, report negative associations between calcium intake and body weight at midlife and between calcium and body fat accumulation during childhood (Heaney et al., 2002). The same group has also optimistically concluded that a 300 mg increment in regular calcium intake per day is associated with approximately 1 kg lower body fat in children and 2.5–3.0 kg lower body weight in adults, and they proceeded to state that increasing calcium intake by the equivalent of two dairy servings per day could reduce the risk of overweight by as much as 70 per cent (Heaney et al., 2002). The purpose of the current study was to investigate possible associations between habitual calcium intake and body weight in a group of 7–10 years old children.

Subjects, materials and methods Subjects Eighty-five healthy pre-adolescent children aged 7–10 years were recruited from primary schools in the London area. Subjects were only accepted for entry into the study if they were attending school in the London area, had lived in the United Kingdom for at least 5 years and were able to give written, voluntary informed consent from a guardian. Demographic information on subjects’ age, gender, socioeconomic group and ethnicity was obtained from a guardian. Ethical approval was also obtained from London South Bank University ethic’s committee. Anthropometric measurements Height and weight measurements were taken for all subjects on the day prior to data collection. The measurements were taken without shoes or heavy outdoor clothing. Height measurements were taken using the Leicester height measure (Child Growth Foundation). Body weight measurements were taken using electronic digital weighing scales (Salter electronic scales, calibrated to 500 g). Using the height and weight measurements, a BMI was calculated for each subject using the equation kg/m2. BMI values were then converted into percentiles using BMI charts. Calcium intake Subjects were required to complete a 7-day weighed inventory of all food and drink consumed, with assistance from their guardians at home and from the investigator during school time. Each subject was presented with a diary, a set of Soehnle electronic weighing scales, calibrated to 1 g, and a laminated instruction sheet outlining the cumulative weighing method. The investigator visited subjects on the day prior to data collection to provide verbal instructions on how to complete the diaries. Daily contact was made to ensure that the diaries were completed accurately and to help maintain the subjects’ motivation. If a subject had school meals, they were recorded by the investigator. Packed lunches were weighed by the children or guardians at home and leftovers were recorded by the investigator. Daily nutrient and calcium intakes were estimated for each subject using the nutritional software programme Dietplan 5 (Forestfield Software Ltd). Dietplan 5 has also identified the major source of calcium in each child’s diet. Statistical analysis One-way analysis of variance (ANOVA) and Pearson correlations were conducted using SPSS/PC version 10.0. Results There were no significant correlations between body weight or BMI and habitual intake of dietary calcium in this age group. Data also suggest that girls have significantly lower intakes of calcium than boys (Table I) with the average intakes of girls failing to meet the reference nutrient intake for calcium, which is 550 mg/d. Girls were also more likely to consume less dairy products than boys. It was noted that in six children, the main source of dietary calcium was white bread whereas the main source of calcium for three other children was pizza. Forty eight per cent of boys and 38 per cent of girls were overweight (above the 91st centile), which is very worrying given the fact that the average age of the group was 9.2 years (SD: 0.9). It may be of some importance that children with dietary calcium mainly derived from dairy

Calcium and body weight in children

339

NFS 36,5

340

sources tended to be of smaller body weight than children with calcium derived mainly from non-dairy sources, which however was not statistically significant, after adjusting for age and energy intake. Of the 85 children, 14 derived their calcium mainly from dairy sources and 71 from non-dairy sources (Figure 1). Discussion This study set out to investigate a possible relationship between habitual dietary calcium intake and body weight in a group of 7–10 years old London children. The strength of the relationship between dairy and calcium intake and body fat and body weight mainly derives from studies conducted in adults (Shapses et al., 2004). This relationship has been demonstrated in both black and white cohorts and in pre- and post-menopausal women (Parikh and Yanovski, 2003). Studies conducted in children are limited. The earlier study by Carruth and Skinner has suggested a possible role of dietary calcium in moderating body fat levels in children (Carruth and Skinner, 2003). Another recent study which was set out to investigate risk of prepubertal bone fractures and milk intake, suggested that children who avoid milk are more likely to be of heavier weight than children who do not avoid milk (Goulding et al., 2004).

All subjects (n585), mean¡SD

Table I. Body weight and BMI in relation to habitual calcium intake in children

Figure 1. Body weight and source of dietary calcium in children

Age (year) Weight (kg) Height (m) BMI Calcium intake/d (mg) Energy intake/d (kcals)

9.2 38.26 1.4 19.19 559.95 1558.31

1.00 11.41 0.10 3.63 263.13 585.61

Boys (n521), mean¡SD 9.09 36 1.37 19.1 648.32* 1708.79

1.04 9.5 0.09 3.4 251.76 526.91

Girls (n564), mean¡SD 9.23 38.6 1.4 19.16 530.96 1508.93

0.88 11.8 0.10 3.7 266.86 604.87

Note: *Significantly different compared to the calcium intake of girls: p,0.05 (one-way ANOVA)

In our study, we found no significant correlations between body weight or BMI and habitual intake of dietary calcium in this age group in both boys and girls, which is in contrast with the results of similar studies conducted in adults. It is important to note, however, that percentage of body fat was not measured in this study. The finding that children who derived their dietary calcium mainly from dairy sources tended to be of a smaller body weight than children who derived their calcium mainly from non-dairy sources, was not statistically significant and may be reflective of the low number of subjects. Anthropometric measurements in children of this age must be interpreted with some caution due to the growth and development patterns seen (Gregory and Lowe, 2000). The different rates of growth and development in boys and girls, in addition to the gender imbalance in this study (21 boys and 65 girls), may have had some effect on the results. In another study by Phillips et al. (2003), dairy food consumption, body weight and fatness were investigated in a total of 196 non-obese pre-menarcheal girls aged 8–12 years who were enrolled between 1990 and 1993. Girls were followed until 4-year postmenarche. They found no evidence that dairy food consumption was associated with BMI or per cent body fat during adolescence (Phillips et al., 2003). One explanation for our findings could be that the possible effect of calcium on adiposity and body weight is more pronounced in adulthood than in childhood. It is important for future studies to measure levels of body fat in children together with body weight in conjunction with calcium intake in order to elucidate the original hypothesis. Children, however, should be strongly encouraged to regularly include calcium-rich foods and beverages in their diets because of the general well documented effects of calcium on bone mass and overall health. References Carruth, B.R. and Skinner, J.D. (2001), ‘‘The role of dietary calcium and other nutrients in moderating body fat in preschool children’’, Int. J. Obes., Vol. 25, pp. 559–66. Davies, K.M., Heaney, R.P., Recker, R.R., Lappe, J.M., Barger-Lux, J.M., Rafferty, K. and Hinders, S. (2000), ‘‘Calcium intake and body weight’’, J. Clin. Edocrinol. Metab., Vol. 85, pp. 4635–8. Goulding, A., Rockell, J.E., Black, R.E., Grant, A.M., Jones, I.E. and Williams, S.M. (2004), ‘‘Children who avoid drinking cow’s milk are at increased risk for prepubertal bone fractures’’, J. Am. Diet. Assoc., Vol. 104 No. 2, pp. 250–3. Gregory, J. and Lowe, S. (2000), National Diet and Nutrition Survey, The Stationary Office, London. Heaney, R.P., Davies, K.M. and Barger-Lux, M.J. (2002), ‘‘Calcium and weight: clinical studies’’, J. Am. Coll. Nutr., Vol. 2, pp. 152S–5S. Matayka, K. (2002), ‘‘Managing obesity in children’’, Obes. Prac., Vol. 4, pp. 2–6. Melanson, E.L., Sharp, T.A., Schneider, J., Donahoo, W.T., Grunwald, G.K. and Hill, J.O. (2003), ‘‘Relation between calcium and fat oxidation in adult humans’’, Int. J. Obes., Vol. 27, pp. 196–203. Papakonstantinou, E., Flatt, W.P., Huth, P.J. and Harris, R.B. (2003), ‘‘High dietary calcium reduces body fat content, digestibility of fat, and serum vitamin D in rats’’, Obes. Res., Vol. 11, pp. 387–94. Parikh, S.J. and Yanovski, J.A. (2003), ‘‘Calcium intake and adiposity’’, Am. J. Clin. Nutr., Vol. 77, pp. 281–7.

Calcium and body weight in children

341

NFS 36,5

342

Parikh, S.J., Elderman, M., Uwaito, G.I., Freedman, R.J., Semega-Janneh, M., Reynolds, J. and Yanorski, J.A. (2004), ‘‘The relationship between obesity and serum 1,25 dihydroxy vitamin D concentrations in healthy adult’’, J. Clin. Endocrinol. Metab., Vol. 89, pp. 1196–9. Phillips, S.M., Bandini, L.G., Cyr, H., Colclough-Douglas, S., Naumova, E. and Must, A. (2003), ‘‘Dairy food consumption and body weight and fatness studied longitudinally over the adolescent period’’, Int. J. Obes., Vol. 27, pp. 1106–13. Shapses, S.A., Heshka, S. and Heymsfield, S.B. (2004), ‘‘Effect of calcium supplementation on weight and fat loss in women’’, J. Clin. Endocrinol. Metab., Vol. 89, pp. 632–7. Shi, H., Dirienzo, D. and Zemel, M.B. (2001), ‘‘Effects of dietary calcium on adipocyte lipid metabolism and body weight regulation in energy-restricted aP2-agouti transgenic mice’’, FASEB J., Vol. 15, pp. 291–3. Skinner, J.D., Bounds, W., Carruth, B.R. and Ziegler, P. (2003), ‘‘Longitudinal calcium intake is negatively related to children’s body fat indexes’’, J. Am. Diet. Assoc., Vol. 103, pp. 1626–31. Teegarden, D. (2003), ‘‘Calcium intake and reduction in weight or fat mass’’, J. Nutr., Vol. 133, pp. 249–51. Zemel, M.B. (2003), ‘‘Mechanism of adiposity and obesity risk by dietary calcium: mechanism and implications’’, J. Nutr., Vol. 133, pp. 252s–6s. Zemel, M.B., Thompson, W., Milstead, A., Morris, K. and Campbell, P. (2004), ‘‘Calcium and dairy acceleration of weight and fat loss during energy restriction in obese adults’’, Obes. Res., Vol. 12, pp. 582–90. Corresponding author V. Costarelli can be contacted at: [email protected]

To purchase reprints of this article please e-mail: [email protected] Or visit our web site for further details: www.emeraldinsight.com/reprints

The current issue and full text archive of this journal is available at www.emeraldinsight.com/0034-6659.htm

Nutritional knowledge and dietary intakes of young professional football players Sue Murphy and Yvonne Jeanes

Nutritional knowledge and dietary intakes

343

Roehampton University, London, UK Abstract Purpose – To determine how nutritional knowledge and residential status influences the diets of a group of young professional football players and compare them to controls of the same age. Design/methodology/approach – Seven day dietary records and nutritional knowledge questionnaires were analyzed and anthropometric measurements were taken mid-way through the competitive season. Findings – The football players, with a mean body mass index of 23.6 ¡ 1.2 kg m2 and body fat of 15.3 ¡ 3 per cent were significantly lighter than the controls. They also consumed significantly fewer calories than the controls (10.26 + 1.8 v. 13.89 + 0.7 MJ per day), and less than the recommended amounts for soccer players. Both groups could benefit from increasing their carbohydrate intakes, although fat and protein intakes were appropriate. Nutritional knowledge had little impact on dietary intakes. However, players who resided in the soccer club hostels had significantly greater energy intakes, consumed more carbohydrate and less fat (p , 0.05) than players who lived in their parental home. Originality/value – It was identified that youth players require assistance in the implementation of their knowledge of nutrition to their own diets. In particular they need to increase their nutritional intakes inline with recommendations, in order to optimize their playing ability and provide the energy they need for growth. This is particularly true for those who live away from the scrutiny of the football club. Keywords Nutrition, Diet, Football Paper type Research paper

Introduction Football can be a physiologically demanding game that is characterized by irregular changes of pace and anaerobic efforts superimposed on light to moderate aerobic activity (Reilly and Doran, 2000). This places a heavy demand on the body’s liver and muscle glycogen stores, which consequently contributes to fatigue and a reduction in performance (Hargreaves, 1994). A suitable nutritional intake that contains a variety of nutrients and adequate amounts of energy is essential to supply the required fuel sources; namely carbohydrate, protein and fat. Appropriate nutrition can optimize energy stores for competition, reduce fatigue and allow players to train for a longer duration and recover faster between sessions, as well as maintain general health. The importance of carbohydrate cannot be over emphasized since carbohydrate depletion causes fatigue which may disrupt concentration, fine motor coordination and skill performance (MacLaren, 1996). Adequate protein intakes are also essential to enhance tissue repair and strength and supply amino acids for oxidation to provide energy during intense prolonged exercise (Lemon, 1994). The physiological demands of growth mean that there are additional nutritional requirements. Many youth soccer players are still growing and this puts further stress on their energy and nutrient reserves. The nutrients energy, protein, calcium, and iron The authors would like to thank Mr R. Reeves, Mr J. Keith and all the footballers that took part E in the study.

Nutrition & Food Science Vol. 36 No. 5, 2006 pp. 343-348 Emerald Group Publishing Limited 0034-6659 DOI 10.1108/00346650610703199

NFS 36,5

344

have been highlighted as being particularly important in supporting growth (National Dairy Council, 1995). As well as the energy requirements of exercise and growth there are many factors that affect food intake including access, availability, individual circumstances such as living conditions and nutritional knowledge. Whilst many football players are aware of the importance of diet very few actually employ ideal dietary practice. In fact studies on footballers have shown that most (Ingram and Davies, 1996) do not consume a diet considered compatible with peak physical performance and leave much room for improvement. The aim of this study was to determine some of the factors including nutritional knowledge and residential status that influence the diets of a group of professional football players from a Premier division and a 1st division football clubs youth squads. Methodology Thirty five players were recruited mid-season from two professional football clubs; one club was in the English premier league and the other in the first division. Twentytwo players with a median age of 17 years (range 16–19 years) completed the study. For comparative purposes, 20 controls who did not participate regularly in sport were also recruited. The participants were provided with verbal and written instructions on how to complete a 7 day food diary, which they were asked to carry with them at all times and record everything they ate and drank. A full description of the foods consumed was requested, including the type and brand, how the food was cooked and the amount consumed. The diaries were then analyzed using Diet 5 (Univation, Aberdeen). To eliminate the possibility of under-reporting, the basal metabolic rate (BMR) of all participants was calculated using the FAO/WHO/UNU (1985) equations. These are equations based on individual body weights. If energy intakes are less than 1.5 times BMR, this suggests that unless there is a loss in body weight, that the subjects are not recording all foods consumed. Any subjects thought to be underreporting were eliminated from the study. The participants were interviewed about their exercise and training schedules, living situation and were asked to complete a questionnaire, tailored for football players, which tested their knowledge of nutrition. This entailed ten multiple choice questions and ten questions in a true/false format. Questions were included from the following categories: energy, macronutrients, vitamins and minerals, supplements, hydration and weight control. For the multiple choice section of the questionnaire correct responses were scored as 1 and incorrect as 0. For the true or false section correct answers scored 1 whereas incorrect answers scored 21. This method prevented artificially high scores since random responding would tend to sum to zero rather than 50 per cent. Both sections of the questionnaire were combined and presented as a percentage; the maximum possible score was therefore 100 per cent. This score was then used in subsequent analyses. The questionnaire was piloted using university students studying nutrition. There was a significant difference (p , 0.05) in the mean scores of the nutrition students and the football players. Body mass was measured with a digital balance (Seca, Germany) to the nearest 0.1 kg. The balance was calibrated for accuracy with known weights. Height was measured using a portable stadiometer to the nearest 0.5 cm. Subjects were measured bare footed, heels together with heads in the Frankfort plane. To estimate body fat,

skinfolds were measured using Harpenden calipers (British Indicators, UK) to the nearest 0.1 mm. Total body fat was estimated from the sum of four skinfold values taken at the biceps, triceps, sub-scapular and supra-iliac and calculated using the Durnin and Womersley (1974) equations. All data are presented as mean values ¡ standard deviation (SD). T-tests and Pearsons correlations were calculated using SPSS (v 10.1) and graphed using Excel (Microsoft Corporations) software. A significance level of p,0.05 was adopted.

Nutritional knowledge and dietary intakes

345

Results The participants’ anthropometric characteristics are presented in Table I. There was no significant difference in age between the two groups, however the football players were significantly (p , 0.05) lighter, had a lower body mass index and less body fat than the controls. Results of energy intake and macronutrient consumption are shown in Table II, and show that the football players ate significantly (p , 0.05) less than the controls and their intakes were below the 11.54 MJ day21 recommended for adolescents (Department of Health, 1996) as well as the guideline of 14–15 MJ day21 for football players (Shepherd, 1999). In addition, the macro-nutrients were not consumed in optimal proportions. The football players consumed significantly (p , 0.05) more carbohydrate as a percentage of energy intake than the controls, although both groups would benefit by increasing their intakes. The football players consumed 51 per cent of their energy from carbohydrate and an equivalent of 4.3 grams per kilogram of body weight per day (g kg21 day21). This is below the recommendations for football players whereby more than 55 per cent of the diet should be made of carbohydrate rich foods, or 6 g kg21 day21 (Economos et al., 1998). A difference of 4 per cent

Variable Height (m) Weight (kg) Body Mass Index (kg m22) Body fat (per cent)

Football players 1.75 72.3 23.6 15.0

¡ ¡ ¡ ¡

0.07 4.1 1.2 5

Controls 1.80 87.1 26.9 24.1

¡ ¡ ¡ ¡

0.04 3* 1.6* 3*

Note: * p,0.05.

Nutrient Energy (MJ) Carbohydrate (per cent) Carbohydrate (g) Protein (per cent) Protein (g) Fat (per cent) Fat (g) Alcohol (per cent) Alcohol (g) Notes: *p , 0.05. **p , 0.01.

Football players 10.26 51 310.05 17 104.1 32 87.7 0.3 0.9

¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡

1.8 4* 22 2 16 3 4 1 1

Table I. Anthropometric characteristics of youth football players and controls (mean ¡ SD)

Controls 13.89 44.9 373 15.1 135 31.7 117 6.73 31.9

¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡

0.7* 5.0 32 2.3 13 5 2* 0.6** 11**

Table II. The energy and macronutrient intakes of youth football players and controls (mean ¡ SD)

NFS 36,5

346

between the average amount of carbohydrate consumed and the recommendations may seem minor but for some individuals this deficit was as much as 15 per cent and such an amount is likely to affect performance (Brouns, 2002). Both protein and fat were consumed in appropriate amounts by both groups, however the controls consumed significantly (p , 0.05) more fat. Alcohol was consumed in very small quantities by the football players and significantly (p , 0.01) less than the controls. Adequate intakes of all vitamin and minerals were consumed (Table III), with the exception of calcium, which was below recommendations for both groups (Department of Health, 1996). There was a disparity between nutritional knowledge and the nutritional practices employed by the players. For example, you would expect the more a player knew about nutrition the greater they would understand the need for high intakes of carbohydrate. Correlation between carbohydrate intake and nutritional knowledge score was determined by carrying out a Pearsons correlation. From this it was revealed that carbohydrate intake and nutritional knowledge were poorly correlated (R 5 0.2, p , 0.07). Energy intake and nutritional knowledge score were also weakly correlated (R 5 0.3, p , 0.06). Similar patterns were seen in the control subjects. When player living situation was investigated, it was revealed that players who resided in the club hostel had significantly greater energy intakes, consumed more carbohydrate and less fat (p , 0.05) than players who lived in their parental home. This was not the case for the control subjects. There were no significant differences in the diets consumed by the players from the premier division club and those from the first division club. Discussion Measurements of body composition are necessary in order to assess appropriate nutritional intakes and the fact the football players were lighter and had less body fat may account for and be a result of the differences in energy intakes between the two groups. The football players could do with increasing their energy intakes inline with recommendations for athletes (Economos et al., 1998). It is also recommended that the football players increase their carbohydrate intakes since low carbohydrate intakes are also associated with less distance covered and lower speeds during matches (Rico-Sanz et al., 1998). Although protein was consumed in adequate amounts it was still below the 142 g day21 consumed by elite soccer players reported by Rico-Sanz et al. (1998). Fat intakes were also appropriate in both groups but for a comparison were less than the 158 g day21 consumed by Greek football players (Hassapidou et al., 2000). The controls reported drinking alcohol between two and four times a week, however the football players rarely drunk. This is probably a sensible decision on behalf of the football players since even small quantities of alcohol can produce a

Table III. The micronutrient intakes of youth football players and controls (mean ¡ SD)

Nutrient Vitamin C (mg) Vitamin E (mg) Calcium (mg) Iron (mg)

Football players 90.1 4.82 665 11.14

¡ ¡ ¡ ¡

4.6 3.1 189 3

Controls 82.9 5.5 626 17.82

¡ ¡ ¡ ¡

6 4.5 320 48

negative effect on aerobic performance, although anaerobic performance may not be affected (O’Brien, 1993). In accordance with the findings of Rockwell et al. (2001), who studied female university athletes, there was a disparity between nutritional knowledge and the nutritional practices employed by the players. Even in those clubs which do provide a good level of nutritional education perhaps in conjunction with a college based training programme this knowledge does not always manifest itself into a good diet. In theory nutritional education should have an impact on the adequacy of food choices however, in reality this rarely occurs. Many studies have shown even when life and/or livelihood dependant, subjects are still reluctant to alter their habitual diets (Webb, 2002). Yet this is no reflection on their level of education or the dietary information provided, hence generally there is a large disparity between nutritional knowledge and the dietary practices employed (Packman and Kirk, 2000). This discrepancy may be due to the fact that most subjects are over optimistic about their own diets, and do not relate general nutritional advice to their own lifestyle habits (Fieldhouse, 1998). Yet when given accurate information about their own individual intakes, it more likely improvements will be made (Raats et al., 1999). There is a need to improve understanding of personal dietary intakes in order to improve personal attitudes towards and desire to modify dietary habits. These dietary changes can then in turn lead to an improvement in the football players’ physical condition, provide better protection against injuries, faster recovery, maintain growth and ultimately better performance on the pitch. Conclusions It is apparent that the players need assistance in the implementation of their knowledge of nutrition to their own diets, to increase their nutritional intakes in line with recommendations. Nutritional guidance may be particularly beneficial to those who live away from the scrutiny of the football club. References Brouns, F. (2002), Essentials of Sports Nutrition, John Wiley & Sons, Chichester. Department of Health (1996), Dietary Reference Values, HMSO, London. Durnin, J.V.G.A. and Womersley, J. (1974), ‘‘Body fat assessed from total body density and it’s estimation from skinfold thickness: measurements on 481 men and women aged 16–72’’, British Journal of Nutrition, Vol. 32 No. 1, pp. 77–97. Economos, C.D., Botrz, S.S. and Nelson, M.E. (1998), ‘‘Nutritional practices of elite athletes’’, Sports Medicine, Vol. 16 No. 6, pp. 381–94. FAO/WHO/UNU (1985), Protein and Energy Requirements, Technical Report Series 724, WHO Press, Geneva. Fieldhouse, P. (1998), Food and Nutrition: Customs and Culture, Routledge, London. Hargreaves, M. (1994), ‘‘Carbohydrate and lipid requirements in soccer’’, Journal of Sport Science, Vol. 12 No. 1, pp. 13–16. Hassapidou, M.N., Grammatikopoulou, L. and Liarigovinos, T. (2000), ‘‘Dietary intakes of Greek professional football players’’, Nutrition and Food Science, Vol. 30 No. 4, pp. 191–4. Ingram, L. and Davies, J. (1996), ‘‘Nutritional awareness of professional football teams with particular reference to carbohydrate’’, Nutrition and Food Science, Vol. 96 No. 3, pp. 12–14. Lemon, P. (1994), ‘‘Protein requirements of soccer’’, Journal of Sports Science, Vol. 12 No. 1, pp. S17–22.

Nutritional knowledge and dietary intakes

347

NFS 36,5

348

MacLaren, D. (1996), ‘‘Nutrition’’, in Reilly, T. (Ed.), Science and Soccer, E & FN Spon, London. The National Dairy Council (1995), Nutrition and Teenagers, Fact File Number 5, London. O’Brien, C.P. (1993), ‘‘Alcohol and sport; the impact of social drinking on recreational and competitive sports competition’’, Sports Medicine, Vol. 15 No. 2, pp. 71–7. Packman, J. and Kirk, S. (2000), ‘‘The relationship between nutritional knowledge, attitudes and dietary fat consumption in male students’’, Journal of Human Nutrition and Dietetics, Vol. 13 No. 6, pp. 389–95. Raats, M.M., Sparks, P., Geekie, M.A. and Shepherd, R. (1999), ‘‘The effects of providing personalized dietary feedback’’, Patient Education Counsel, Vol. 37 No. 2, pp. 177–89. Reilly, T. and Doran, D. (2000), ‘‘Science and Football: A review’’, Journal of Sports Science, Vol. 19 No. 3, pp. 181–93. Rico-Sanz, J., Frontera, W., Mole, P., Rivera, M., Rivera-Brown, A. and Meredith, C. (1998), ‘‘Dietary and performance assessment of elite soccer players during a period of intense training’’, International Journal of Sports Nutrition, Vol. 8 No. 8, pp. 230–41. Rockwell, M.S., Nickols, S.M. and Thye, F.W. (2001), ‘‘Nutritional knowledge and practices of coaches at University’’, International Journal of Sport Nutrition and Metabolism, Vol. 11 No. 3, pp. 174–85. Shepherd, R. (1999), ‘‘Biology of medicine and soccer’’, Journal of Sport Sciences, Vol. 17 No. 10, pp. 757–86. Webb, G. (2002), Nutrition a Health Promotion Approach, Arnold, London. Corresponding author Yvonne Jeanes can be contacted at: [email protected]

To purchase reprints of this article please e-mail: [email protected] Or visit our web site for further details: www.emeraldinsight.com/reprints

The current issue and full text archive of this journal is available at www.emeraldinsight.com/0034-6659.htm

Probiotic acidophilus milk for infants and children

Probiotic acidophilus milk

S. Sarkar Department of Quality Assurance at Metro Dairy Limited, Kolkata, West Bengal, India

349

A.K. Misra Department of Dairy Bacteriology, Faculty of Dairy Technology, West Bengal University of Animal and Fishery Sciences, West Bengal, India Abstract Purpose – The objective of the present investigation is to evaluate the effect of incorporation of Bifidobacterium bifidum NDRI and Propionibacterium freudenreichii subsp. shermanii MTCC 1371 along with Leuconostoc acidophilus R on the technological and dietetic behaviour of starter cultures and to assess their suitability for the manufacture of probiotic acidophilus milk for infant feeding. Design/methodology/approach – The paper assesses the effect of incorporation of Propionibacterium freudenreichii subsp. shermanii MTCC 1371 and Bifidobacterium bifidum NDRI with Lactobacillus acidophilus R on the technological and dietetic characteristics and their suitability for the manufacture of probiotic acidophilus milk. Findings – Based upon the results of technological and dietetic characteristics of starter cultures, conjugated use of Propionibacterium freudenreichii subsp. shermanii MTCC 1371 and Bifidobacterium bifidum NDRI with Lactobacillus acidophilus R, inoculated at 1 per cent level individually and incubated at 37¡1 ˚C for 12 h, is recommended for the manufacture of probiotic acidophilus milk with better nutritional and therapeutic properties. Probiotic acidophilus milk may be recommended for feeding normal as well as lactose-intolerant infants. Originality/value – The paper offers an assessment of the suitability of probiotic acidophilus milk for infant feeding. Keywords Milk, Diet, Nutrition, Infants Paper type Research paper

Introduction Breast milk is considered superior over any other modified infant formula due to its inherent properties and advantages. In the absence or with insufficient production of breast milk, various modified milk formulae developed may be nutritionally adequate but could not confer any protection to the infants. Technological innovations made in the commercial infant milk powder have not been able to meet the critical nutritional and physiological needs of infants (Thompkinson and Mathur, 1995). Under this circumstance, various cultured milk products developed for infants and children can be a practical and suitable substitute (Sarkar, 2003). Lactobacilli is the normal resident of gastro-intestinal tract (Mitsuoka, 1992) and capable of restoring the normal microbial balance in the intestine (Garvie et al., 1984), whose application during the manufacture of cultured milk products are proposed to exert ‘‘probiotic’’ effects in humans (Gilliland, 1989). Bifidobacteria based cultured milk products may be beneficial as a probiotic for improving the intestinal flora and for maintaining the healthy intestinal conditions of infants during and after weaning Nutrition & Food Science (Fukushima et al., 1997; Fukushima and Yamano, 2003). Vol. 36 No. 5, 2006 Propionibacterium spp. is reported to synthesise vitamins (Skupin et al., 1974), pp. 349-356 Limited exhibit antagonism (Al-Zoreky et al., 1993) and possess b-D-galactosidase activity E Emerald Group Publishing0034-6659 DOI 10.1108/00346650610703207 (Kujawski et al., 1990). Inclusion of Propionibacterium freudenreichii subsp. shermanii

NFS 36,5

350

with Lactobacillus acidophilus resulted in a product, which was more efficacious than acidophilus milk in preventing the gastro-intestinal disease in infants (Nabukhotnyi et al., 1983). Reddy (1989) suggested associative application of propionic acid bacteria with Lactobacillus acidophilus, Bifidobacterium bifidum and Leuconostoc citrovorum during the preparation of dietary supplements for enhanced viability of these organisms in the human intestinal tract. The objective of the present investigation was to evaluate the effect of incorporation of B. bifidum NDRI and P. freudenreichii subsp. shermanii MTCC 1371 along with L. acidophilus R on the technological and dietetic behaviour of starter cultures and to assess their suitability for the manufacture of probiotic acidophilus milk for infant feeding. Materials and methods Type of milk Reconstituted skim milk (SM) [0.5 per cent fat and 7.64 per cent solid non-fat (SNF)] was used for evaluating rate of acid production by starter cultures. Formulated milk (FM) was obtained on fortification of standardised cow milk (2.5 per cent fat and 10.46 per cent SNF) with vitamins A, D and E (Roche Chemicals, Bombay, India) at the levels of 500 IU, 80 IU and 750 mg respectively and addition of 12 per cent sucrose (Misra and Kuila, 1992). Different technological and dietetic attributes of starter cultures were evaluated in both SM and FM. Starter cultures Freeze dried cultures of Bifidobacterium bifidum NDRI (National Collection of Dairy Cultures, National Dairy Research Institute, Karnal, India) and Propionibacterium freudenreichii subsp. shermanii MTCC 1371 (Institute of Microbial Technology, Chandigarh, India) were maintained in sterile SM containing 1 per cent dextrose and 0.1 per cent yeast extract as suggested by Misra and Kuila (1991). Lactobacillus acidophilus R (National Collection of Dairy Cultures, National Dairy Research Institute, Karnal, India) was maintained in plain sterile SM. Pathogenic cultures Virulent pathogenic strains of Bacillus cereus, Shigella dysenteriae (National Collection of Dairy Cultures, National Dairy Research Institute, Karnal, India), Escherichia coli 03, 018, 078 and Salmonella typhimurium P3 (Department of Veterinary Microbiology, West Bengal University of Animal and Fishery Sciences, Nadia, India) were maintained on nutrient agar slants (Hi-Media, Bombay, India) by weekly propagations and were activated by three successive transfers at 24 h intervals in nutrient broth (Hi-Media, Bombay, India). Analytical techniques Technological characteristics Technological attributes of starter cultures were evaluated on the basis of titratable acidity (BIS, 1960), diacetyl and acetoin production (King, 1948), volatile acidity (Hempenien and Liska, 1968) and extent of proteolysis (Hull, 1947). Dietetic characteristics Dietetic attributes of starter cultures were evaluated on the basis of lactic acid content (Barker and Summerson, 1941), lactose hydrolysing activity (Citti et al., 1965), antibacterial activity (BSI, 1968) and bile salt tolerance using Man Rogosa Sharpe (MRS) broth (Hoier, 1992).

Statistical analysis Results obtained in the present investigation were analysed statistically by the method of Snedecor and Cochran (1967). Results and discussion Technological characteristics Titratable acidity. Effect of incorporation of P. freudenreichii subsp. shermanii MTCC 1371 and B. bifidum NDRI along with L. acidophilus R on the rate of acid production, expressed in terms of lactic acid in autoclaved SM and FM, incubated at 37¡1 ˚C, was investigated. Rate of acid production by L. acidophilus R and its association with P. freudenreichii subsp. shermanii MTCC 1371 and/or B. bifidum NDRI were higher in FM than in SM (Table I). Incorporation of B. bifidum NDRI with L. acidophilus R in FM induced an improvement in acid production throughout the incubation. Incorporation of P. freudenreichii subsp. shermanii MTCC 1371 with L. acidophilus R also induced an improvement in the rate of acid production in FM (0.378–1.368 per cent lactic acid) throughout the incubation, however, improvement could be observed after 8 h of incubation in SM (1.116 per cent lactic acid). Conjugated use of P. freudenreichii subsp. shermanii MTCC 1371 and B. bifidum NDRI with L. acidophilus R induced a higher rate of acid production after 4 and 12 h of incubation in SM and throughout the incubation in FM. Because the starter cultures attained the desired level of acidity of 0.6–0.7 per cent as suggested by Foster et al. (1958), an incubation period of 12 h was recommended, keeping in consideration the dietetic characteristics. A minimum incubation period of 12 h for optimum antibacterial activity of B. bifidum and L. acidophilus has been reported (Anand et al., 1984; Prasad and Gandhi, 1987). Incorporation of B. bifidum NDRI and P. freudenreichii subsp. shermanii MTCC 1371 with L. acidophilus R may be suggested for the manufacture of probiotic acidophilus milk for infant feeding. Volatile acidity. The volatile acidity expressed in terms of ml 0.1 N NaOH/50 g curd is depicted in Table II. L. acidophilus R in association with B. bifidum NDRI showed no improvement in volatile acid production in either of the milks, however, significant improvement (p,0.05) could be registered in SM due to its association with P. freudenreichii subsp. shermanii MTCC 1371. Parker and Moon (1982) reported a beneficial synergistic effect on volatile acid production between L. acidophilus and P. freudenreichii subsp. shermanii. Extent of volatile acid production by L. acidophilus R in association with P. freudenreichii subsp. shermanii MTCC 1371 in SM remained unaltered (2.5 ml 0.1 N NaOH/50 g curd) even after introduction of B. bifidum NDRI.

4 Starter culturesa LA LA+P LA+B LA+P+B

SM 0.315 0.261 0.405 0.333

Acid production (per cent lactic acid) Duration of incubation at 37¡1 ˚C (h) 8 FM SM FM SM 0.360 0.378 0.513 0.495

0.585 0.468 0.783 0.567

0.622 0.783 0.864 0.990

1.052 1.116 0.865 1.206

Probiotic acidophilus milk

351

12 FM 1.126 1.368 1.260 1.332

Table I. Effect of incorporation of bifidobacterium and Notes: aAll cultures were inoculated at 1 per cent level individually. SM: skim milk; FM: formulated propionibacterium on the milk; LA: Lactobacillus acidophilus; P: Propionibacterium freudenreichii subsp. shermanii; B: rate of acid production by Lactobacillus acidophilus Bifidobacterium bifidum

NFS 36,5

352

Brown and Townsley (1970) reported Bifidobacterium cultures to produce less than 0.05% volatile acidity. Diacetyl and acetoin content. The diacetyl and acetoin contents along with volatile acids contribute to the characteristic aroma and flavour of the product. Incorporation of P. freudenreichii subsp. shermanii MTCC 1371 with L. acidophilus R induced a significant (p,0.05) improvement in diacetyl and acetoin production, irrespective of the type of milk. However, introduction of B. bifidum NDRI with L. acidophilus R induced an improvement in diacetyl and acetoin production only when cultured in SM (Table II). B. bifidum cultures are reported to produce mainly acetoin while diacetyl is present only in traces (Dolezalek and Plockova, 1981). Conjugated use of P. freudenreichii subsp. shermanii MTCC 1371 and B. bifidum NDRI with L. acidophilus R resulted in a significant (p,0.05) improvement in diacetyl and acetoin production, irrespective of type of milk used. Conjugated use of all these three cultures in the manufacture of probiotic acidophilus milk is recommended. Proteolytic activity. It is difficult to set certain parameters of selection because proteolysis exerts opposite effects, such as an increase in the digestibility (dietetic characteristic) and a decrease in the consistency or flavour of culture (technological characteristic). The results pertaining to the proteolytic activity of starter cultures, expressed in terms of mg tyrosine/ml are given in Table II. L. acidophilus R alone or in association with P freudenreichii subsp. shermanii MTCC 1371 and/or B. bifidum NDRI had significantly (p,0.05) higher proteolytic activity in SM than in FM. L. acidophilus R in association with B. bifidum NDRI and/or P. freudenreichii subsp. shermanii MTCC 1371 showed no improvement in proteolytic activity in SM, however, a significant (p,0.05) improvement was registered when cultured in FM. Extent of proteolysis by L. acidophilus R in FM was higher when used in association with P. freudenreichii subsp. shermanii MTCC (240 mg tyrosine/ml) than with B. bifidum NDRI (200 mg tyrosine/ml). Results indicate P. freudenreichii subsp. shermanii MTCC 1371 to be more proteolytic in nature than B. bifidum NDRI. Proteolytic nature of B. bifidum (Misra and Kuila, 1991) and propionic acid bacteria (Brendehaug and Langsrud, 1985) has been reported. Conjugated use of P. freudenreichii subsp. shermanii MTCC 1371 and B. bifidum NDRI with L. acidophilus R may be suggested to have a moderate proteolytic activity and to satisfy both technological and dietetic criteria of probiotic acidophilus milk.

Starter culturesa

Table II. Effect of incorporation of bifidobacterium and propionibacterium on the technological and dietetic characteristics of Lactobacillus acidophilus

LA LA+P LA+B LA+P+B

b-D-gal Volatile Proteolytic actosidase activity Lactic acidity (ml 0.1 Diacetyl Titratable acid activity acidity (per cent N NaOH/ and acetoin (mg tyrosine/ ml) (mg/ml) (mg ONP/ml) lactic acid) 50 g curd) (ppm) SM FM SM FM SM FM SM FM SM FM SM FM 1.052 1.116 0.855 1.206

1.126 1.368 1.260 1.332

1.5 2.5 1.2 2.5

1.8 0.8 0.5 1.5

5.0 9.0 7.0 10.0

5.0 7.0 4.6 11.0

440 310 215 240

170 240 200 187

330 320 330 330

220 220 220 220

108 95 85 86

38 33 31 44

Notes: aInoculated at 1 per cent level individually and incubated at 37¡1 ˚C for 12 h. SM: skim milk; FM: formulated milk; LA: Lactobacillus acidophilus; P: Propionibacterium freudenreichii subsp. shermanii; B: Bifidobacterium bifidum

Dietetic attributes Lactic acid. Lactic acid production was observed to be significantly (p,0.05) higher in SM (330 mg/ml) than in FM (220 mg/ml) by all starter combinations except for mixed cultures of L. acidophilus R and P. freudenreichii subsp. shermanii MTCC 1371, which produced the same degree of lactic acid (220 mg/ml) in both type of milk (Table II). Lactic acid production by L. acidophilus R in FM remained unaltered either due to incorporation of P. freudenreichii subsp. shermanii MTCC 1371 and/or B. bifidum NDRI. Results indicate disparity in the behaviour of P. freudenreichii subsp. shermanii MTCC 1371 in SM and FM. Lowering of lactic acid content may be due to its utilisation by P. freudenreichii subsp. shermanii MTCC 1371 as reported by Parker and Moon (1982). Incorporation of B. bifidum NDRI and P. freudenreichii subsp. shermanii MTCC 1371 with L. acidophilus R may be recommended for the manufacture of probiotic acidophilus milk for infant feeding without the risk of high acid load. Probiotic acidophilus milk with B. bifidum NDRI may be assumed to have L(+) lactic acid as a major form of lactic acid because in bifidobacteria based fermented milk, dominance of the desired L(+) lactic acid to a level of 90 per cent is reported (Klupsch, 1983). b-D-galactosidase activity. b-galactosidase (b-gal) activity of L. acidophilus R in association with P. freudenreichii subsp. shermanii MTCC 1371 and/or B. bifidum NDRI was observed to be significantly (p,0.05) higher in SM (85–108 mg ONP/ml) than in FM (31–44 mg ONP/ml). Introduction of P. freudenreichii subsp. shermanii MTCC 1371 or B. bifidum NDRI to L. acidophilus R showed lower b-gal activity with respect to control, irrespective of the type of milk (Table II). Conjugated use of L. acidophilus R, B. bifidum NDRI and P. freudenreichii subsp. shermanii MTCC 1371 in FM induced an improvement in b-gal activity. Presence of b–gal enzyme in L. acidophilus (Fisher et al., 1985), B. bifidum (Premi et al., 1972) and P. freudenreichii subsp. shermanii (Kujawski et al., 1990) has been reported. Conjugate application of all these three cultures is suggested to obtain probiotic acidophilus milk, which would be highly suitable for lactose-intolerant infants. Antibacterial activity. All starter combinations exhibited variable inhibitory activity against the pathogenic test organisms (Table III). Incorporation of P. freudenreichii subsp. shermanii MTCC 1371 with L. acidophilus R in SM induced an improvement in the antagonism against all the test organisms except for E. coli 078. However, when cultured in FM, an improvement in antagonism against S. typhimurium P3 could only be observed. Incorporation of B. bifidum NDRI also induced an improvement in antagonism against all test organisms in both SM and

Starter culturesa LA LA+P LA+B LA+P+B

Probiotic acidophilus milk

353

Diameter of zone of inhibitionb (mm) E.coli 03 E. coli 018 B. cereus S. dysenteriae S. typhimurium P3 E. coli 078 SM FM SM FM SM FM SM FM SM FM SM FM 6.5 7.0 7.0 7.5

7.0 7.5 7.5 8.0

6.5 6.5 7.0 7.0

7.0 6.5 7.5 7.5

5.5 6.0 7.0 7.0

6.5 6.5 7.5 8.0

5.5 6.0 6.5 6.5

6.0 6.0 7.0 7.0

5.5 6.0 6.0 7.0

6.0 6.0 6.5 7.0

6.5 7.0 7.0 7.0

7.0 7.0 7.0 8.0

Table III. Effect of incorporation of bifidobacterium and Notes: aInoculated at 1 per cent level individually and incubated at 37¡1 ˚C for 12 h. Including the propionibacterium on the diameter of the well (5 mm). SM: skim milk; FM: formulated milk; LA: Lactobacillus acidophilus, antibacterial properties of Lactobacillus acidophilus P: Propionibacterium freudenreichii subsp. shermanii; B: Bifidobacterium bifidum

NFS 36,5

354

FM, however, no difference in antagonism against S. dysenteriae in FM could be observed. Acidophilus milk exhibited antimicrobial activity against 92 per cent Salmonella, 76 per cent Shigella and 67 per cent E. coli (Anon, 1999). Results indicate better antagonism of pathogens by L. acidophilus R when used in association with B. bifidum NDRI than with P. freudenreichii subsp. shermanii MTCC 1371. Amelioration in the antibacterial activity may be attributed to the production of a higher amount of antimicrobial compounds by increased B.bifidum NDRI population in mixed culture with L. acidophilus. R. Khedkar et al. (1994) registered viable cell counts of Bifidobacteria and L. acidophilus to be much higher in mixed culture. Conjugated use of B. bifidum NDRI and P. freudenreichii subsp. shermanii MTCC 1371 with L.acidophilus R exhibited improved degree of antagonism against all test organisms with respect to antagonism registered due to L. acidophilus R alone. Production of bacteriocin-like compounds, designated as MicrogardTM (Al-Zoreky et al., 1993), acidophilin (Shahani et al., 1977) and bifidin (Anand et al., 1984) by P. freudenreichii subsp. shermanii, L. acidophilus and B. bifidum respectively, has been reported. Banina et al. (1998) reported that antagonism of L. acidophilus may be due to lactic acid production rather than hydrogen peroxide or bacteriocin. Exhibition of maximum antagonism against all test organisms suggested conjugated use of P. freudenreichii subsp. shermanii MTCC 1371, B. bifidum NDRI with L. acidophilus R for the manufacture of probiotic acidophilus milk, which would compete with undesirable flora and maintain the normal gut flora of infants. Bile salt tolerance. The most important criteria for selection of a starter culture for the manufacture of a therapeutic product for infants are its ability to withstand and grow under the conditions prevailing in the intestine. Bile salt tolerance of starter cultures was determined by their capability to grow in the presence of 0.5, 1.0 and 2.0 per cent bile salt within 2 h of incubation at 37¡1 ˚C in MRS broth. Results showed that P. freudenreichii subsp. shermanii MTCC 1371 failed to grow in the presence of 0.5–2.0 per cent bile salt and hence were not bile salt tolerant. However, B. bifidum NDRI and L. acidophilus R had appreciable growth in the presence of 0.5 per cent bile salt. Survival of B. bifidum in the presence of 0.2 per cent sodium tauroglycocholate (Misra, 1988) and L. acidophilus in the presence of 0.15% oxgall (Brennan et al., 1986) has been reported. Shah and Jelen (Misra, 1992) have reported a higher bile salt tolerance of L. acidophilus and B. subsp. than in yoghurt cultures. Survival of L. acidophilus R and B. bifidum NDRI in the presence of bile salt suggested their use in the manufacture of probiotic acidophilus milk for infants with better prophylactic properties. Conclusion Based upon technological and dietetic characteristics, incorporation of B. bifidum NDRI and P. freudenreichii subsp. shermanii MTCC 1371 along with L. acidophilus R is recommended for the manufacture of probiotic acidophilus milk with enhanced dietetic properties. An inoculation rate of 1 per cent each culture and an incubation temperature of 37¡1 ˚C for 12 h are recommended for the manufacture of probiotic acidophilus milk. Probiotic acidophilus milk may be suitable for normal as well as lactose-intolerant infants and children and possess the capability to maintain the normal gut flora. References Al-Zoreky, N., Ayres, J.W. and Sandine, W.E. (1993), ‘‘Characterization of propionibacterial growth metabolites inhibitory for Gram negative bacteria’’, Cult. Dairy Prod. J., Vol. 28, p. 4.

Anand, S.K., Srinivasan, R.A. and Rao, L.K. (1984), ‘‘Antibacterial activity associated with Bifidobacterium bifidum’’, Cult. Dairy Prod. J., Vol. 20, pp. 21–3. Anon (1999), ‘‘Probiotic characteristics of Bulgarian acidophilus milk’’, Khranitelnv Kusova Prom., Vol. 48, pp. 18–20. Banina, A., Vukasinovic, M., Brankovic, S., Fira, D., Kojic, M. and Topisirovic, L. (1998), ‘‘Characterization of natural isolate Lactobacillus acidophilus BGRA 43 useful for acidophilus milk production’’, J. Appl. Microbiol., Vol. 84, pp. 593–9. Barker, S.B. and Summerson, W.H. (1941), ‘‘Colorimetric determination of lactic acid in biological material’’, J. Biol. Chem., Vol. 138, pp. 535–8. BIS (1960), ‘‘Methods of test for dairy industry. Rapid examination of milk’’, BIS (Bureau of Indian Standards):1479 (Part I), Indian Standard Institution, Manak Bhavan, New Delhi. Brendehaug, J. and Langsrud, T. (1985), ‘‘Amino acid metabolism in propionibacteria: resting cells experiments with four strains’’, J Dairy Sci., Vol. 68, p. 281. Brennan, M., Wanismail, B., Johnson, M.C. and Ray, B. (1986), ‘‘Cellular image in dried Lactobacillus acidophilus’’, J. Food Prot., Vol. 49, pp. 47–53. Brown, C.D. and Townsley, P.M. (1970), ‘‘Fermentation of milk by Lactobacillus bifidus’’, J. Inst. Can. Technol. Aliment., Vol. 3, pp. 212–29. BSI (1968), ‘‘Methods of microbiological examination for dairy purposes’’, BS:4285, BSI (British Standards Institution), London. Citti, J.E., Sandine, W.E. and Elliker, P.R. (1965), ‘‘b-galactosidase of Streptococcus lactis’’, J. Bacteriol., Vol. 89, pp. 937–42. Dolezalek, J. and Plockova, M. (1981), ‘‘Influence of the cultivation temperature of pure and pooled bifidogenic cultures on ripening’’, Sbornik Vysoke Skoly emicko-Technologicke V. Prague, Vol. E52, pp. 85–97. Fisher, K., Johnson, M.C. and Ray, B. (1985), ‘‘Lactose hydrolyzing enzymes of Lactobacillus acidophilus strains’’, Food Microbiol., Vol. 2, pp. 23–9. Foster, E.M., Nelson, F.E., Speck, M.L., Doetsch, R.N. and Olson, J.C. (1958), Dairy Microbiology, Macmillan, London, p. 327. Fukushima, Y., Li, S.T., Hara, H., Terada, A. and Mitsuoka, T. (1997), ‘‘Effect of follow up formula containing bifidobacteria (NANBF) on fecal flora and fecal metabolites in healthy children’’, Bioscience Microflora, Vol. 16, pp. 65–72. Fukushima, Y. and Yamano, T. (2003), ‘‘Adhesion of probiotics onto intestinal epithelial cells and host defences’’, J. Intest. Microbial., Vol. 17, pp. 1–8. Garvie, E.I., Cole, C.B., Fuller, R. and Hewitt, D. (1984), ‘‘The effect of yoghurt on some components of the gut microflora and the metabolism of lactose in rats’’, J. Appl. Microbiol., Vol. 56, pp. 237–45. Gilliland, S.E. (1989), ‘‘Acidophilus milk products: a review of potential benefits to consumers’’, J. Dairy Sci., Vol. 72, pp. 2483–94. Hempeniens, W.L. and Liska, B.J. (1968), ‘‘Method for determining volatile acids in cultured dairy products’’, J. Dairy Sci., Vol. 51, pp. 221–2. Hoier, E. (1992), ‘‘Acid and bile tolerance of Lactobacillus acidophilus and bifidobacteria’’, DMZ Lebensmittelindustrie und Milchwirtschaft, Vol. 113, pp. 269–72. Hull, M.E. (1947), ‘‘Studies on milk protein II. Colorimetric determination of the partial hydrolysis of the proteins in milk’’, J. Dairy Sci., Vol. 30, pp. 881–3. Khedkar, J.N., Dave, J.M. and Sannabhadti, S.S. (1994), ‘‘Associative relationship of bifidobacteria with lactic cultures’’, Indian J. Dairy Sci., Vol. 47, pp. 692–4. King, N. (1948), ‘‘A modification of Voges – Proskauer test for rapid colorimetric determination of acetyl methyl carbinol+diacetyl in butter cultures’’, Dairy Ind., Vol. 8, pp. 860–4.

Probiotic acidophilus milk

355

NFS 36,5

356

Klupsch, H.J. (1983), ‘‘Bioghurt–Biogarde–acidified milk products with optimum qualities’’, N. Eur. Dairy J., Vol. 49, pp. 29–32. Kujawski, M., Rymaszewski, J. and Cichosz, G. (1990), ‘‘Enzymatic activity of propionic acid bacteria’’, Int. Dairy Fed., p. 279. Misra, A.K. (1988), ‘‘Studies on Bifidobacterium bifidum based fermented milk products’’, PhD thesis, Bidhan Chandra Krishi Viswavidyalaya, Mohanpur, Nadia, West Bengal. Misra, A.K. and Kuila, R.K. (1991), ‘‘The selection of bifidobacteria for the manufacture of fermented milks’’, Austr. J. Dairy Technol., Vol. 5, pp. 24–6. Misra, A.K. and Kuila, R.K. (1992), ‘‘Use of Bifidobacterium bifidum in the manufacture of bifidus milk and its antibacterial activity’’, Lait, Vol. 72, pp. 213–20. Mitsuoka, T. (1992), ‘‘The human gastrointestinal’’, in Wood, B.J.B. (Ed.), Lactic Acid Bacteria, Vol. 1, Elsevier Appl. Sci., London, pp. 69–114. Nabukhotnyi, T.K., Cherevko, S.A., Samigullina, F.I. and Grushko, A.I. (1983), ‘‘Use of adapted propiono acidophilic gastrointestinal diseases of infants’’, Vopr. Pitan., Vol. 6, p. 27. Parker, J.A. and Moon, N.J. (1982), ‘‘Interactions of Lactobacillus and Propionibacterium in mixed culture’’, J. Food Prot., Vol. 45, pp. 326–30. Prasad, R.V. and Gandhi, D.N. (1987), ‘‘Factors affecting the production of antibacterial substance(s) in Lactobacillus acidophilus strain R’’, Indian J. Dairy Sci., Vol. 40, pp. 74–7. Premi, L., Sandine, W.E. and Elliker. P.R. (1972), ‘‘Lactose-hydrolyzing enzymes of Lactobacillus species’’, Appl. Microbiol., Vol. 24 No. 1, pp. 51–7. Reddy, M.S. (1989), ‘‘Shelf-life and subsequent growth of Lactobacillus acidoplilus, Propionibacterium shermanii and Leuconostoc citrovorum in dietary fibre based supplemented preparations’’, US Patent 806 368, p. 7. Sarkar, S. (2003), ‘‘Recent innovations in cultured milk products for infants’’, Nutr. Food Sci., Vol. 33, pp. 268–72. Shah, N.P., Fedorak, R.N. and Jelen, P.J. (1992), ‘‘Food consistency effects of quarg in lactose malabsorption’’, Int. Dairy J., Vol. 2, pp. 257–69. Shahani, K.M., Vakil, J.R. and Kilara, A. (1977), ‘‘Natural antibiotic activity of Lactobacillus acidophilus and bulgaricus. II. Isolation of acidophilin from L. acidophilus’’, Cult. Dairy Prod. J., Vol. 12 No. 2, p. 8. Skupin, J., Pedziwilk, F., Giec, A., Jaszewski, B., Trojanowska, K. and Nowakowska, K. (1974), ‘‘Utilization of propionic acid bacteria in production of protein/vitamin preparations based on whey’’, Roczniki Technologii i Chemii Zywnosci, Vol. 24, p. 17. Snedecor, G.W. and Cochran, W.G. (1967), Statistical Methods, 6th ed., Oxford and IBH Publishing Co., New Delhi. Thompkinson, D.K. and Mathur, B.N. (1995), ‘‘Compositional developments for infant foods’’, Indian Food Ind., Vol. 14, pp. 23–7. Corresponding author S. Sarkar can be contacted at: [email protected]

To purchase reprints of this article please e-mail: [email protected] Or visit our web site for further details: www.emeraldinsight.com/reprints

The current issue and full text archive of this journal is available at www.emeraldinsight.com/0034-6659.htm

Cultured milk products for lactose-intolerant recipients

Cultured milk products for lactose

S. Sarkar Department of Quality Assurance, Metro Dairy Ltd, Kolkata, West Bengal, India

357

Abstract Purpose – The purpose of this paper is to enlighten the prophylactic aspect of cultured milk products, which render it suitable for lactose-intolerant subjects. Design/methodology/approach – The paper outlines the significance of lactase enzyme and the mechanism of lactase digestion. This is followed by a discussion of lactase activities in starter cultures and cultured milk products for lactose-intolerant participants. Factors affecting lactase activity are described. Findings – Starter cultures possess the enzyme b-galactosidase, required for lactose hydrolysis and their application led to the development of a number of cultured milk products, which are more easily digestible than milk by lactose-intolerant individuals. Reasons attributable for better digestion of cultured milk products than milk are reduction in lactose content, increase in microbial lactase enzyme, stimulation of host’s mucosal lactase activity and slower transit of cultured milk products as compared to milk. Originality/value – Consumption of cultured milk products by lactose-intolerant recipients is suggested. Keywords Milk, Digestive sysytem Paper type Research paper

Introduction Inability of human beings to digest lactose is often referred to as ‘‘Lactose-intolerance’’ and has been attributed to insufficient amounts of lactase in the small intestine to hydrolyze lactose consumed in the diet (Littman and Hammond, 1965; Bayless and Rosenweig, 1966). b-galactosidase, commonly known as lactase is capable of hydrolyzing b-D-galactoside bond between D-galactose and glucose. The enzyme is widely distributed in nature and has been isolated from plants, animals and microorganisms. Lactobacilli is the normal resident of gastro-intestinal tract (Mitsuoka, 1992) and capable of restoring the normal microbial balance in the intestine (Garvie et al., 1984); utilization of lactobacilli during the manufacture of cultured milk products are proposed to exhibit ‘‘health-promoting’’ or ‘‘probiotic’’ effect in humans, which include improvement of lactose digestion (Gilliland, 1989). Shahani and Chandan (1979) pointed out that cultured milk products may provide supplementary quantities of lactase and other constituent enzymes, elaborated by cultures during fermentation, contributing towards the assimilation of lactose by lactose-intolerant individuals. In the present article, an endeavor has been made to enlighten the prophylactic aspect of cultured milk products, which render them more suitable for ingestion by lactose-intolerant recipients. Nutrition & Food Science Significance of lactase enzyme Vol. 36 No. 5, 2006 Lactose, a disaccharide composed of glucose and galactose, is the major solid pp. 357-364 Limited component of milk and must be hydrolyzed into its components under the influence of E Emerald Group Publishing0034-6659 enzyme lactase, a membrane bound enzyme present in the brush border of the small DOI 10.1108/00346650610703216

NFS 36,5

358

intestinal epithelial cell prior to its absorption by humans (Miller and Brand, 1980; Hourigan, 1984). In case the quantum of lactose ingested exceeds the hydrolytic capacity of the available intestinal lactase, the undigested portion of lactose is transported to the large intestine, where it increases the osmolarity of the intestinal fluids. Undigested lactose undergoes bacterial fermentation in the colon, generating organic acids, carbondioxide and hydrogen, which along with the large amount of water is drawn into the intestine, are primarily responsible for various symptoms such as bloating, flatulence, abdominal cramps, diarrhoea and loss of appetite (Hourigan, 1984; Hofi, 1990). Lactose maldigestion occurs due to either gastro-intestinal disease or physiological decline in the intestinal lactase activity and may lead to clinical symptoms of lactose-intolerance. Semenza and Auricchio (1995) registered reduction in lactase activity due to digestion of lactase–phlonizin hydrolase molecule by pancreatic proteases at the brush border membrane. Deficiency of enzyme lactase may be of three types (Swaminathan, 1998). Congenital lactase deficiency Persons cannot tolerate lactose due to absence of lactase enzyme in the intestine, resulting in accumulation of lactose in the intestine causing abdominal pain and loose motion. Lactase deficiency in premature infants This condition occurs in premature infants due to decrease lactase enzyme activity in the intestinal mucosa. Initially, infants cannot utilize lactose efficiently, however they are able to tolerate and digest milk after one month due to increase in lactase activity. Acquired lactase deficiency Adults and older children cannot tolerate large amounts of milk due to their nonhabitual consumption of milk resulting in low lactase in the intestinal mucosa. Mechanism of lactose digestion Lactic acid bacteria must survive the gastro-intestinal tract to provide the beneficial effect. Cells of yoghurt cultures contain b-galactosidase as an intracellular enzyme, therefore it is protected during passage through the harsh environment of stomach and is able to reach the small intestine, while still inside the bacterial cells. Permeability of yoghurt cultures is altered, when it comes in contact with bile so that lactose can enter and get hydrolyzed (Gilliland and Kim, 1984). The sensitivity of yoghurt cultures to bile has been proposed as an advantage for lactose digestion, because it increases the permeability of the bacterial cell (McDonough et al., 1987). Shah and Lankaputhra (1997) noted that rupturing of bacterial cells of yoghurt cultures reduced viable counts but the released intracellular b-galactosidase improved the viability of probiotic bacteria such as Bifidobacterium spp. and L. acidophilus which remained above the recommended level of 106 cfu/mL. Microorganisms residing in the large intestine made themselves tolerant to lactose through modifications of their metabolic activity (Hertzler and Savaiano, 1996) Efficient utilization of lactose from cultured milk products than in milk may be attributed to improved digestion of lactose resulting from lactase activity of bacteria, stimulation of host’s mucosal lactase activity or slower intestinal transit of cultured milk product compared to milk (Kolars et al., 1984; Gibson and Fuller, 1998).

Lactase activity in starter cultures Galactose activity has been demonstrated in many lactobacilli (Mittal et al., 1974) and differs greatly in their lactase activity (Premi et al., 1972; Fisher et al., 1985). Variation in lactase activity of different strains of lactobacillus delbrueckii subsp bulgaricus and streptococcus thermophilus were noted (Gilliand and Kim, 1984) and the later organism possess higher b-galactosidase activity than the former (Lee, 1992). Probiotic cultures such as lactobacillus acidophilus and bifidobacterium, possess lower levels of lactase and being more resistant to bile than yoghurt cultures are less efficacious in helping lactose digestion (Shah and Jelen, 1992). Lactase activity of L. acidophilus strains was reported to vary within a range of 0.5 to 9.5 units (Fisher et al., 1985) and this disparity may be due to micro-heterogeneity in the amino acid composition of lactose (Styrer, 1988). Higher lactase activity of propionic acid bacteria than lactic acid bacteria (Kujawski et al., 1990) suggested their conjugated use during the manufacture of cultured milk products such as dietetic yoghurt (Sarkar and Misra, 1998a, 2001) and Propiono-Acido-Bifido (PAB) milk (Sarkar and Misra, 1998b). Cultured milk products for lactose-intolerant recipients Better tolerance of yoghurt and acidophilus milk in comparison to milk by lactase non-persistent subjects has been reported (Alm, 1982; Sieber, 2000). A decline in lactose content from 5.26 to 3.19 per cent and an increase in glucose and galactose from 0.05 to 2.11 per cent in yoghurt (Abd-Rabo et al., 1992) and digestion of .90 per cent lactose in small intestine of lactase-deficient subjects due to lactase activity of yoghurt cultures were noted (Streiff et al., 1990). Efficient absorption of lactose by rats from yoghurt containing viable flora (Goodenough and Kleyn, 1976) and a decline in faecal lactase activity in lactase non-persistent human subjects consuming nonpasteurized yoghurt (Pochart et al., 1989) indicated that presence of lactase enzyme and viable flora are necessary for the beneficial effects. Efficacy of fermented and non-fermented acidophilus milk or bifidus milk is under debate for their benefits for lactose-intolerant subjects. Short-term ingestion of acidophilus milk proved to be not better than milk (Newcomer et al., 1983), and less than yoghurt (Shah et al., 1992; Vesa et al., 1996), however sonication of bacterial cells induced better tolerance by lactase non-persistent subjects and may be ascribed to elevation of lactase activity due to lysis of bacterial cells (McDonough et al., 1987). Kim and Gilliland (1983) reported that addition of a large number of L. acidophilus (2.5 6 106 to 2.5 6 108 cfu/mL) to milk prior to ingestion improved lactose digestion and noted a reduction in breath hydrogen due to prolonged consumption of sweet acidophilus milk for 6 days, which may be related to hydrolysis of lactose by L. acidophilus or by lactase in gastro-intestinal tract or reduction in hydrogen producing bacteria (Fernandes and Shahani, 1989). Effect of feeding cultured milk products on breath hydrogen test in humans is shown in Table I. A number of cultured milk products, namely Antoshka-L (based on bifidobacterium), Gnomik – 2 (based on bifidobacterium), Zdorove – 2 (based on L. acidophilus, lactic streptococci, bifidobacterium), Progurt (based on streptococcus diacetylactis or S. cremoris, L. acidophilus and/or B. bifidum), butter milk or yoghurt-like product (based on S. lactis, Leuconostor citrovorum, L. bulgaricus, S. thermoplilus, L. acidophilus or B. bifidum) and PAB milk (based on L. acidophilus, B. bifidum and propionibacterium freudenreichii subsp. shermanii) were recommended for lactose – intolerant infants and children (Schacht and Syrazyski, 1975; Roberts, 1977; Lipatov et al., 1998; Sarkar and Misra, 1998b). Cultured milk products containing

Cultured milk products for lactose

359

NFS 36,5

Cultured milk product Sweet acidophilus milk

360 Yoghurt

Lactose content (%) 6.30 4.80

1427 (mg glucose/dL) 0.09 (units/g)

4.90

0 (mg/h g)

3.60 4.20

Table I. Effect of ingesting cultured milk products on breath hydrogen test in humans

Lactase Cell count activity (cfu/g) (cfu/g)

4.80 4.00

2.20 (ONPG units) 6.8 (ONPG units) 3724 (mg glucose/dL) 0.64 (mg/h g)

Breath hydrogen (ppm) Reference

16108

28.30

–

33.00

1.16107 6.0610

8

< 200.00 1593

–

9.90

2.06108

5.40

3.06108

< 50.0

McDonough et al. (1987) Onwulata et al. (1989) Savaiano et al. (1984) Dewit et al. (1988) Gilliland and Kim (1984) Mc Donough et al. (1987) Savaiano et al. (1984)

bifidobacterium and S. thermophilus were tolerated well by infants and the higher level of hydrogen exhaled indicated an earlier bacterial colonization in the digestive tract. (Leke et al., 1999). Factors affecting lactase activity Microbial growth conditions b-galactosidase activity of L. acidophilus depends on the growth temperature and pH of medium (Seema et al., 1994). Acid tolerant strains have an advantage in surviving the low pH conditions in the stomach (pH 2.0), where hydrochloric and gastric acids are secreted (Toit et al., 1998). During incubation of yoghurt cultures up to 4 h, bgalactosidase activity reached a maximum value (8 units/g), followed by lowering to a level of 3 units/g, before leveling off. A decrease in enzyme activity between 4–6 h of incubation is due to an increase in titratable acidity (Kilara and Shahani, 1976; Dave et al., 1993). Microbial viability Strains of starter cultures must survive the gastro-intestinal tract, which is dependent on buffering capacity of the medium (Conway et al., 1987). Bile-salt tolerance is important for strains to grow and survive in upper small intestine (Toit et al., 1998) and survivality of greater number of bile – resistant lactobacilli strains in gastrointestinal tract have been reported (Gilliland et al., 1984). A viable population of . 106 cfu/mL is known to exhibit a positive prophylactic effect (Mijacevic et al., 2001). Product processing and storage conditions Dave et al. (1993) registered higher b-galactosidase activity in dahi made from milk with higher total solids. Higher activity was also noted in formulated milk than in skim milk due to higher total solid content in the former milk (Sarkar and Misra, 1998a). b-galactosidase activity in dahi (Dave et al., 1993) and PAB milk (Sarkar and Misra, 1998b) decreased during refrigerated storage with increasing periods of storage due to shift in pH (Dave et al., 1993). Galvao et al. (1995) noted b-galactosidase activity of 0.58 to 3.3 units in yoghurt, which declined throughout the storage.

Post-processing treatments Untreated yoghurt containing live and active flora is tolerated better by lactase nonpersistent individuals than pasteurized yoghurt (McDonough et al., 1987; Dewit et al., 1988; Pochart et al., 1989). Pasteurization of yoghurt reduced viable counts from 3 6 108/g to 3.4 6 106/g and lactase activity from 0.64 to 0.07 units/g (Savaiano et al., 1984). Thermization of dahi reduced the lactase activity by 50 to 73.68 per cent and differed with the strains of cultures adopted for dahi manufacture (Sarkar et al., 1992). Conclusion Possession of b-galactosidase enzyme required for lactose hydrolysis by starter cultures led to their utilization for the manufacture of cultured milk products, suitable for lactose-intolerant individuals. Better tolerance of cultured milk products than milk by lactose-intolerant subjects may be attributed to reduction in lactose content, increase in microbial lactase, stimulation of host’s mucosal lactase activity and slower transit of cultured milk products in comparison to milk. Factors affecting the lactase activity are growth condition survivability of starter cultures, surviability of starter cultures, product manufacturing and storage conditions and post-processing treatments. References Abd-Rabo, F.H., Ahmed, N.S., Abou-Dawood, A.E. and Hassan, F.A.M. (1992), ‘‘Changes in milk constituents during the manufacture of goat’s milk yoghurt’’, Egypt. J. Dairy Sci., Vol. 20, pp. 317–28. Alm, L. (1982), ‘‘Effect of fermentation of lactose, glucose and galactose content in milk and suitability of fermented milk products for lactose intolerant indiniduals’’, J. Dairy Sci., Vol. 65, pp. 346–52. Bayless, T.M. and Rosenweig, N.S. (1966), ‘‘A radical difference in incidence of lactase deficiency: a survey of milk intolerance and lactase deficiency in healthy adult males’’, J. Am. Med. Assoc., Vol. 197, p. 968. Conway, P.L., Gorbach, S.L. and Goldin, B.R. (1987), ‘‘Survival of lactic acid bacteria in the human stomach and adhesion to intestinal cells’’, J. Dairy Sci., Vol. 70, pp. 1–12. Dave, R.I., Dave, J.M. and Sannabhadti, S.S. (1993), ‘‘Effect of starter culture and total solids on b-D-galactosidase activity during manufacture and storage of dahi’’, Indian J. Dairy Sci., Vol. 46, pp. 544–6. Dewit, O., Pochart, P. and Desjeux, J.F. (1988), ‘‘Breath hydrogen concentration and plasma glucose, insulin and free fatty acid levels after lactose, milk, fresh and heated yoghurt ingestion by healthy young adults with or without lactose malabsorption’’, Nutrition, Vol. 4, pp. 1–5. Fernandes, C.F. and Shahani, K.M. (1989), ‘‘Lactose intolerance and its modulation with lactobacilli and other microbial supplements’’, J. Appl. Nutr., Vol. 42, pp. 50–64. Fisher, K., Johnson, M.C. and Ray, B. (1985), ‘‘Lactose hydrolyzing enzymes in Lactobacillus acidophilus strains’’, Fd. Microbiol., Vol. 2, pp. 23–9. Galvao, L.C., Fernandes, M.I.M. and Sawamura, R. (1995), ‘‘Lactose content and b-galactosidase activity in yoghurts, cheeses and cultured milk products in Brazil’’, Arquivos de Gastroenterologia, Vol. 32, pp. 8–14. Garvie, E.I., Cole, C.B., Fuller, R. and Hewitt, D. (1984), ‘‘The effect of yoghurt on some components of the gut microflora and on the metabolism of lactose in the rats’’, J. Appl. Bacteriol, Vol. 56, pp. 237–45.

Cultured milk products for lactose

361

NFS 36,5

362

Gibson, G.R. and Fuller, R. (1998), ‘‘The role of probiotics and prebiotics in the functional food concept’’, in Sadler, M.J. and Saltmarsh, M. (Eds), Functional Foods, the Consumer, the Products and the Evidence, Royal Soc. Chem., UK, pp. 3–14. Gilliland, S.E. (1989), ‘‘Acidophilus milk products: a review of potential benefits to the consumer’’, J. Dairy Sci., Vol. 72, pp. 2483–94. Gilliland, S.E. and Kim, H.S. (1984), ‘‘Effect of viable starter culture bacteria in yoghurt on lactose utilization in humans’’, J. Dairy Sci., Vol. 67, pp. 1–6. Gilliand, S.E., Staley, T.E. and Bush, L.J. (1984), ‘‘Importance of bile tolerance of Lactobacillus acidophilus used as a dietary adjunct’’, J. Dairy Sci., Vol. 67, pp. 3045–51. Goodenough, E.R. and Kleyn, D.H. (1976), ‘‘Influence of viable yoghurt micro-flora on digestion of lactose by the rats’’, J. Dairy Sci., Vol. 59, p. 601. Hertzler, S.R. and Savaiano, D.A. (1996), ‘‘Colonic adaptation to daily lactose feeding in lactose maldigesters reduces lactose intolerance’’, Am. J. Clin. Nutr., Vol. 64, pp. 232–6. Hofi, M.A. (1990), ‘‘Low-lactose labneh and zabady by ultrafiltration’’, Scan. Dairy Infor., Vol. 4, pp. 30–3. Hourigan, J.A. (1984), ‘‘Nutritional implication of lactose’’, Aus. J. Dairy Tech., Vol. 39, pp. 114–20. Kilara, A. and Shahani, K.M. (1976), ‘‘Lactase activity of cultured and acidified dairy products’’, J. Dairy Sci., Vol. 59, pp. 2031–5. Kim, H.S. and Gilliland, S.E. (1983), ‘‘Effect of viable starter culture bacteria in yoghurt on lactose utilization in humans’’, J. Dairy Sci., Vol. 67, pp. 1–6. Kolars, J.C., Levitt, M.D., Aouji, M. and Savaiano, D.A. (1984), ‘‘Yoghurt – an autodigesting source of lactose’’, New Eng. J. Med., Vol. 310, pp. 1–3. Kujawski, M., Rymaszewski, J. and Cichosz, G. (1990), ‘‘Enzymatic activity of propionic acid bacteria’’, Int. Dairy Fed., p. 279. Lee, K.H. (1992), ‘‘Lactase activity in yoghurt and lactic acid bacteria’’, J. Korean Soc. Fd. Nutr., Vol. 21, pp. 60–3. Leke, L., Romond, M.B., Tene, G., Kilani, L., Krim, G., Gallet, M., Kremp, O., Rochette, J.B., Galent, A. and Risbourg, B. (1999), ‘‘Weaning in the neonatal period: advantages of cultured milks’’, Anales Espanoles de Pediatria., Vol. 50, pp. 176a–176d. Lipatov, N.N., Baryshnikova, E.P., Sazhinov, G. Yu, Shcherbakova, E.G., Kon’ I. Ya, Sorvacheva, T.N., Kuznetsova, G.G., Ladodo, K.S. and Borovik, T.E. (1998), ‘‘New specialized cultured milk products for prophylactic nutrition of children’’, Pishchevaya Prom., No. 12, pp. 14–5. Littman, A. and Hammond, J.B. (1965), ‘‘Diarrhea in adults caused by deficiency in intestinal disaccharides’’, Gastroenterology, Vol. 48, p. 237. McDonough, F.E., Hitchins, A.D., Wong, N.P., Wells, P. and Bodwell, C.E. (1987), ‘‘Modifications of sweet acidophilus milk to improve utilization by lactose – intolerant persons’’, Am. J. Clin. Nutr., Vol. 45, pp. 570–4. Mijacevic, Z., Bulajic, S. and Nedic, D. (2001), ‘‘Survival and therapeutic potential of probiotic microorganisms in fermented milk’’, Acta Veterinaria,, Vol. 51, pp. 325–32. Miller, J.J. and Brand, J.C. (1980), ‘‘Enzymatic lactose hydrolysis’’, Fd. Tech. Aus., Vol. 32, pp. 144–7. Mitsuoka, T. (1992), ‘‘ The human gastrointestinal tract’’, in Wood, B.J.B. (Ed.), The lactic Acid Bacteria, The lactic acid bacteria in health and disease, Elsevier Appl. Sci., London, pp. 64–114. Mittal, B.K. (1974), ‘‘Growth of lactic acid bacteria in soy milks’’, J. Fd. Sci., Vol. 39, pp. 1018–22.

Newcomer, A.D., Park, H.S., O’ Brien, P.C. and McGill, D.B. (1983), ‘‘Response of patients with irritable bowel syndrome and lactase deficiency using unfermented acidophilus milk’’, Am. J. Clin. Nutr., Vol. 38, pp. 257–63. Onwulata, C.I., Rao, D.R. and Vankineini, P. (1989), ‘‘Relative efficiency of yoghurt, sweet acidoplilus milk, hydrolyzed lactose milk and a commercial lactase tablet in alleviating lactose maldigestion’’, Am. J. Clin. Nutr., Vol. 49, pp. 1233–7. Pochart, P., Dewit, O., Desjeux, J.F. and Bourlioux, P. (1989), ‘‘Viable starter culture, bgalactosidase activity and lactose in duedenum after yoghurt ingestion in lactase deficient humans’’, Am. J. Clin. Nutr., Vol. 49, pp. 828–31. Premi, L., Sandine, W.E. and Elliker, P.R. (1972), ‘‘Lactose hydrolyzing enzymes of Lactobacillus species’’, Appl. Microbiol., Vol. 24, pp. 51–7. Roberts, J.G. (1977), ‘‘Multi-cultured product and process for the preparation thereof’’, US Patent 4034 115. Sarkar, S. and Misra, A.K. (1998a), ‘‘Selection of starter cultures for the manufature of probitic yoghurt’’, Egypt. J. Dairy Sci., Vol. 26, pp. 293–307. Sarkar, S. and Misra, A.K. (1998b), ‘‘Process for the manufature of a new cultured milk product for infants and children’’, Milchwiss., Vol. 53, pp. 603–5. Sarkar, S. and Misra, A.K. (2001), ‘‘Characteristics of dietetic yoghurt’’, Indian J. Dairy Biosciences, Vol. 12, pp. 76–9. Sarkar, S.P., Dave, J.M. and Sannabhadti, S.S. (1992), ‘‘Effect of thermization of misti dahi on shelf – life and b-D-galactosidase activity’’, Indian J. Dairy Sci., Vol. 45, pp. 135–9. Savaiano, D.A., Abou El Anouar, A., Smith, D.E. and Levitt, M.D. (1984), ‘‘Lactose malabsorption from yoghurt, pasteurized yoghurt, sweet acidophilus milk and cultured milk in lactase – deficient individuals’’, Am. J. Clin. Nutr., Vol. 40, pp. 1219–23. Schacht, E. and Syrazynski, A. (1975), ‘‘Progurt – a new cultured product. Its manufacturing technology and dietetic value’’, Industria Lechere, Vol. 646, pp. 9–11. Seema, Garg, S.K., Ahmad, S., Singh, S.P. and Mital, B.K. (1994), ‘‘Kinetic studies on partially purified b-galactosidase from Lactobacillus acidophilus 301’’, Indian J. Dairy Sci., Vol. 47, pp. 240–2. Semenza, G. and Auricchio, S. (1995), ‘‘Small – intestinal disaccharides’’, in Scriver, C.R. and Beaudet, W.S. (Eds), Metabolic and Molecular Basis of Inherited Disease, McGraw-Hill, London, pp. 4451–79. Shah, N.P., Fedorak, R.N. and Jelen, P.J. (1992), ‘‘Food consistency effects of quarg in lactose malabsorption’’, Int. Dairy J., Vol. 2, pp. 257–69. Shah, N.P. and Lankaputhra, W.E.V. (1997), ‘‘Improving viability of Lactobacillus acidophilus and Bifidobacterium spp. in yoghurt’’ Int. Dairy J., Vol. 7, pp. 349–56. Shahani, K.M. and Chandan, R.C. (1979), ‘‘Nutritional and healthful aspects of cultured and culture-containing dairy foods’’, J. Dairy Sci., Vol. 62, pp. 1685–94. Sieber, R. (2000), ‘‘Lactose-intolerance and milk consumption’’, Mljekarstvo, Vol. 50, pp. 151–64. Streiff, P.J., Hoyda, D.L. and Epstein, E. (1990), ‘‘Process for the production of low-calorie yoghurt’’, US Patent, 4 956, p. 7. Styrer, L. (1988), Biochemistry, Freeman, W.H. & Co., New York, NY, USA. Swaminathan, M. (1998), ‘‘Therapeutic nutrition and diets’’, Essentials of Food and Nutrition, Vol. 2, Bangalore Printing & Pub. Co. Ltd, Bangalore, India, pp. 178–9. Toit, M. du, Franz, C.M.A.P., Dicks, L.M.T., Schillinger, U., Haberer, P., Warlies, B., Ahrens, F. and Holzapfel, N.H. (1998), ‘‘Characterisation and selection of probiotic lactobacilli for a preliminary minipig feeding trial and their effects on serum cholesterol levels, faeces pH and faeces moisture content’’, Int. J. Fd. Microbiol., Vol. 40, pp. 93–104.

Cultured milk products for lactose

363

NFS 36,5

364

Vesa, T., Marteau, P., Zidi, S., Pochart, P. and Rambaud, J.C. (1996), ‘‘Digestion and toleance of lactose from yoghurt and different semi-solid fermented dairy products containing Lactobacillus acidophilus and bifidobacteria in lactose maldigesters – Is bacterial lactase so important ?’’, Eur. J. Clin. Nutr., Vol. 50, pp. 730–3.

Corresponding author S. Sarkar can be contacted at: [email protected]

To purchase reprints of this article please e-mail: [email protected] Or visit our web site for further details: www.emeraldinsight.com/reprints

Food facts Chartered Institute of Environmental Health (CIEH) Food businesses have a duty of care to their customers in an environment where more people than ever before are eating out and food allergies are on the rise. Acknowledging this trend the Chartered Institute of Environmental Health (CIEH) has launched a new DVD to raise awareness of food allergens. Addressing legal requirements to keep customers safe and to help avoid expensive liability claims for businesses, the DVD provides clear guidance for food businesses on how to manage allergens in food production and the knowledge required by staff to answer customer enquiries competently. The Caterers Guide to Food Allergy DVD, sponsored by the CIEH, aims to reduce the risks faced by the UK’s 1.5 million food allergy sufferers – an element of the Food Standards Agency’s Safer Food, Better Business campaign. Speaking on behalf of the CIEH, policy officer Jenny Morris said: ‘‘Peanut allergy, for example, has risen dramatically in recent years and only small amounts of the nut can cause fatal or near fatal reactions.’’ ‘‘While businesses are currently reviewing their food safety management procedures, to comply with new legislation, it is an ideal time to ensure that those procedures address the serious risk allergens can pose. The DVD provides guidance on the common types of food allergens, such as nuts, milk, egg, fish and shellfish, soya wheat and sesame. Common causes of concern, such as unintentional cross contamination, proper cleaning, the safe preparation and cooking of foodstuffs, are explained. Training of staff, so that they have knowledge of ingredients in products they sell, and their potential to harm allergy sufferers, is also an essential ingredient of the DVD. To obtain a copy please email AMT productions, makers of Action for Anaphylaxis, at: [email protected] For further information and to view a clip of the film please visit: www. amtproductions.co.uk

Food facts

365

LACA School caterers plan to use a national television campaign to convince parents that Jamie Oliver is not the only cook capable of serving up healthy school meals. A spokeswoman for the Local Authority Caterers Association (LACA), Hazel Green, said the TV chef was to blame for the slump in demand for school meals. Ms Green said caterers would use the adverts to prove to parents that their school meals were equally as healthy as Oliver’s creations. Jamie’s School Dinners was seen as the driving force behind the government’s decision to introduce tough new nutritional standards in the autumn. Since the show was launched, in March last year, school meals have fallen from favour, threatening to put some caterers out of business. LACA, which represents the suppliers of 85 per cent of school meals, says there has Nutrition & Food Science been a 12.5 per cent drop in the consumption of dinners since Oliver’s show first aired. Vol. 36 No. 5, 2006 pp. 365-380 She said Oliver may have correctly identified ‘‘a few bad school meals" but most Emerald Group Publishing Limited E caterers only used ‘‘fresh raw ingredients’’. 0034-6659

NFS 36,5

366

The adverts, will focus on the new standards school caterers will be following, which include limiting chips to twice a week and serving at least two portions of fresh fruit and vegetables a day. Ms Green said: ‘‘What we want to do is make parents aware of these standards and the importance of school meals in providing quality nutritional food.’’ Recycling milk cartons Tetrapak provide 200 million school milk cartons each year and work with the Milk Development Council. Along with other dairy industry partners, we help fund the School Milk Project under which a team of facilitators visit schools to promote the uptake of school milk. http://www.tetrapakrecycling.co.uk/07.htm Danone Institute The Danone Institute have produced information on ‘‘Novel concepts in the developmental origins of adult health and diseases’’ which is available on their website. More information can be obtained from Barbara Vanheule, Protein Health Communications, Av Louise 287, Box 5, 1050 Brussels Belgium. Chestnut flour Chestnut flour is an ideal substitute for wheat flour. It is 100 per cent natural; gluten free; moderate carbohydrate (mostly starch, moderate energy); high sugar content (natural sugar of 25 ˚ Brix); low fat and no cholesterol; and is very fine powder (about 70 per cent pass 200 mesh) – plus very useful fibre, protein, minerals and vitamins – all of which enhance health in general. You can contact us by email: [email protected] or [email protected] Mountglory Food Corporation, Shijiazhuang, Hebei, China, Web: www.chestnutchina.com. President HCA Lady Caroline Waldegrave has agreed to become the President of the Hospital Caterers Association. Lady Waldegrave is a fellow caterer who was previously involved at Guy’s Hospital. She is a published author and was a Founder President and Managing Director of Leith’s School of Food and Wine who appreciates and understands the issues surrounding hospital catering and the challenges of hospital caterers. I understand that Lady Waldegrave will attempt to attend at least some of our Conference, prior commitments allowing. Real choice New companies have registered with the Health Education Trust’s Real Choice healthy vending scheme: see www.healthedtrust.com/pages/realchoice for further details. Food in hospitals The above seminar papers have just been published, and are available to order now. The Westminster Diet and Health Forum (WDHF) seminar papers contain the text of all speeches made, together with transcripts of the Q&A sessions, and additional articles from interested parties.

Food in Hospitals discusses progress in hospital food service since the implementation of the ‘‘Better Hospital Food’’ programme, and aims to share best practice and move forward thinking on improving patients’ experience. Issues discussed include the role of food in treatment and recovery, progress in hospital nutrition and the future of hospital food, with a focus on practical solutions including the introduction of snacks, upgrading food for visitors and staff, and improvement of menus and supply chains. If you would like to order copies of the briefing papers, please contact us again via [email protected]. MEND The MEND programme is a family-based prevention and treatment programme for obesity, aimed at children aged 7–12 and their parents/carers. MEND emphasises practical, hands-on learning about healthy living and exercise, expressly designed to deliver sustained improvements in families’ diets, fitness levels and health – for life. The randomised control trial is currently averaging an attendance rate of 92 per cent across five sites – largely due to its relevance to the everyday lives of participants, the research-based design of the 18 6 2 hour sessions and the fact that it is fun. A high level of interest in implementing the MEND programme is from PCTs, Local Authorities and other local or national bodies – either as a pilot or, in some cases, as a multi-year multi-site implementation for hundreds of families (in fact we are starting one such project in May). This is despite, or possibly because, of the current tightening of budgets in the NHS. One of the major benefits of the MEND programme is that it is a relatively straightforward way to implement a multidisciplinary/agency intervention cost-effectively. Our ‘‘train the trainer’’ approach, coupled with the detailed trainers’ manual, allows a number of people to devote a small portion of their time, e.g. one hour per week, to the project thus minimising impact on people’s stretched time and finances. The detailed training and manual also allow non-specialists to become trainers, further reducing the costs. It does not need a large team or even full-time attention from one person. Where Choosing Health money has been retracted or reduced and a full obesity team cannot be put in place for some time MEND allows PCTs to begin to make immediate progress towards their PSA targets. In addition MEND can be deployed as both a treatment and a prevention. MEND programme, 3rd Floor Norvin House, 45–55 Commercial Street, London E1 6BD, United Kingdom. www.mendprogramme.org Randomized control trial (RCT) The multi-site RCT being conducted into the efficacy of the MEND programme as an obesity treatment programme for children is continuing at the Institute of Child Health, University College London. At the end of May, we will have 6-month data on 92 families and will begin the analysis and write-up of the RCT results. The RCT will continue to run after May, with additional children’s data being added to the sample, and with additional follow-up assessments being conducted on all the children at 6 and 12 months. We believe that this RCT will constitute one of the largest sets of data on a community child obesity intervention in the UK. While we are not permitted to release any comparative data between control and intervention groups from the RCT prior to completion (i.e. not before June/July), I have

Food facts

367

NFS 36,5

368

attached a slide containing some preliminary results from 41 children who have completed the MEND programme intervention. Statistically significant results were achieved in most of the key outcome measures, including BMI reduction and waist circumference reduction (see attached). A notable point to mention is that across all five sites participating in the RCT, over a period of a year, only 3 of the 92 children recruited dropped out. This, combined with an overall mean attendance rate of 92 per cent is both impressive and unusual in such a long programme (ten weeks; twice weekly for two hours). Furthermore, we were pleased to see that these preliminary results show very similar health improvements to the successful results achieved on MEND’s initial research pilot, conducted in 2002–2003. MEND rolls out across PCTs in London, Suffolk, Essex and Northamptonshire We continue to receive a significant amount of interest in the MEND programme from PCTs, Local Authorities and other local partners looking to implement obesity treatment (or prevention) programmes. (It is important to note that while the RCT is focusing on treatment of obesity, the MEND programme is also suitable for use as a prevention programme, as it is expressly NOT a diet but rather a healthy lifestyle programme teaching children and parents about sustained behavioural change, healthy eating and the benefits of exercise). MEND is currently running at two sites in Lewisham (London) and in Southwark (London) and Waveney (Suffolk), with new programmes anticipated to start Essex, London and Northamptonshire in May. Many other PCTs are in active discussions with us about implementing MEND in their local areas. (See ‘‘Private sector sponsorship’’ below for details of more programmes running and starting in May.) PCTs and LA’s are pursuing varying strategies in relation to rolling out MEND at the moment. Some are engaging in quite extensive multi-year programmes involving multiple sites and total numbers of families covered in the 60–300 range. Others, (often due to budgetary constraints) are initially implementing MEND on a pilot basis (12–15 families) as a starting point to develop an evidence base, with the idea to then use this evidence base to substantiate funding for a more comprehensive roll-out thereafter. Based on feedback we have been getting from PCTs running the MEND programme, it is becoming increasingly evident that that the key differentiating attributes of the MEND programme as an obesity solution (as compared to other locally-administered obesity programmes) are: N Statistically significant results achieved in key outcome measures such as BMI, Waist circumference and cardiovascular fitness. N Recruitment of children and families has been relatively straightforward. Indeed, programmes are often over-subscribed. N Very high retention and attendance rates: Average attendance and retention achieved on MEND programmes completed to date is 92 per cent with only three drop-outs. N Quality-assurance and standardisation: The MEND teaching manual consists of almost 300 pages, comprising 18 structured sessions, all of which are lessonplanned, contain plenaries and are accompanied by multiple handouts to reinforce key messages. MEND trainers are also required to go through four

days of MEND training and satisfy a test of knowledge before being approved to run the programme.

Food facts

N External monitoring and evaluation: MEND analyses the measurement data collected on the programme and reports the data back in concise, statistical reports, providing the requisite monitoring and evaluation required to justify (further) results-based funding. It is interesting to note that PCTs are being very creative how they go about financing MEND in the current climate of budgetary pressure and uncertainty combined with a lack of ring-fenced obesity funds. They often engage in multi-agency collaboration with Local Authorities, local leisure centres and schools, and tap into a combination of different funding sources, including, for example – pump prime funding through LPSA/LAA stretch targets for obesity; using obesity training money to pay for the training element of the MEND costs; combining Choosing Health money and Health Inequalities money to fund MEND (since the incidence of obesity has been shown to be higher in areas of greater social deprivation), tapping into NRF and NDC funding in areas of social deprivation, etc. If you are interested in running a MEND programme in your area, we would be pleased to facilitate a brainstorm on this issue and provide you with examples of innovative practice. MEND as a practical and cost-effective means to achieve the government’s PSA target ‘‘Tackling child obesity – first steps’, the joint report by the National Audit Office, the Audit Commission and the Healthcare Commission warns that there is a risk that the Government’s target to halt the rise in obesity in under-11s will not be met. The research-based MEND programme has been specifically developed to ensure that it can be rolled out rapidly and cost-effectively in a standardised manner – it is literally a ‘‘solution in a box’’. It is this investment and its multi-disciplinary nature that allow rapid implementation. Multi-agency working can be fraught with difficulty and frustration, especially if the solution has to be invented by the team before it can be delivered. However, MEND allows you to bypass this due to the clarity of its training materials, including a 300 page manual with 100 handouts per participant. In Waveney, Suffolk, the Public Health Clinician said, ‘‘Everyone gave a little bit to deliver the whole Programme, yet it met everybody’s individual targets’’. The 2 6 2 hours per week Programme was delivered by two PE teachers from Education, one Counsellor from Social Services and a Nutritionist and a Dietitian from the PCT, each contributing about an hour per week – a case-study of multi-agency good practice. MEND believes strongly that the private sector bears the same responsibility as the public sector in being part of the ‘‘solution’’ to the obesity crisis and to financially supporting community-based programmes like MEND that will allow as many families as possible nationwide to benefit from learning about how to bring about long-term improvements in their nutrition, fitness and health. In this respect, we will continue to work to secure private sector sponsorship for MEND. MEND receives positive feedback from government departments, agencies and the charitable sector In recent months, we have had positive and encouraging cross-departmental policy discussions with senior officers leading on obesity at the Department of Health, Department for Education and Skills and the Department for Culture, Media and

369

NFS 36,5

370

Sport, who have expressed great interest in MEND and community-based obesity programmes like MEND. Furthermore, positive discussions have been held with senior Healthy Schools representatives, and Sport England has indicated a willingness to match-fund an emerging MEND project being planned for East London. MEND has received endorsement from The Obesity Awareness and Solutions Trust and has had discussions with several charities regarding the possibility of engaging in (further) joint research into obesity and obesity-related illnesses and is also engaging in the current public consultation on NICE Guidelines regarding child obesity. Consistently positive feedback received from children and parents who have been on the MEND programme Please take a look at the attached testimonials for examples of the type of representative feedback that both children and parents/carers consistently give us about their experiences both on (and, more importantly, several months after) the MEND programme. We believe strongly that it is much more powerful to hear directly from the beneficiaries themselves, in what ways they feel they have benefited from MEND, than anything we could say. New services N Obesity management solution. We are increasingly being asked by PCTs about the possibility of being able to offer MEND as a managed solution – i.e. where MEND would employ and provide the staff and run the programme for you, as well as do all the recruiting, assessments (pre and post) the programme and the monitoring and evaluation, thereby negating the need for any internal PCT management time or resources to implement MEND. We are able to offer this to those interested although we would strongly advise that this is not generally the best solution – it is preferable, where finances allow, to train local staff to run a/ several MEND programme(s). N One-day obesity training for health-care professionals (HCPs). At the request of several PCTs seeking to invest their obesity training funds in the most meaningful manner, we have created a one-day obesity training session for training front-line staff/HCPs on obesity (see attached outline). The training incorporates and explains the current guidelines contained in the Department of Health’s Obesity Care Pathway Booklet as well as ‘‘Measuring childhood obesity: guidance to primary care trusts’’. In addition the training provides knowledge and a selection of practical insights learned from the MEND Pilot Study as well as the current MEND RCT. The cost for this is £50 per person for up to 30. Weight management The Weight Management Guide has now been finalised and launched at: www.weightmanagementguide.co.uk IFST The IFST has re-launched its website (www.ifst.org). The new-look site has been completely rewritten and rebuilt using a content management system to provide improved functionality and navigation. The website will provide many extra facilities

such as easy access to information services, on-line membership application and publication ordering via the online shop. An additional feature is the exclusive Member Only area which will provide many new services including:

Food facts

N downloads including the latest keynote and food science and technology meetings; N a young members’ area which includes information on employability skills, exam techniques, graduate recruitment and revision techniques amongst many others; N facilities to update your membership details and pay your subscription online.

Water for health Two new key Alliance members join the work to improve hydration, Sport Relief 2006 has water at its heart; water as a basic nutrient; tap water at conferences and bottled water in Governments; community initiatives from regional water companies. Royal College of Nursing join Alliance Building on the Water for Health Alliance work to improve hydration in NHS hospitals, we are delighted to advise that the Royal College of Nursing have now joined the group, and they will be active in building and promoting the message of good hydration to patients and to staff. The RCN represents nurses and nursing, promotes excellence in practice and shapes health policies. They lobby governments and others to develop and implement policy that improves the quality of patient care, and builds on the importance of nurses, health care assistants and nursing students to health outcomes. Provision of fresh drinking water is an important part of their approach to good health and nutrition, and RCN believe water can contribute positively to patient recovery. www.rcn.org.uk Consumer Council for Water join Alliance The Consumer Council for Water (CCWater) has joined the Water for Health Alliance, bringing with them very welcome direct representation for the many consumers in England and Wales. CC Water is independent of both the water industry and its regulators, and its Chair is respected health professional, Dame Yve Buckland. CC Water advise that ‘‘Water is a valuable and precious health resource for society, and having water on tap – a safe, secure, reliable supply of water – is absolutely essential for maintaining a healthy lifestyle, and a wholesome diet’’. CCWater are very active in ensuring that customers are empowered with the information they need, to be able to demand the best value from their water suppliers. They advise that ‘‘Helping consumers to recognise the important health benefits of their water supply, and promoting the significance of remaining well hydrated throughout the day is central to this work.’’ www.ccwater.org.uk Water a key partner of Sport Relief 2006 The 2006 Sainsbury’s Sport Relief Mile is about to be launched by the BBC and Comic Relief, supported by many of the UK’s top celebrities, sports stars and comedians. As

371

NFS 36,5

372

part of the Water for Health work, the UK water industry has joined together to become a partner to the event, and tap water is now the official drink of this high profile occasion. In 2004, 81,000 people donned a single red sock and took part in the first ever Comic Relief led Sport Relief Mile. It incorporated 14 national and 125 local events, raised 5 A316 million, involved 253 celebrities and attracted 8.2 million viewers to the Sport Relief programme on the BBC. The people who went the extra mile on the day included Prince William, and Prince Harry, Prime Minister Tony Blair, Sir Steve Redgrave, Jonathan Ross, Dame Tanni Grey Thompson, Frank Bruno, Chris Moyles, Rachel Stevens, Gordon Ramsay, Jo Brand and many, many more. This year’s Sainsbury’s Sport Relief Mile will be even bigger, with 15 BBC televised events across the UK, 200,000 registered participants and UK wide support from personalities. Water and all the positive health messages of good hydration will be featured prominently in the Promotional material, water companies will provide fresh tap water to each televised flagship event, tap water will be provided to the related TV programmes such as Ready Steady Cook, Blue Peter and A Question of Sport Relief and the health benefits of drinking water will be endorsed by high profile celebrities who have fully backed the work to improve the nations health. Past beneficiaries of funds raised by Sport Relief have included Water for Health Alliance members WaterAid and Action on Elder Abuse. www.sportrelief.com Scottish Water leap the water hurdle Lee McConnell, the UK’s number one four hundred metre sprinter is backing the Scottish Water ‘‘On Tap’’ campaign for Scots to drink more tap water. Underlining the importance of drinking enough water, she advises ‘‘As I have a degree in Sports Science and Nutritional Management I am very aware of what is and isn’t good for me. Drinking the right amount of water helps keep you hydrated and keep concentration and energy levels at their peak. Drinking water is so important to everyone, but as an athlete it’s vital. Your muscles need to be well hydrated at all times to make sure they function properly and when you’re training and sweating you need to make sure that you replace the fluid you’re losing. But, you don’t have to train like a professional athlete to achieve a healthier lifestyle. Everyone can help boost their memory and energy levels with the turn of the tap.’’ http://www. scottishwater.co.uk ‘‘Wise up on Water’’ medical evidence leaflets now available direct Water for Health Alliance members have been contacting Water UK recently to ask how they can get printed copies of the ‘‘Wise up on Water’’ leaflets, and also the brand new Hydration Best Practice Toolkit for Care Homes to use at their conferences, meetings and to support their policy work. Having investigated the requirements of the Alliance, Water UK has developed two methods of obtaining the literature. All documents are now available to download free of charge from the Alliance website www.waterforhealth.org.uk/ and conference teams can simply download what they need for delegate packs, meetings etc. Water Aid ‘‘Drink More Water’’ Campaign Committed Water for Health Alliance supporters, Water Aid, are continuing to raise the profile of the important links between good hydration and good health through

their ‘‘Drink More Water’’ campaign. The excellent initiative is actively encouraging UK companies to promote tap water provision for the health of their employees in the workplace, and to use that educational platform to raise money for those who have no safe water provision at all. In support of the latest part of this campaign, Bodyshop founder Anita Roddick says ‘‘Water is elemental, life-giving and sustaining. It flows out of our taps so easily that we rarely give it a second thought, yet many of us do not drink enough. Water really does help you at work, rest and play – for our health and beauty what could be simpler than to drink more water?’’ The developing WaterAid work can be seen www.wateraid.org/uk/get NHS Direct hydration advice on line The NHS internet and telephone advice service has increased its advice on the subject of hydration www.nhsdirect.nhs.uk NHS Good Practice in Continence Services For carers, incontinence is sometimes the last straw and is often a major reason for the breakdown of the caring relationship which can then lead to admission to residential or nursing home care. Often dehydration can play a major part and increase the likelihood of soiling incidents, as concentrated and highly acidic urine is expelled automatically by the body. NHS has issued its latest guidance for best practice in continence care and it reinforces the important role of the ‘‘Availability of accessible, clean, fresh-water drinking facilities’’ The full information is available from the NHS response line 0541 555 455. Scotland increase water provision for oral health In its Action Plan for improving oral health and modernising NHS dental services, the Scottish Executive has again increased its focus on healthy fluids and its expectations are that by 2007 NHS and Local Authorities should expand oral health programmes to ensure that ‘‘All schools have supporting healthy eating and drinking (water) policies’’. The Executive have already increased children’s access to fresh drinking water by 600 per cent, and have funded improved water facilities through increases in the school meal funding system. Further information on the guidance can be seen by ordering ISBN 0-7559-4557-8. Office of the Deputy Prime Minister swing to tap Just before Christmas, the ODPM/MITIE launched a re-usable bottle scheme for the water provided at official Government meetings. General guidance within Government offices is now to move away from bottled water, although while this particular scheme has both financial and environmental benefits, ODPM has recently advised their staff that these are not being met because bottles are going missing or are not being returned after use. Details of the scheme can be obtained from Andy Barnes [email protected] Netherlands say ‘‘Neau’’ to expensive bottled water Sold as an empty bottle, that requires the buyer to fill it up from their own tap, there is a new brand of water in the Netherlands that is rapidly making a name for itself. Neau is positioning itself explicitly against the bottled mineral water trend by advertising

Food facts

373

NFS 36,5

374

the fact that Netherlands tap water is of renowned and excellent quality; and tastes good. And that is exactly the crux of Neau, says Menno Liauw, of Amsterdam-based advertising bureau Vandejong and Stichting Neau (the Neau Foundation). ‘‘Neau is being sold in empty bottles that you can fill with drinking water, over and over, as often as you like,’’ he explains. The Neau brand has a dual effect: It makes people conscious of the worldwide water problem, and its revenues are spent in drinking water projects in underdeveloped countries in Africa, Vietnam, Peru, and other poor parts of the world. These drinking water projects are being coordinated by wellknown Dutch charity organizations like Unicef Nederland and Plan Nederland, with whom Neau cooperates. Neau is being sold in the form of a firm, clear blue plastic bottle at the price of regular mineral water. However, the bottle is empty. Instead of water it contains a rolled-up Neau flyer, a message in a bottle that explains Neau’s position. Liauw explains. ‘‘When you drink a bottle of Neau,’’ he continues. ‘‘You indirectly provide a refugee camp in Sudan with seventeen litres of clean drinking water.’’ Tap water offered at all future conferences? Following a recommendation from the last Water for Health Alliance meeting, the Chartered Institute of Environmental Health, UKPHA, Water UK and an active Primary Care Trust are now working together to develop guidance for conference organisers to have fresh, iced tap water served at conferences. Many organisers have either been pressured in to buying large volumes of bottled water, or have simply felt they do not have the option of tap at large commercial venues. In practice many venues are very happy to meet the needs of their clients as long as they fully understand what is required of them, and the implications of not simply providing pre packaged water. Where venues do not offer tap water, or advise that they can not, a little effort can see this turned round. Campaigner of the month award goes to UKPHA Chief Executive and Water for Health Alliance supporter Angela Mawle for an incredible job in getting tap water supplied across their huge national conference in Telford recently. In the face of many dubious objections by the venue owners, Angela pursued the point on the grounds of sustainability, good hydration and the protection of public health – and eventually had the entire event served with iced tap water. Angela has inspired us all to build ‘‘iced tap water’’ into our conference contracts from the start and insist on it at the point before we place the order. Fresh water for delegates at Bournemouth Care Conference Following an invitation from Alliance members, the National Association of Care Catering, Water UK spoke on the importance of hydration at the Care Home Conference and local water supplier Bournemouth and West Hampshire Water provided a tap water tasting for all the delegates. Fresh tap water was consumed in large quantities and received excellent feedback on the taste, as the Bournemouth Water Company innovatively served it to delegates directly within the main auditorium. The team encouraged people to adopt water as part of healthy nutrition and offered side servings of freshly prepared strawberry’s, pineapple, oranges and melon. www.bwhwater.co.uk Thames Water bring hydration to older people in Nunhead Thames Water have been working in partnership with Age Concern Southwark to promote the Nunhead Healthy Ageing Centre to people living in the local area. At a

recent launch event, Thames hosted an open day, inviting local residents aged 55 and over to attend activities including exercise classes, a sing along with the Pearly King and a ‘‘talk and walk’’ presentation by the Southwark Primary Health Care Trust aimed at promoting the benefits of walking for exercise. Water was made available throughout the day and local residents were given encouragement to take on board the health benefits of drinking more fluid. The main aim of the open day was to encourage people to make greater use of the valuable services provided by Age Concern, and to raise awareness of the importance of healthy ageing, in particular the benefits of drinking water for good hydration. www.thameswater.co.uk Top Chef says ‘‘water is an important part of nutrition’’ Top chef and restaurateur Anthony Worrall Thompson has agreed to support the objectives of the Water for Health Alliance, and has kindly given the work a supporting statement to help encourage people to ask for tap water when the eat in restaurants and cafes. He advises that ‘‘The way we give our customer’s an enjoyable dining experience is to give them what they want – we wouldn’t have any problem in serving fresh tap water in our restaurant, and we have done so for years. Water is an important part of good nutrition, and drinking enough each day is an essential ingredient for a healthy life’’. Alliance members are working hard to give the public the knowledge and confidence they will need to simply ask for tap water with their meals, and to help overcome their beliefs that they will be frowned upon if they choose not to order bottled water. More supporting statements will follow as UK chefs endorse the health drive. Nutrition for Life says ‘‘Get in to the habit of drinking water’’ ‘‘Nutrition for Life’’. In its pages it advises that water is an essential part of the diet, the best drink to quench thirst and that we all need to drink six to eight glasses of water each day, with more when it is hot or when we are exercising. The diet manual advises on the high quality of UK tap water and ensures that readers understand the importnace of water to the body. ‘‘Involved in every function of the body, water controls body temperature; gives you energy, assists in weight control....and is needed for all digestive, absorptive, circulatory and excretory functions’’. ISBN 1-4053-03069520. Northern Ireland MP ‘‘flabbergasted’’ over bottled water bill The Northern Ireland Office has landed itself in hot water after admitting spending a significant on bottled water in the last year. Severn Trent aid bottle water purge at Council Thanks to the Alliance members for the BBC report (20 February 2006) that a purge on lunch time perks at Gloucestershire County Council has so far seen the taxpayers’ bill for county councillors’ lunches’ fall by two-thirds. Councillor Barry Dare, leader of Gloucestershire County Council, said the drop was thanks to several measures introduced by the Tory administration. ‘‘Since the Conservatives took control we have banned free lunches for councillors and are looking to change council rules to prevent councillors claiming expenses for lunches. We are also working on replacing bottled water with tap water at council meetings – which should save even more money.’’ Director of customer relations at the water provider Jonathan Bailey said using tap

Food facts

375

NFS 36,5

water saved the taxpayer thousands. ‘‘It would cost 73p a year for a person to drink eight glasses of Severn Trent water a day.’’

376

Oh! Sushi An observant Alliance member sent in this web consumer feedback contribution criticising the well known Sushi Company for its bottled water charges in restaurants. The clearly irritated customer advised ‘‘The food was fair value for money. What infuriated me was that you charge for still or carbonated filtered tap water. I didn’t see that there was a charge, until I came to pay the bill. If I went into a restaurant and asked for a jug of tap water I would not pay for it under any circumstances’’. Ofsted on Healthy Eating in Schools As preparation for a major survey of food in schools to be carried out in 2006/07, Her Majesty’s Inspectors of Schools (HMI), accompanied by nutritionists appointed by the Food Standards Agency (FSA), undertook a small scale survey, including visits to ten schools from clusters of primary and secondary schools in three local authorities. It notes the success of introducing drinking water in to the top performing schools, but fails to draw the obvious conclusions in its summary. The report also fails to link the expectation of the Secretary of State that free, fresh water should be provided, with the fact that in many schools it is simply not available. Additional evidence was gathered from over 50 reports of school inspections that had been conducted under the new framework for inspection, from reports on personal, social and health education (PSHE) and from reports on schools visited as part of a survey on learners. health and well-being. The report assesses how schools have responded to guidance on school meals and healthier eating. It uses case studies as examples of how schools have improved pupils’ healthier eating and the quality of school meals Primary Schools www.ofsted.gov.uk/publications Food Technology in Secondary Schools www.ofsted.gov.uk/publications Parliamentary Questions on water in the schools Paul Burstow MP has asked the Secretary of State for Education and Skills: pursuant to the answer of 14 December 2005, Official Report, column 2,074 W, on drinking water, whether she plans to issue guidance to schools on drinking water provision in relation to the aims of her healthy schools policy. Jacqui Smith responded: In order to keep properly hydrated throughout the day, children need access to water at school. The promotion of good hydration is included within the Government’s Food in Schools programme (www.dh.gov.uk/PolicyAndGuidance/ HealthAnd SocialCareTopics/FoodInSchools), which supports the National Healthy Schools Standard (www.wiredforhealth.gov.uk). It advises that good quality drinking water should be available to pupils throughout the day and not from taps or drinking fountains located in toilet areas (http://foodinschools.datacenta. uk.net Care Directions Care Directions has written to advise the Alliance that, as an internet’s guide to care and the rights of older people, they are now publishing the hydration message for older people. They say that gradual, steady loss of body water is a factor of ageing

and older people do become dehydrated more easily. Dehydration can then be a major complicating factor of illness and can have a negative effect upon recovery prospects. Fear of the likelihood of urinary incontinence and the need for visits to the toilet, will also mean that many older people will be reluctant to drink as much as they should. This frame of mind is, of course, made worse when diuretic medications (‘‘water tablets’’) have been prescribed. Care Directions advise that whatever the reluctance to drink, the effort really must be made. Water intake is vital, as dehydration can result in illness, mental confusion, and can speed the ageing process generally. Care Directions recommend that older people should drink at least eight cups of fluids a day. It is worth noting that tea, coffee, fizzy drinks or worse, alcohol, actually contain dehydrating agents. They advise older people that for every alcoholic drink you consume, you will lose the same volume of water from your body. www.caredirections.co.uk Water related malnutrition in care Water for Health Alliance members, The English Community Care Association, has welcomed the National Institute for Clinical Excellence’s latest guideline on tackling malnutrition in the NHS, but wants to ensure that there is a properly co-ordinated approach between NICE and CSCI who are the body responsible for regulating care services. The National Institute for Clinical Excellence (NICE) and the National Collaborating Centre for Acute Care have launched a clinical guideline to help the NHS identify patients who are malnourished or at risk of malnutrition. It recommends that all people in care homes should be screened on admission and when there is clinical concern. It also recommends that all healthcare professionals who are directly involved in patient care should receive education and training on the importance of providing adequate nutrition. ECCA advised NICE that the training and education could benefit from the hydration toolkit for care homes produced by the Alliance. The toolkit provides fact sheets, checklists and advice to enable care homes to improve water consumption with older people and care home staff. ECCA said ‘‘ECCA members strive to provide high quality care and nutritious food. Malnutrition is a complex issue and although the NICE guideline is welcome, it is essential that CSCI inspectors have the relevant training and experience to examine malnutrition on a case by case basis rather than a statistical basis which may not allow for differing circumstances’’. Fresh tasting water Three Valleys Water Company has advised us of their guide to ensuring that the public in their region continue to get great tasting tap water. Keep your water tasting fresh covers everything from household plumbing to chilling water in the fridge. www.3valleys.co.uk/pdf/water_tasting_fresh.pdf Health Professions Council The Health Professions Council (HPC) consulted on proposals for a new ‘Returners to practice’ process from 1st July 2005 until 9th September 2005. When all the responses were received (49 responses from organisations and 17 from individuals) they were analysed and assessed in order to draw out the key themes. As part of the consultation process, the HPC also investigated the various approaches taken by other regulators.

Food facts

377

NFS 36,5

378

Article 19(3) of the Health Professions Order 2001 allows the HPC to, require persons who have not practised for or during a prescribed period to undertake such education or training or to gain such experience as it shall specify in standards... The inclusion of the phrase ‘‘in standards’’ means that the HPC cannot carry out individual assessments of returners’ requirements. The standards can make different provision for different classes of returner. The following decisions have been made with regards to those returning to practise after a period ‘‘out of practice’’: Health professionals who have been out of practice will be required to complete a period of updating before they can come back onto the register. They should complete this period before they apply for ‘‘readmission’’. The period required are as follows: N 0–2 years out of practice: no requirements; N 2–5 years out of practice: 30 days updating; N 5 or more years out of practice: 60 days updating. For further information about the consultations, please contact Rachel Tripp on 020 7840 9760 or email [email protected] Snacks and drinks www.swipevending.com There you will find comparisons and analysis of the nutritional value and ingredients of popular snacks and drinks vended in the UK. Cholesterol lowering cheese Fayrefield Foods, the UK’s largest independent dairy company, is launching heartfelt+, a fully flavoured 12 per cent fat cheese, in the UK. Heartfelt+ cheese has been specifically developed to help people who want to lower their cholesterol and maintain a healthy diet, while continuing to enjoy the taste of cheese. Heartfelt+ contains ReducolTM, a well established and clinically proven ingredient for lowering cholesterol safely and naturally. Reducol is a unique ingredient containing plant sterols and stanols, which was developed by the Canadian company, Forbes Medi-Tech Inc. Reducol is incorporated into foods such as milk, spreads and yoghurts, to offer cholesterol lowering benefits to consumers who want to continue to enjoy those products. It is supported by numerous reviewed clinical studies (see www.reducol.com) and is supplied to manufacturers as an odourless, tasteless powder that contains no fat, protein or carbohydrates. The combination of a prudent diet and consumption of products containing the recommended amount of Reducol may help consumers to lower their cholesterol by up to 24 per cent. HPC introduce CPD The Health Professions Council (HPC) will require all health professionals on the Register to undertake Continuing Professional Development (CPD) from 1st July 2006. This will now be a legal requirement for the future registration of 170,000 health professionals across the UK. The first audit of these standards will take place in July 2008 with chiropodists and podiatrists being the first profession to be audited, followed by operating department practitioners. The 11 other professions currently on the HPC register, will be audited during 2009/2010. The standards mean that health professionals will have to provide evidence of CPD relating to their previous two years of practice from summer 2008. The evidence will

have to show that the CPD an individual has undertaken has contributed to the quality of their practice and demonstrates that it benefited the service user. The standards apply not only to those in clinical practice, but also to those working in research, management or education. Speaking about the CPD standards, Professor Norma Brook, President of the Health Professions Council said: ‘‘This is an important event in the development of self-regulation. We believe that it is a vital part of our basic function, which is to protect the public, that we require individual registrants commit themselves to their own professional development and that employers, too, recognise the importance of CPD. We will therefore be requiring all of our registrants to undertake CPD and be seeking to ensure that the CPD carried out by our professions is robust and effective. ‘‘The HPC offers a clear framework with flexibility at the centre of our decisions, but CPD will be the responsibility of the individual.’’ The Health Professions Council is an independent, UK-wide health regulator set up by the Health Professions Order (2001). Hospitality Leadership Excellence Survey The 2006 Hospitality Leadership Excellence Survey. This involves conducting indepth interviews with up to 25 of the top leaders in the UK hospitality industry to identify how they approach their leadership role and what makes them so successful. The Chartered Management Institute recently asked over 1,000 mid-ranking managers what they thought about their work. The respondents, more than 40 per cent of them women, came from a mix of private and public sector companies and organisations, including some industry big players. Nearly 80 per cent felt that a major influence on job satisfaction for managers was to have autonomy. It was clear from the research that senior managers who give their junior colleagues a free hand are those that are respected. http://www.hospitalityleadership.com New standards for school food The new standards for school food were announced on Friday 19 May. This is a robust set of standards which will make an important contribution towards improving our children’s health. You can view them on the DfES website: www.teachernet.gov.uk/wholeschool/healthyliving www.schoolfoodtrust.org.uk FSA meeting The FSA board meeting was in Bristol on 15th June. You might like to see agenda papers on eating for health strategy. http://www.food.gov.uk/news/newsarchive/2006/jun/bristol 4th International School Milk Conference The full conference programme is available on internet: http://www.schoolmilksa. co.za/ Time permitting, all delegates will be encouraged to participate in the conference by: making a country presentation; making a presentation on a specific school milk related issue; having a poster/display presentation. See the registration form for details.

Food facts

379

NFS 36,5

380

MIP MIP Technologies has just brought out a highly innovative way of detecting the presence of beta-blockers in water using molecularly imprinted polymers separation technology. N A wide variety of pharmaceutical compounds have been detected at low levels (10–400 mg/L) in aquifers, sewage treatment plant effluent, and rivers in several areas of Europe, that could pose a threat to living organisms. N Often the improper disposal of unused or expired pharmaceuticals leak out of landfills and infiltrate water supplies. N Pharmacokinetic studies have shown that more than half of all pharmaceutical compounds consumed are excreted unchanged from the body into wastewater. These compounds can potentially survive sewage treatment systems because of their high stability against biological degradation. While the potential effects of these compounds on humans and aquatic organisms are unknown, a method of detection would be the first step in the investigation toward defining the potential risks.

Book reviews

Book reviews Micronutrient Deficiencies in the First Months of Life Francois M. Delange and Keith P. West Jr Karger-Nestle Nutrition CV 4358

381

This is a very specialised book consisting of a series of papers on international studies on micronutrients and infants. It would be of assistance to those studying in this area or developing products for use in infant feeding.

Weight Matters for Young Children Rachel Pryke Radcliffe ISBN 1-85775-772-6 Obesity is a major problem for children and young people and with approximately 30 per cent of children being overweight and obese, help in dealing with it is important. Throughout this book, guidance is given for helping young people take responsibility and work at helping themselves with various strategies to lose weight. It will be useful for anyone dealing with overweight young people.

Nutritional Support For Adults and Children – a Handbook for Hospital Practice Edited by Tim Bowling Radcliffe ISBN 1-85775-831-5 Nutritional support is critical in times of trauma and serious illness. This is a very specialised book giving very clear guidance on how to feed patients and procedures. It is an excellent resource for specialists such as dietitians in this area.

E

Nutrition & Food Science Vol. 36 No. 5, 2006 p. 381 Emerald Group Publishing Limited 0034-6659

NFS 36,5

382

Conference reports Hospital Caterers Association National Conference April 2006 The Hospital Caterers Association held its Annual Conference in April 2006 at the Hilton Birmingham Metropole Hotel on the National Exhibition Centre Campus. This year the member organisations of Healthcare Caterers International (HCI) attended the Conference. The association was delighted to host HCI’s 2nd International Symposium which this year focused on nutritional care. The main topic of the symposium was on dysphagia. The conference included a large exhibition of more than 60 food and equipment suppliers which was open and free of charge to non-delegates on Thursday 27 April 2006 from 10.30 am to 4.00 pm. For further information, please contact www.hospitalcaterers.org Chartered Institute of Environmental Health (CIEH) The CIEH has produced a new level 2 qualification in Nutrition. This is a short course culminating with an examination and covers a basic level of nutrition. It is organising various training seminars around the country for trainers who wish to deliver the course as well as providing course books and trainers’ notes and information. More information is available at: www.cieh.org/events or call the events department on 020 7827 5856

Nutrition & Food Science Vol. 36 No. 5, 2006 pp. 382-383 Emerald Group Publishing Limited 0034-6659

E

Westminster Diet and Health Forum Consultation Seminar: Food Promotion to Children Timing: morning, 1 June 2006; venue: Westminster, SW1 This meeting brought together key stakeholders to discuss Ofcom’s consultation on food advertising to children. Timing of this seminar was arranged with Ofcom to tie in with their consultation. Its purpose was to provide an opportunity to share opinions and to help move forward thinking in this area. The discussions were reported in a policy briefing document – an extremely important output from the day. This publication contains transcripts of all the speeches and comments made during the day, together with further articles submitted by interested parties. It was distributed to the key figures deciding policy in these areas in Government and Parliament, as well as to all delegates. Ian Blair, who is leading the consultation for Ofcom, agreed to take part, together with Rosemary Hignett, Head of Nutrition Division at the Food Standards Agency. Claire Phillips, Director of Policy and Research at the Office of the Children’s Commissioner, gave a keynote address. Other speakers included: Andrew Brown, Chairman, Broadcast Committee of Advertising Practice; Malcolm Earnshaw, Director General, Incorporated Society of British Advertisers (ISBA); Trish Fields, Consumer Impact Director, Cadbury Schweppes; Richard D. North, Media Fellow, Institute of Economic Affairs; Kate Stross, Commercial Director, Ofcom; and a senior representative from Which?.

Attendees, invited from the contacts of both the Westminster Diet and Health Forum and the Westminster Media Forum, were a senior and informed group numbering over 100, including members of both Houses of Parliament, officials involved in this area of public policy and representatives of industry, the food, healthcare, media and advertising sectors, interest groups, consumer groups and academia. The Westminster Diet and Health Forum, and its sister forum the Westminster Media Forum, are impartial and cross-party, and have enjoyed considerable support from within Parliament and government. They organise senior level seminars on public policy in nutrition and health, and media, which receive prominent coverage in the national and trade media. The Forums have no policy agenda of their own. For more information, please contact www.dietandhealthforum.co.uk Vitafoods International 9–11 May, Geneva PALEXPO Vitafoods International was held again in Geneva. This exhibition had 50 companies exhibiting the latest products in the dietary supplement, functional food and functional drinks industries. There were also 350 exhibiting companies organised into seven international pavilions which made it a truly global event. For more information, please contact Charlie Hastings, Marketing Director, Vitafoods International.

Conference reports

383