nutrition, health and schoolchildren

BRIEFING PAPER

Nutrition, health and schoolchildren

E. Weichselbaum and J. ButtrissBritish Nutrition Foundation, London, UK

Summary1 Nutritional requirements of schoolchildren2 Findings of the National Diet and Nutrition Surveys3 Physical activity in schoolchildren4 Nutrition, physical activity and health in childhood

� 4.1 Overweight and obesity� 4.2 Cardiovascular risk factors� 4.3 Iron deficiency anaemia� 4.4 Oral health� 4.5 Bone development� 4.6 Food allergy and intolerance� 4.7 Mental health

5 Factors affecting food choice6 Food provision in school7 Food in the curriculum8 Promoting healthy lifestyles in children• Acknowledgements• References

Summary Healthy eating and being physically active are particularly important for childrenand adolescents. This is because their nutrition and lifestyle influence their wellbe-ing, growth and development. The nutritional requirements of children and ado-lescents are high in relation to their size because of the demands for growth, inaddition to requirements for body maintenance and physical activity. Data from theNational Diet and Nutrition Surveys (NDNS) show that the contribution of proteinto food energy intake has increased between 1997 and 2008/2009 in both boys andgirls aged 4-to-18-years. The contribution of fat to food energy intake has decreasedin boys and girls aged 4-to-10-years, and in boys aged 11-to-18-years; saturatedfatty acid intakes have decreased in boys and girls of both age groups. A decreasein the contribution of non-milk extrinsic sugars to food energy has been found inthe younger age group, whereas it has hardly changed in the older age group. Themost recent NDNS data (Year 1 of the NDNS Rolling Programme) on micronu-trient intake showed that low intakes of almost all minerals and vitamin A in boysand girls in the older age group, and also of riboflavin and folate in girls in the older

Correspondence: Dr Elisabeth Weichselbaum, Nutrition Scientist, British Nutrition Foundation, High Holborn House, 52–54 High Holborn,London WC1V 6RQ, UK.E-mail: [email protected]

© 2011 The AuthorsJournal compilation © 2011 British Nutrition Foundation Nutrition Bulletin, 36, 295–355

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age group were evident. In the younger age group, low intake of zinc was evidentin boys and girls. Data on micronutrient status is as yet only available from the1997 NDNS. There was some evidence of poor status of riboflavin, thiamin,vitamin C, folate, vitamin D and iron. A comparison of data from the Low IncomeDiet and Nutrition Survey (2003–2005) and the 1997 NDNS showed that childrenfrom low-income families tended to have higher intakes of whole milk; fat spreads;meat and processed meats; and non-diet soft drinks compared with children fromthe general population. Intakes of wholemeal bread; buns, cakes and pastries;semi-skimmed and skimmed milk; vegetables; fruit and fruit juices; and diet softdrinks were lower in children from low-income families.

Physical activity has a major impact on health at all stages of life. In children andyoung people physical activity is particularly important to maintain energy balanceand therefore a healthy bodyweight, for bone and muscoskeletal development, forreducing the risk of diabetes and hypertension, and for numerous psychological andsocial aspects. There is concern that many children spend too much time engaged orsedentary activity and not enough time being active. In the UK, it is recommendedthat children undertake at least 60 minutes of moderate to vigorous intensityphysical activity every day, and vigorous activities, including those that strengthenmuscle and bone, should be incorporated at least three times a week. Children andyoung people should also minimise the amount of time spent being sedentary(sitting) for extended periods.

Data from the 2008 Health Survey for England suggested that 32% of boys and24% of girls aged 2-to-15-years met the previous target to be active for 60 minuteseach day. However, as only out-of-school activity was assessed, this is likely to bean underestimation of actual activity. Physical activity levels in girls dropped withage, whereas in boys no clear patterns were observed. The average reported timespent doing sedentary activities (excluding sleeping or school time) was 3.4 hourson weekdays and 4.1 hours on weekend days. The Scottish National Health Survey2009 found that 69–72% of boys and 56–60% of girls in Scotland met the previous60 minute-per-day recommendation. The large differences between England andScotland can in large part be explained by the use of a revised questionnaire in thelatest Health Survey for England. The Welsh Health Survey 2009 reported that47% of boys and 29% of girls were physically active for at least an hour a day,whereas research in Northern Ireland has indicated that only 15% of 8-to-12-year-olds take part in 60 minutes of activity, which ‘made them out of breath or hot andsweaty’ everyday. In England, children and young people, in particular girls, fromsome ethnic groups (Black African, Indian, Chinese, Pakistani, Bangladeshi) hadlower activity levels compared with the general population.

Trends in overweight and obesity in children and adolescents have becomeincreasingly worrying. Data from the Health Surveys for England showed that ratesof overweight and obesity have increased over the past 15 years, the overall increasebeing mainly due to increasing obesity rates. In Scotland, overweight and obesitylevels in girls aged 2-to-15-years and boys aged 2-to-6-years have not changedconsiderably between 1998 and 2009, whereas more boys aged 7-to-15-years wereoverweight or obese in 2009 compared with 1998. For Wales and Northern Ireland,no data showing long-term trends of overweight and obesity are available.

296 E. Weichselbaum and J. Buttriss


Overweight and obesity are associated with an increased risk of various condi-tions in adulthood, but consequences of overweight and obesity are alreadyobserved in children. Obese children have been shown to already have many of thechanges associated with vascular disease in adults, including insulin resistance, highblood pressure and elevated levels of blood cholesterol. Considered previously tobe a disease of adults, in the last decade, type 2 diabetes mellitus has become a farmore common occurrence in children and adolescents. In addition, multiple studieshave suggested that childhood overweight and obesity track into adulthood. Evi-dence shows that there seems to be no single dietary or lifestyle factor that leads tooverweight and obesity, but a variety of different, often interlinked factors, exist.

Oral health has clearly improved since the 1970s. Data from the Children’sDental Health Surveys show that in 1973, 12-year-olds had an average of 5decayed, missing and filled teeth (DMFT), and in 2003, this had fallen to less thanone DMFT. Fifteen-year-olds had an average of around 8 DMFT in 1973 and 1.5DMFT in 2003. The highest proportion of children with dental decay was found inNorthern Ireland, followed by Wales, and the lowest proportion was found inEngland (no information for Scotland available). The decrease in dental decay sincethe 1970s is mainly due to fluoridation of water and toothpaste and generallyimproved oral hygiene, although nutrition plays a role as well.

A sufficient supply of calcium and vitamin D, as well as being physically active,is important for healthy bone development. However, data from the most recentNDNS show that 11% of girls aged 11-to-18-years and 6% of boys of this agegroup have calcium intakes below the Lower Reference Nutrient Intake, suggestinginsufficient intakes. Data from the 1997 NDNS found that more than 1 in 10 (13%)11-to-18-years-olds had low vitamin D status (no newer status data availableas yet).

Estimates of the prevalence of food allergy in the UK vary, but have beensuggested to be around 5–8% in children, the incidence of perceived food allergiesand intolerances usually being considerably greater than the actual prevalence. Ithas been suggested that avoidance of certain allergens at an early age may decreasethe risk of food allergy, although not all experts share this view, some suggestingthat there are critical periods in early life when exposure triggers normal immunesystem tolerance.

It has been suggested that diet affects mental health, including cognitive functionand depression, although there is limited evidence. The best-studied factor, inrelation to cognitive function, is breakfast consumption. There is some evidencethat eating breakfast may improve cognitive function, but inconsistencies andshortcomings of many studies do not allow firm conclusions to be drawn. There isconflicting evidence on the effect of fish oils on cognitive function.

One way to improve dietary habits of schoolchildren is via food provided inschools. Standards for school food are available in all UK countries. In England,food-based standards for school lunches were introduced in 2006, followed byfood-based standards for food other than school lunches in 2007. Finally, nutrient-based standards were implemented in primary schools in 2008 and in secondaryschools and special schools in 2009. A survey found that, compared with 2005,caterers in English primary schools now provide a healthier lunch that meets

Nutrition, health and schoolchildren 297


food-based and most nutrient-based standards, with substantial increases in fruitand vegetable consumption (60% on average), and a 32% decrease in sodiumintake, although improvements still need to be made for some nutrients (e.g. ironand zinc). The Scottish government has also set out nutrient standards for schoollunches, and food and drink standards for school lunches and for school food anddrinks other than school lunches. The regulations came into effect in August 2008for primary schools and in August 2009 for secondary schools. In Wales, minimumfood-based standards apply to primary and secondary schools. More stringentfood-based standards for school lunches and other food and drinks served atschool, as well as nutrient-based standards for school lunches, are outlined in theAppetite for Life Action Plan, but are not compulsory. In Northern Ireland, newfood-based standards for school lunches were introduced and made compulsoryfrom September 2007, and in 2008 were extended to include all other foods anddrinks served at school. Nutrient-based standards for school lunches are not inplace in Northern Ireland.

Nutritional standards for packed lunches prepared at home have not been set,and research in England has shown that the composition of these lunches is lessfavourable than lunch provided at school. Ways of improving the quality of packedlunches have been investigated, with only limited success. Other schemes, such asfruit and vegetable schemes and breakfast clubs, have also been initiated with theaim to improve the dietary habits of schoolchildren. Furthermore, each UK countryhas the study of food and nutrition incorporated into the school curriculum.Examples of other projects aiming to improve children’s health includeChange4Life and SmallSteps4Life; the Healthy Schools initiative; Food and Fitnessin Wales; Healthy Eating, Active Living in Scotland; Investing for Health in North-ern Ireland; MEND; Let’s Get Cooking; and Food Dudes.

Keywords: nutritional requirements, overweight and obesity, physical activity, schoolchil-

dren, school food standard

1 Nutritional requirements ofschoolchildren

It has long been recognised that good nutrition is ofcrucial importance for the wellbeing, growth and devel-opment of children. Even though the energy cost ofgrowth is a minor component of total energy require-ments, growth rate is a sensitive indicator of overalldietary adequacy (Butte 2000). The nutritional require-ments (in addition to energy) of children and adoles-cents are high in relation to their size because of thedemands for growth, in addition to requirements formaintenance and physical activity. In the longer term,food patterns in childhood, particularly adolescence,can set the scene for future dietary preferences andeating behaviour in adult life. There is also substantial

evidence that poor diet and poor physical activity pat-terns in childhood can lead to problems that manifestlater in life, particularly in relation to heart disease,obesity, type 2 diabetes, osteoporosis and some forms ofcancer.

Growth and development

Children are expected to gain about 30 cm in height and12 kg in weight between the ages of 5 and 10 years.During this period, the rate of height gain slows gradu-ally, and at the same time, weight gain increases slowly.While the proportion of bodyweight as fat remains con-stant for boys with normal weight, this increases slowlyfor girls. Up to the age of 8 years, boys are typically



heavier than girls but, after this age, girls becomeheavier because of their greater fat gain, which is linkedwith puberty. Lean body mass as a proportion of totalbody mass remains greater in boys (Buttriss 2002a). SeeSections 3.0 and 4.1 for detailed information on trendsin obesity, physical activity and relationships betweendiet and bodyweight.

During adolescence (10-to-18-years), puberty isassociated with an increased requirement for energyand nutrients (see Tables 1,2) because of the hormon-ally driven rate of increase in height and weight. Inboys, the linear growth spurt resulting in increasedheight is greater than in girls and is accompanied byan increase in muscle growth. Concurrently, the physi-ologically driven rapid bone mass increase is accom-panied by deposition of calcium and phosphate (seeSection 4.5).

The 2004 Health Survey for England, which focusedon minority ethnic groups, highlighted differences inaverage height between ethnic groups and in compari-son to the general population (see Fig. 1) (Becker et al.2006). This pattern was similar to that reported in 1999(Erens et al. 2001), although in the earlier survey, themean heights of Bangladeshi boys and Indian andChinese girls were less than the average for the generalpopulation, whereas in 2004, they were not significantlydifferent. See Section 4.1 for obesity prevalence rates indifferent ethnic groups.

Dietary reference values (DRVs)

DRVs are estimates of the requirements of energy andnutrients for groups of people, taking into account

various factors that influence requirements includinggrowth and development. DRVs are useful as a generalguide for a whole population group, but they are notintended for the assessment of the needs of individuals.Examples of their use include interpreting outcomes ofdietary surveys to detect low intake levels of populationgroups, setting standards for food provision, and plan-ning meals in schools or hospitals. DRVs for a givennutrient comprise: (1) the Estimated Average Require-ment (EAR), which is an estimate of the average require-ment for energy or a nutrient – approximately 50% of agroup of people will require less, and 50% will requiremore; (2) the Reference Nutrient Intake (RNI), which isthe amount of a nutrient that is enough to ensure thatthe needs of nearly all the group (97.5%) are being met;and (3) the Lower Reference Nutrient Intake (LRNI),which is the amount of a nutrient that is enough for onlythe small percentage of the group (2.5%) who have lowrequirements.

Typically, DRVs for protein, vitamins and mineralsfor groups of children are expressed as RNIs. Forenergy, EARs are used as an indication of requirements.Use of RNI values (equivalent to the mean plus 2 stan-dard deviations) is not suitable for energy, as this wouldmean that predicted intakes would be greater than mostpeople’s needs and hence would result in weight gainover a period of time. Energy requirements are influ-enced by physical activity levels, in particular, and canvary significantly depending on the amount of physicalactivity undertaken habitually. Guidelines for energyintake assume a sedentary lifestyle, as this is the situa-tion for the majority of people in Britain, thoughincreased activity is advised. DRVs for macronutrients

Figure 1 Average height of children aged2-to-15-years living in England in 2004, byminority ethnic group and sex. Source: Beckeret al. (2006).

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are expressed in terms of food (or total) energy intakeand again are population mean values rather than rec-ommendations for individuals.

Tables 1 and 2 show the UK DRVs for energy andselected nutrients for children from 4-to-18-years.

Limitations of available data in 1991, when the DRVswere set, meant that the EARs for energy for 4-to-10-year-olds had to be based on intake data from a numberof studies conducted in healthy well-nourished childrenin the UK and elsewhere (FAO et al. 1985; Departmentof Health 1989). However, energy expenditure data wasavailable for older children 11-to-18-years (FAO et al.1985; Schofield 1985). Since then, there is a greaterunderstanding of the energy expenditure of children andadolescents, and the distribution of time spent in activi-ties of differing levels of energy expenditure, largely as aresult of the application of the doubly labelled watermethod and other techniques such as heart rate moni-toring (Torun et al. 1996). In 2004, following an expertconsultation of the Food and Agriculture Organizationof the United Nations (FAO), the World Health Orga-nization (WHO) and the United Nations University(UNU), new values for the energy requirements of

infants, children and adolescents were proposed basedon more accurate techniques for measuring energyexpenditure (FAO/WHO/UNU 2004). These indicatedthat previous values had been overestimated for childrenunder 10 years of age, and had been underestimated forchildren over 11 years of age and for adolescents. Com-pared with the old values, the new FAO/WHO/UNUrecommendations were on average 18% and 20% lowerin 4-to-6-year-old boys and girls, respectively and onaverage 12% and 5% lower in boys and girls aged7-to-10-years, respectively. In children and adolescentsaged 12 years and older, the revised estimates were onaverage 12% higher than the values produced in 1985 inboth boys and girls.

The reference values for energy intake in the UK arecurrently being updated by the Scientific Advisory Com-mittee on Nutrition (SACN), using data from studiesthat use the doubly labelled water method, as this hasproved to be the most useful approach. Data were con-sidered if the measurements obtained were judged to berepresentative of the current UK population. The draftrecommendations were open for consultation in late2009, and the final recommendations are expected in

Table 1 UK DRVs for boys aged 4-to-18-years, expressed as RNIs for protein and micronutrients, and EARs for energy

Age (years) Units 4–6 7–10 11–14 15–18

Energy* MJ 7.16 8.24 9.27 11.51kcal 1715 1970 2200 2755

Protein g 19.7 28.3 42.1 55.2Iron mg 6.1 8.7 11.3 11.3Calcium mg 450 550 1000 1000Zinc mg 6.5 7.0 9.0 9.5Magnesium mg 120 200 280 300Phosphorus mg 350 450 775 775Sodium mg 700 1200 1600 1600Vitamin A mg 400 500 600 700Vitamin B1 (thiamine) mg 0.7 0.7 0.9 1.1Vitamin B2 (riboflavin) mg 0.8 1.0 1.2 1.3Niacin mg 11 12 15 18Vitamin B6 mg 0.9 1.0 1.2 1.5Vitamin B12 mg 0.8 1.0 1.2 1.5Folate mg 100 150 200 200Vitamin C mg 30 30 35 40DRVs for macronutrients, for the population in general, i.e. all agesFat % food energy 35

of which saturated fatty acids % food energy 11Carbohydrate % food energy 50

of which starch, intrinsic sugars and milk sugars % food energy 39of which NMES % food energy 11

Source: Department of Health (1991).*Expressed as EARs.DRVs, Dietary Reference Values; EARs, Estimated Average Requirements; NMES, Non-Milk Extrinsic Sugars; RNI, Reference Nutrient Intake.



due course. As with the findings of FAO/WHO/UNU,the suggested EARs for younger children in the draftSACN report are lower compared with the EARs from1991, whereas in children older than 10 years, the newdraft EARs are higher compared with the 1991 values(www.sacn.gov.uk).

Desirable intakes of carbohydrates and fats areexpressed as a proportion of total dietary energy.These take into account eating habits in the UK andthe practical implications of dietary changes in linewith those considered desirable for health. They havebeen calculated with the needs of the adult populationin mind. While these values provide a useful guide forolder (school age) children, the recommendation forfat, in particular, should not be applied in full to thediets of pre-school children especially where appetite ispoor.

There are no specific figures for the desirable amountof fibre [non-starch polysaccharide (NSP)] for children.The Department of Health recommends that childrenshould have proportionally lower fibre intakes thanadults; the current UK DRV for adults is 18 g of NSP perday as measured by the Englyst method (Department of

Health 1991). This equates to approximately 24 g if theAssociation of Official Analytical Chemists (AOAC)method is used (Lunn & Buttriss 2007).

SACN is currently reviewing the DRVs for fibre.Meanwhile, the European Food Safety Authority(EFSA) has defined fibre as non-digestible carbohydrates(including NSP, resistant oligosaccharides, resistantstarch) plus lignin (EFSA 2007, 2010). This definition isin accord with methods of analysis approved by theAOAC. EFSA’s definition of fibre has been adopted bythe European Commission as the basis of fibre declara-tions on pack in Europe (European Commission 2008).EFSA’s recommended intake level for adults is 25 g perday. For children, EFSA suggests that ‘dietary fibreintake of 2 g per MJ should be adequate for normallaxation in children, based on the dietary fibre intakethat is considered adequate for normal laxation inadults (25 g, equivalent to 2 to 3 g per MJ for dailyenergy intakes of 8 to 12 MJ) and taking into accountthat energy intake relative to body size in children ishigher than in adults’ (EFSA 2010).

For most essential nutrients, current UK requirementsfor children have been estimated by extrapolating pub-

Table 2 UK DRVs for girls aged 4-to-18-years, expressed as RNIs for protein and micronutrients, and EARs for energy

Age (years) Units 4–6 7–10 11–14 15–18

Energy* MJ 6.46 7.28 7.92 8.83kcal 1545 1740 1845 2110

Protein g 19.7 28.3 41.2 45.0Iron mg 6.1 8.7 14.8 14.8Calcium mg 450 550 800 800Zinc mg 6.5 7.0 9.0 7.0Magnesium mg 120 200 280 300Phosphorus mg 350 450 625 625Sodium mg 700 1200 1600 1600Vitamin A mg 400 500 600 600Vitamin B1 (thiamin) mg 0.7 0.7 0.7 0.8Vitamin B2 (riboflavin) mg 0.8 1.0 1.1 1.1Niacin mg 11 12 12 14Vitamin B6 mg 0.9 1.0 1.0 1.2Vitamin B12 mg 0.8 1.0 1.2 1.5Folate mg 100 150 200 200Vitamin C mg 30 30 35 40DRVs for macronutrients, for the population in general, i.e. all agesFat % food energy 35

of which saturated fatty acids % food energy 11Carbohydrate % food energy 50

of which starch, intrinsic sugars and milk sugars % food energy 39of which NMES % food energy 11

Source: Department of Health (1991).*Expressed as EARs.DRVs, Dietary Reference Values; EARs, Estimated Average Requirements; NMES, Non-Milk Extrinsic Sugars; RNI, Reference Nutrient Intake.



lished data for infants and adults, as little specific infor-mation for school-aged children existed when the DRVswere developed (Department of Health 1991). Duringadolescence, DRVs are set higher for boys than for girlsbecause of their increased rates of growth, bone synthe-sis and bone mineralisation. The DRV for iron intake inpost-pubertal girls is higher than for boys and is basedon data from a study carried out in 1966, showing thatonce menarche is reached and periods start, girls lose onaverage the equivalent of 12.5 mmol of iron per day,although there is a wide individual variation in theamount of blood lost, with girls on the 95th centilelosing around 34 mmol per day. Newer data from arecent study carried out in UK women found that onaverage, over a menstrual cycle, the mean iron loss was7.7 mmol per day, and 70% of the women lost less than9 mmol per day (Harvey et al. 2005). Discrepanciesbetween iron intake data and iron status data (seeSection 2) have led to discussions around whether theiron recommendations may be set higher than necessary,and some experts have suggested reassessing the DRVsfor iron, although more good quality dose-response dataare required (SACN 2010).

Sodium intake in children, as well as in adults, hasbeen associated with increased risk of high blood pres-sure. Therefore, SACN has established target averagesalt intakes for adults and children (Table 3), which areupper intake levels (SACN 2003).

Vitamin D supplements (in the form of vitamin dropsalso containing vitamins A and C) are recommended forchildren under the age of 5 years. For schoolchildren,there are no recommendations for dietary vitamin Dintakes because it is expected that most people, with theexception of very young children, pregnant women andelderly people, obtain an adequate amount of thevitamin via the action of sunlight on the skin. However,it has become apparent that a substantial proportion ofchildren have low vitamin D status (see Sections 2 and4.5).

Various factors affect an individual’s ability toproduce vitamin D, including latitude, pigmentation of

skin and style of dress. In higher latitudes, such as theUK, the wavelength of sunlight radiation is not suffi-cient during winter months. Research shows that evenwithin the UK, there is a divide between the north andthe south of the country, with observed vitamin Dlevels being lower in the north than in the south (Mac-donald et al. 2010). Members of ethnic groups livingin the UK, in particular those who have limited sunexposure because of the style of their dress, may notget enough vitamin D. There is currently insufficientdata from some population groups, including SouthAsian and African-Caribbean groups, to estimate pre-cisely the prevalence of low vitamin D status (SACN2007). The Department of Health recommends thatAsian children continue taking vitamin D supplements(10 mg/day) after the age of 5 years, particularly wherereligion and customs dictate that their skin is keptcovered outside, resulting in limited exposure of theirdarker skin to the relatively weak sunlight available inthe UK (Department of Health 1991). A SACN grouphas been set up to look at the evidence around vitaminD and health and to review the current DRVs(www.sacn.gov.uk).

Fluid requirements

Fluid requirements are an often overlooked aspect ofdiet. If lost fluid is not replaced, dehydration will result.In the short term, poor hydration causes headaches andconstipation, and can cause irritability and impairmental performance, which is particularly relevant forschoolchildren. In the longer term, chronic mild dehy-dration is associated with increased risk of a number ofconditions, including urinary tract infections, hyperten-sion, coronary heart disease and stroke (Benelam &Wyness 2010).

It is generally accepted that six to eight glasses offluid per day (appropriate for the size and age of thechild, older children consuming larger drinks thansmaller children) should be sufficient to replace waterlosses. However, children are less heat tolerant thanadults and can become dehydrated more quickly whenexercising, particularly in hot weather. Therefore,more water will be needed in hot weather and aftervigorous physical activity (Benelam & Wyness 2010).In adults, thirst is a good indicator of fluid needs, ifresponded to promptly. However, children may need tobe encouraged to drink sufficiently to rehydrate, e.g.after exercise, and provision of flavoured water isoften more acceptable than plain water (Saltmarsh2001). There is some evidence that patterns ofdrinking are established in childhood; therefore, it is

Table 3 Target average salt intake in children aged 4-to-18-years

Age (years) Salt (g/d) Sodium equivalents (g/d)

4–6 3 1.27–10 5 2

11–14 6 2.415+ 6 2.4

Source: Scientific Advisory Committee on Nutrition (SACN 2003).



important that children become used to maintainingan adequate fluid intake.

The importance of adequate hydration has been rec-ognised and access to water has been included as arequirement in the various school food standards in theUK (see Section 6). In England, the food-based stan-dards for lunch and other eating occasions at schoolinclude the requirement of having free-of-charge wateravailable to children at all times. For lunch time, servingsuggestions are made, including jugs of freshly pouredtap water together with cups/glasses on tables and at theserving counter, installation of a point-of-use watercooler that uses mains water, and modern water foun-tains as an additional water point in the dining room(School Food Trust 2007). In Scotland, the Schools(Health Promotion and Nutrition) (Scotland) Act 2007states that free drinking water must be available inschools at all times (The Scottish Government 2008a);and in Wales, the Appetite for Life Action Plan declaresthat schools need to ensure that schoolchildren haveeasy access to drinking water, at no cost, in an appro-priate place and throughout the day (Welsh AssemblyGovernment 2008b). The nutritional standards forschool lunches in Northern Ireland (School Food: topmarks) state that free water, i.e. tap water, must beprovided every day (Health Promotion Agency forNorthern Ireland 2008).

2 Findings of the National Diet andNutrition Surveys (NDNS)

The NDNS provide comprehensive data on eating pat-terns of people aged 1.5 years and older living in privatehouseholds in the UK. Comprehensive data are availablefrom an NDNS carried out in 1997 in children aged4-to-18-years (Gregory et al. 2000), in which the eatingpatterns and nutrient intakes of over 1700 schoolchil-dren and adolescents in Britain were assessed. Morerecent data is also available for the first year (2008/2009)of the NDNS Rolling Programme, currently commis-sioned for a total period of four years (i.e. 2008–2012)(Bates et al. 2010).* Preliminary data on 462 childrenare available and, until more data become available,have to be interpreted with caution. Also, because of thesmall sample size, data from schoolchildren are pre-sented for only two age categories (4-to-10-years and11-to-18-years) instead of the four categories in theearlier survey (4-to-6-years, 7-to-10 years, 11-to-14-

years and 15-to-18-years). This means that comparisonwith DRVs, which are specific to the four subcategoriesused in the 1997 survey, was not always possible. Thedata will become more robust over the next few years.Nevertheless, the initial findings of the NDNS RollingProgramme give a useful insight into energy and nutrientintakes in young people in 2008/2009.

To be able to compare the data from 1997, which wasbased on a 7-day dietary record, with data from 2008/2009, which was based on a 4-day dietary record, thedata from 1997 were re-analysed by the researcherscarrying out the NDNS Rolling Programme (for moredetail see Bates et al. 2010).

Energy intake

The mean energy intakes reported in 2008/2009 werecomparable with the energy intakes reported in 1997(see Table 4).

Comparison of the new data with EARs for energy(Department of Health 1991) was not possible, but datafrom the 1997 NDNS showed that for boys and girls ineach of the four separate age groups studied, meanenergy intakes were lower than the EARs for theirdefined age and gender groups (see Table 5). Energyintakes in 1997 were lowest in relation to the EARs for15-to-18-year-old girls. This may be due in part tounder-reporting of foods consumed, particularly inolder girls. Even though the mean reported daily energyintakes were on average below the EARs, actual intakesare still likely to have been at least adequate in thecontext of existing physical activity patterns (given thestatistics on overweight and obesity, see Section 4.1).Already in 1997, children were heavier and taller com-pared with earlier data from 1989, and it is thereforeunlikely that children were not meeting their require-ments for energy (Buttriss 2002a).

*Since drafting the paper, data for the second year of the NDNSRolling Programme was published (combined with year 1). Thedata for the second year confirm the findings of year one.

Table 4 Average reported daily energy intakes, MJ (kcal), in boysand girls aged 4-to-18-years, in 1997 and 2008/09

Age (years)1997 NDNS young people

2008/09 NDNS rollingprogramme year 1

MJ (kcal) per day MJ (kcal) per day

Boys4–10 7.08 (1680) 6.71 (1591)

11–18 8.95 (2130) 9.07 (2154)Girls

4–10 6.34 (1510) 6.41 (1523)11–18 6.98 (1660) 7.02 (1668)

Source: Bates et al. (2010); Gregory et al. (2000).NDNS, National Diet and Nutrition Survey.



Macronutrient intakes

Intakes of macronutrients in the 1997 NDNS YoungPeople Survey and in Year 1 of the NDNS RollingProgramme are compared in Table 6. Table 7 reportsthe main contributors to energy and macronutrientintake in Year 1 of the NDNS Rolling Programme(Bates et al. 2010)

Protein

Data from Year 1 of the NDNS Rolling Programmeshow that protein intake was higher compared with1997 (Table 6). Even though direct comparison withRNIs is not possible because of the age categorisation in

the Year 1 report, findings from the earlier report showthat protein intakes were well above the RNI in girls andboys of all age groups (see Section 1 for protein RNIs).The main sources of protein in the diets of UK childrenare shown in Table 7.

Carbohydrate

The contribution of total carbohydrates to food energyin young people in 2008/2009 was similar to that in1997 (Table 6), and was in both age groups close to theDRV of 50% of food energy (see Section 1). The mainsources of carbohydrates in the diet of UK children arepresented in Table 7.

In the NDNS report, sugar intake is reported as non-milk extrinsic sugars (NMES), and intrinsic sugars andmilk sugars. NMES are sugars that are not containedwithin the cellular structure of food, whether natural,unprocessed or refined. NMES are typically present intable sugar, honey, fruit juice and all foods to whichsugar has been added (e.g. cakes, biscuits, drinks, con-fectionery). In 2008/2009, NMES contributed onaverage 14.5% of food energy in 4-to-10-year-olds and15.7% in 11-to-18-year-olds (Table 6). In 1997, therespective values were 17.1% and 16.0%, which meansthat there has been a decrease in the contribution ofNMES to energy intake in 4-to-10-year-olds. The mainsources of NMES in the diets of schoolchildren arepresented in Table 7.

The average intake of fibre in the form of NSP washigher in boys than in girls in both age groups in 2008/2009 (Table 6). A specific DRV for NSP does not existfor children (Department of Health 1991). A slightincrease in NSP intake between 1997 and 2008/2009

Table 5 Average reported daily energy intakes in 1997 NDNS,MJ (kcal), in boys and girls aged 4-to-18-years as a percentageof EARs

Age (years) MJ (kcal) per day % of EARs

Males4–6 6.39 (1520) 897–10 7.47 (1777) 91

11–14 8.28 (1968) 8915–18 9.60 (2285) 83

Females4–6 5.87 (1397) 917–10 6.72 (1598) 92

11–14 7.03 (1672) 8915–18 9.82 (1622) 77

Source: Gregory et al. (2000).NDNS, National Diet and Nutrition Survey; EARs, Estimated AverageRequirements.

Table 6 Average reported daily macronutrient intake and contribution to food energy intake in boys and girls aged 4-to-18 years, in 1997and 2008/2009

1997 NDNS young people 2008/2009 NDNS rolling programme year 1

Boys Girls Boys Girls

Age (years) 4–10 11–18 4–10 11–18 4–10 11–18 4–10 11–18Protein, g/day (%E) 53.0 (12.6) 70.5 (13.5) 48.4 (12.9) 54.6 (13.4) 57.7 (14.5) 77.1 (14.8) 54.3 (14.4) 58.9 (14.5)Total fat, g/day (%E) 66.6 (35.4) 83.6 (35.6) 60.3 (35.9) 66.0 (36.0) 60.2 (34.0) 81.6 (34.5) 59.5 (35.0) 65.9 (35.7)Saturated fatty acids, g/day (%E) 27.3 (14.5) 32.7 (13.9) 24.9 (14.8) 25.6 (13.9) 23.8 (13.4) 30.4 (12.7) 23.4 (13.8) 24.1 (13.1)Total carbohydrate, g/day (%E) 233 (52.0) 286 (51.0) 206 (51.2) 222 (50.8) 218 (51.5) 286 (50.7) 205 (50.6) 219 (49.8)Total sugars, g/day (%E) 109.8 (24.5) 125.8 (22.1) 98.6 (24.4) 97.1 (21.9) 96.6 (22.7) 129.2 (22.6) 96.5 (23.5) 94.2 (21.4)NMES, g/day (%E) 77.4 (17.2) 93.7 (16.4) 69.2 (17.0) 70.3 (15.8) 61.7 (14.4) 93.2 (16.3) 60.9 (14.7) 66.5 (15.0)NSP, g/day 9.8 12.5 9.0 10.4 11.2 13.1 10.3 10.8

Source: Gregory et al. (2000); Bates et al. (2010).NDNS, National Diet and Nutrition Survey; NMES, Non-Milk Extrinsic Sugars; NSP, Non-Starch Polysaccharides; %E, Percent of Energy.



Table 7 Contribution of food groups to energy and nutrient intakes in children and adolescents aged 4-to-18-years (2008/09 NDNSRolling Programme Year 1)

Nutrient Food group

Contribution to intake (% of total)

4–10 years 11–18 years

Energy Cereals and cereal products 35 33Meat and meat products 14 17Milk and milk products 15 9Vegetables and potatoes 10 11Non-alcoholic beverages (excluding milk) 5 7Sugar, preserves and confectionery 6 6Savoury snacks 3 4

Protein Meat and meat products 30 38Cereals and cereal products 27 26Milk and milk products 21 14Fish and fish dishes 5 4

Carbohydrate, total Cereals and cereal products 46 43of which bread 17 17of which breakfast cereals 8 7

Vegetables and potatoes 11 12Non-alcoholic beverages (excluding milk) 9 14Sugars, preserves and confectionery 7 7Milk and milk products 9 6

NMES Non-alcoholic beverages 30 40of which soft drinks 18 31of which fruit juice 12 9

Cereals and cereal products 28 22Sugar, preserves and confectionery 23 21Milk and milk products 12 7

NSP Cereals and cereal products 43 41of which pasta, rice and other cereals 9 11of which white bread 8 10of which wholemeal, brown, granary and wheatgerm bread 10 7of which wholegrain and high fibre breakfast cereals 7 5

Vegetables and potatoes 27 29of which vegetables (excluding potatoes) 16 14of which potatoes 12 15

Fruit 11 7Fat, total Meat and meat products 19 25

Cereals and cereal products 23 22Milk and milk products 20 13Fat spreads 10 8Chips, fried potatoes and potato products 6 8Sugar, preserves and confectionery 5 6

Saturated fatty acids Milk and milk products 31 22Cereals and cereal products 23 23Meat and meat products 18 24Fat spreads 10 8Sugar, preserves and confectionery 6 7

Source: Bates et al. (2010).NMES, Non-Milk Extrinsic Sugars; NSP, Non-Starch Polysaccharides.



was observed in both age groups. The main contributorsto NSP in the diets of young people are shown inTable 7.

Fat

The average contribution of fat to energy intake inyoung children and adolescents decreased slightlybetween 1997 and 2008/09 (Table 6). Findings fromearlier reports showed that there had also been adecrease in average fat contribution to energy intakebetween 1983 and 1997 (see Buttriss 2002a). The olderdata showed that fat had been replaced by sugar,whereas the change from 1997 to 2008/2009 is sugges-tive of a higher proportion of food energy now comingfrom protein.

The most recent data show that average intakes wereclose to the recommended population average intake of35% food energy. The main contributors to total fatintake are shown in Table 7.

Saturated fatty acid intake decreased between 1997and 2008/2009 in both age groups (see Table 6). Theaverage percentage of food energy from saturated fattyacids fell with age for both sexes, and was slightlyhigher in girls than in boys, but intakes remainedabove the recommended upper level of 11% of foodenergy in both age groups and both sexes in 2008/2009. The main contributors to saturated fatty acidintake are shown in Table 7. Together, foods that aretypically found within the high fat and/or sugar foodgroup of the Eatwell plate (e.g. confectionery (mainlychocolate confectionery), ice cream, savoury snacks,biscuits, cakes and pastries; see page 338) providealmost a quarter of fat and saturated fatty acids con-sumed by school-age children.

The average intake of cis n-3 and n-6 polyunsatu-rated fatty acids (PUFA) combined has decreased inboth boys and girls (Table 6). Average intakes arebelow the combined DRV for cis n-3 and n-6 PUFAintake of 6.5% of food energy. The decrease in intakein both boys and girls was mainly due to decreases inn-6 PUFA intake, whereas n-3 PUFA intake as a pro-portion of energy intake has stayed at the same levelor has slightly increased. The decreases in PUFA intakehave also been observed in each age group. The newNDNS report does not provide data on the maindietary contributors to PUFA intake (this will follow insubsequent reports). In the 1997 NDNS (Gregory et al.2000), the major contributors to n-3 PUFA intakewere: the category vegetables, potatoes and savourysnacks (mainly roast and fried potatoes, and chips)providing 34% in boys and 38% in girls; cereals and

cereal products (18% and 16%); and meat and meatproducts (17% and 16%). Fish and fish dishes, mainlycoated and fried white fish, contributed 5% of cis n-3fatty acids in boys and 6% in girls. The main con-tributors to n-6-PUFA intake in 1997 were: the cat-egory vegetables, potatoes and savoury snacks(providing 27% in boys and 29% in girls, respec-tively); cereals and cereal products (23% and 21%);meat and meat products (18% and 16%); and fatspreads (16% in boys and girls) (Gregory et al.2000).

Micronutrient intake

Tables 8 and 9 show the average daily intakes of vita-mins and minerals in 2008/2009 compared with 1997for boys and girls of different ages, expressed as averageintakes, as well as the proportion of children havingintakes below the LRNI. The LRNI is the amount of anutrient that is estimated to be sufficient for only the fewpeople in a group who have low needs (less than 2.5%of a population group), and therefore those who arebelow this level are likely to have insufficient intakes(Department of Health 1991).

By definition, if no more than 2.5% of a populationhave intakes below the LRNI, then the likelihood ofdeficiency in the group is low; however, Tables 8 and 9and Figure 2 demonstrate that significant proportions ofyoung people have low intakes of a number of nutrientsand that the situation is worse in the older age group.Using a cut-off of 5%, low intakes of almost all mineralsand vitamin A in boys and girls in the older age group,and also of riboflavin and folate in girls in the older agegroup were evident. In the younger age group, lowintake of zinc was evident in boys and girls (Bates et al.2010).

There is as yet no information available from thenew NDNS Rolling Programme on the sources of vita-mins and minerals in the diet. However, such informa-tion was available in the previous report and ispresented in Table 10 for those nutrients identified asbeing of potential concern in the 1997 and 2008/2009datasets.

Micronutrient status

The latest NDNS report does not provide nutritionalstatus data. Therefore, this section will look at datafrom the 1997 dataset (Gregory et al. 2000). Ingeneral, nutritional status (as reflected by biochemicalmarkers) was good, but there was evidence of poorstatus in some individuals for riboflavin, thiamin,



vitamin C, folate, vitamin D and iron. For example,impaired riboflavin status was evident among childrenwith low riboflavin intakes and evidence of low folatestatus was present in 9% of girls and 7% of boys.There was evidence of poor iron status in childrenaged 4 years, with 3% of boys and 8% of girls havinglow haemoglobin levels. Among girls aged 15-to-18-years, 9% had low haemoglobin levels. There was alsoevidence of low iron stores (as indicated by serum fer-ritin levels) in 13% of all boys and 14% of all girls,with the proportion rising to 27% in 15-to-18-year-oldgirls (see Section 4.3 for information on iron deficiencyanaemia).

There was evidence of poor vitamin D status in thesurvey. Plasma levels of 25-hydroxyvitamin D (activeform) fell with age, and significant proportions ofthose in the older age groups had a poor vitamin Dstatus (as indicated by levels of less than 25 nmol/L).Overall, more than 1 in 10 (13%) 11-to-18-year-oldshad low vitamin D status. There was strong seasonal

variation in 25-hydroxyvitamin D status, with plasmalevels being highest in blood samples taken betweenJuly and September and lowest for samples takenbetween April and June, when more than one in five15-to-18-year-old boys had levels of25-hydroxyvitamin D below the reference range. Thisreflects higher sunlight exposure during summermonths (see Sections 1 and 4.5).

The micronutrient status data were less alarmingthan the intake data, which may suggest that therequirement estimates for some nutrients need recon-sideration or that the biomarkers used to assess statusare imprecise.

Dietary supplements

Information on dietary supplement use is available fromthe 1997 NDNS (Gregory et al. 2000). In 1997, one infive children in the NDNS survey were taking vitaminand mineral supplements. These young people tended to

Table 8 Average reported daily intake of vitamins from food sources and percentage with intakes below the LRNI in boys and girls aged4-to-18-years, in 1997 and 2008/09

1997 NDNS Young People 2008/09 NDNS Rolling Programme Year 1

Age (years) 4–10 11–18 4–10 11–18

Average dailyintake

% belowLRNI

Average dailyintake

% belowLRNI

Average dailyintake

% belowLRNI

Average dailyintake

% belowLRNI

BoysVitamin A (retinol equivalent) (mg) 485 12 594 14 651 2 776 11Retinol (mg) 274 - 336 - 258 - 333 -Thiamin (mg) 1.36 0 1.84 0 1.33 0 1.69 0Riboflavin (mg) 1.61 1 1.85 8 1.53 0 1.72 4Niacin equivalents (mg) 24.7 0 33.5 0 27.9 0 39.4 0Vitamin B6 (mg) 1.8 0 2.5 0 1.8 0 2.6 0Vitamin B12 (mg) 4.0 0 4.8 1 4.1 0 4.8 0Folate (mg) 204 0 276 1 210 0 256 1Vitamin C (mg) 72.0 0 82.0 0 83.9 0 94.4 2Vitamin D (mg) 2.3 - 2.9 - 1.9 - 2.5 -

GirlsVitamin A (retinol equivalent) (mg) 470 12 524 19 660 3 619 10Retinol (mg) 261 - 277 - 258 - 274 -Thiamin (mg) 1.22 0 1.41 0 1.22 0 1.26 0Riboflavin (mg) 1.39 1 1.34 22 1.40 1 1.28 12Niacin equivalents (mg) 22.2 0 25.4 0 26.1 0 30.7 0Vitamin B6 (mg) 1.6 0 1.9 0 1.7 0 2.1 0Vitamin B12 (mg) 3.5 0 3.4 3 3.7 0 3.9 0Folate (mg) 181 1 210 5 183 0 193 6Vitamin C (mg) 71.6 0 73.8 0 81.2 0 72.4 1Vitamin D (mg) 2.0 - 2.2 - 2.0 - 2.1 -

Source: Bates et al. (2010).LRNI, Lower Reference Nutrient Intake; NDNS, National Diet and Nutrition Survey.



have higher intakes of vitamins and minerals from foodsources than those who did not take supplements.Although supplement use made a significant contribu-tion to intakes of iron, zinc and vitamin A, it did notinfluence the proportions of subjects with intakes belowthe LRNI.

Vegetarians and vegans

In the most recent NDNS, 2% of 4-to-10-year-oldsand 3% of 11-to-18-year-olds were reported to be fol-lowing a vegetarian diet (none were reported to bevegan). As the sample size in this report of the NDNS

Table 9 Average reported daily intake of minerals from food sources and percentage with intakes below the LRNI, in boys and girls aged4-to-18 years, in 1997 and 2008/09

1997 NDNS Young People 2008/09 NDNS Rolling Programme Year 1

Age (years) 4–10 11–18 4–10 11–18

Average dailyintake

% belowLRNI

Average dailyintake

% belowLRNI

Average dailyintake

% belowLRNI

Average dailyintake

% belowLRNI

BoysIron (mg) 9.1 1 11.6 5 9.0 1 11.1 7Calcium (mg) 739 2 843 13 809 0 919 6Magnesium (mg) 186 3 239 24 201 0 242 26Potassium (mg) 2070 0 2620 13 2191 0 2683 14Zinc (mg) 5.9 11 8.0 15 6.8 6 8.7 10Copper (mg) 0.77 - 0.99 - 0.81 - 1.08 -Iodine (mg) 154 4 171 5 149 0 152 2

GirlsIron (mg) 8.0 3 8.8 47 8.1 2 8.5 46Calcium (mg) 659 3 662 23 763 2 702 11Magnesium (mg) 169 3 189 51 182 3 189 46Potassium (mg) 1920 1 2150 31 2052 0 2103 30Zinc (mg) 5.4 19 6.1 26 6.2 9 6.9 15Copper (mg) 0.69 - 0.80 - 0.78 - 0.88 -Iodine (mg) 135 3 134 14 132 4 114 16

Source: Bates et al. (2010).LRNI, Lower Reference Nutrient Intake; NDNS, National Diet and Nutrition Survey.

Figure 2 Proportion of 4-to-18-year-olds withintakes of selected micronutrients below theLower Reference Nutrient Intake (LRNI).Source: Bates et al. (2010).

20 1 0 0 0

63

1 2 2 30

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% b

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Boys 4-10 y Girls 4-10 y Boys 11-18 y Girls 11-18 y



Rolling Programme was still relatively small, no sex-specific data are available. In the 1997 survey, 5% ofgirls and 1% of boys were reported to be vegetarian orvegan, with the proportion rising from 2% among4-to-6-year-olds to 10% among the oldest girls (seeTable 11 for details). No variation with age was foundin boys. Vegetarians tended to come from non-manualfamily backgrounds. About two-thirds said theyavoided meat for moral or ethical reasons and about athird said they did not like the taste of meat. Interest-ingly, parental or religious reasons were given far lessoften. Plasma iron and haemoglobin levels were sig-nificantly lower in vegetarians compared with omni-vores. However, there was no difference in vitamin B12

status, despite the fact that it is only available natu-rally via foods of animal origin (principally milk andmeat), though it is added to a number of fortifiedfoods (e.g. breakfast cereals and soya products). Low-density lipoprotein cholesterol (LDL-C) levels werelower and the biochemical status of several vitaminsand of selenium was higher among the group consum-ing a vegetarian diet (Gregory et al. 2000).

Regional and socio-economic differences

Data on regional and socio-economic differences in foodand nutrient intake are available from the 1997 NDNS(Gregory et al. 2000). The NDNS study population wasdivided into four regions: Northern England; Central/

South West England & Wales; London/South EastEngland; and Scotland. Information from the LowIncome Diet and Nutrition Survey (LIDNS) (Nelsonet al. 2007), which examined dietary and lifestyle habitsof UK citizens on low income, is also included in thissection.

Table 10 Food sources of the micronutrients that may be present in insufficient amounts in the diets of some young people

Nutrients for which low intakes* were evidentMain sources in the 1997 National Diet and Nutrition Survey of young people aged 4-to-18- years, withcontribution (%) provided in brackets

Vitamin A (retinol equivalent) Vegetables (excluding potatoes) (~27%); milk and milk products (~20%); meat and meat products (~15%,half of which came from liver); fat spreads (~13%); cereal and cereal products (~13%)

Riboflavin Milk and milk products (~35%); cereal and cereal products (~32%); meat and meat products (~11%)Folate Cereal and cereal products (~40%); vegetables, potatoes and savoury snacks (~26%); milk and milk

products (~12%)Zinc Meat and meat products (~31%); cereal and cereal products (~25%); milk and milk products (~20%);

vegetables, potatoes and savoury snacks (~12%)Iron Cereal and cereal products, particularly breakfast cereals and bread (~50%); vegetables, potatoes and

savoury snacks (~17%); meat and meat products (~14%)Magnesium Cereal and cereal products (~31%); vegetables, potatoes and savoury snacks (~22%) over half of which

came from potatoes; milk and milk products (~16%); meat and meat products (~11%)Calcium Milk and milk products (~48%); cereal and cereal products, particularly bread (~27%)Potassium Vegetables, potatoes and savoury snacks (~34%), with two thirds coming from potatoes; milk and milk

products (~17%); cereals and cereal products (~15%); meat and meat products (~13%)Iodine Milk and milk products (~50%); cereal and cereal products (~16%); fish and fish dishes (~8%)

Source: Gregory et al. (2000).*Refers to intakes below the Lower Reference Nutrient Intake in the 1997 NDNS of young people.

Table 11 Proportion of young people who reported beingvegetarian or vegan in the 1997 National Diet and NutritionSurvey of young people

Age (years)% reporting beingvegetarian or vegan

Boys4–6 27–10 1

11–14 215–18 1

All Boys 1Girls

4–6 27–10 2

11–14 715–18 10

All Girls 5Social class of head of household:

Non-manual 5Manual 2

Source: Gregory et al. (2000).



Types of foods eaten

In the 1997 NDNS (Gregory et al. 2000), there wasa comparatively large range of foods that were lesslikely to have been consumed by young people fromless advantaged households. Semi-skimmed milk wasless likely to have been drunk by boys from house-holds with low income, or in receipt of benefits andby boys from manual households. Seventy-two percent of boys from households with a gross weeklyincome of less than £160 drank whole milk and 43%drank semi-skimmed milk, compared with 45% and66%, respectively, of boys from households with agross income over £600 per week. It is not yet knownwhether this trend has changed over the interveningdecade.

The types of meat eaten showed little variation withsocio-economic status (SES), although bacon and hamwere less likely to have been eaten by boys from thelowest income households. Boys and girls from lessadvantaged households were also less likely to haveeaten a number of types of fruit and vegetables, includ-ing raw carrots and other raw and salad vegetables,citrus fruits and fruit juice (Fig. 3).

The LIDNS report (low-income families) comparedfindings with data from the 1997 NDNS (general popu-

lation, including low income) and found that there weresome differences between the two reports (see Box 1).

There were some regional differences in the 1997NDNS (Gregory et al. 2000) in the types of foods eaten.Boys and girls in Scotland were less likely to have eatenvarious types of vegetables. During the 7-day recordingperiod, only 20% of boys in Scotland ate green leafyvegetables, a third ate raw or salad vegetables and 30%ate cooked carrots, compared with 50%, 53% and53%, respectively, of boys in London and the SouthEast. Chocolate confectionery was more likely to havebeen eaten by boys in Scotland (94%) compared withtheir counterparts in London and the South East (82%).

In Northern England, boys were less likely to haveeaten beef/veal, lamb and liver than boys in the otherregions, whereas girls in this region were more likely tohave eaten beef/veal and dishes made from these thangirls in London and the South East. Both boys and girlsin Northern England were more likely to have con-sumed standard soft drinks than children elsewhere.Compared with girls in London and the South East, girlsin the North of England were more likely to have eatenpolyunsaturated margarine and, compared with girls inScotland, they were more likely to have consumed poly-unsaturated reduced fat spreads.

Nutrient intake

Although there were some regional differences in thetypes of foods eaten in the 1997 NDNS, there were fewsignificant differences in mean energy intake or protein,carbohydrate and alcohol intake. Overall, intakes ofmost vitamins and minerals tended to be lower in Scot-land and, to a lesser extent, in the northern regions ofEngland compared with other regions. Even afteradjusting for energy intake, lower intakes of vitamin D,iron and manganese in boys, and folate and pantothenicacid in girls still remained in Scotland and in the Northof England. Also, lower intakes were still prevalent afteradjustment for energy intake for iron and manganese ingirls and for zinc in both sexes.

Differences in nutrient intakes between regions weremore marked when analysed against SES, as indicatedby receipt of benefits, household income and social classin the 1997 NDNS. Although, overall, there was nodifference in total energy intake, there were differencesin energy intake among boys, depending on whether ornot their parents were in receipt of benefits (7.22 MJcompared with 8.27 MJ per day). Children from house-holds in lower-income groups and those from house-holds in receipt of benefits were significantly more likelyto have lower mean intakes of protein, total carbohy-

0

10

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60

Raw ca

rrots

Raw to

matoes

Leafy

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vege

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d sala

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etabl

es

Green

bean

s

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and p

ears

Banan

as

Citrus

fruits

Other f

ruit

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juice

Families not receiving benefits Families receiving benefits

Figure 3 Proportion of boys aged 4-to-8-years consuming selected fruitsand vegetables during 1 week in the 1997 NDNS of young people.Source: Gregory et al. (2000).



drate, NMES and NSP than those from other house-holds (Gregory et al. 2000).

With regard to total fat intakes, no socio-economicdifferences were found, but when expressed as a per-centage of energy, it was found that the diets of boys(but not girls) from manual social classes containedmore cis monounsaturated and polyunsaturated fattyacids than those from non-manual backgrounds.

Vitamin C intakes were significantly lower in bothboys and girls from lower socio-economic backgrounds,

even after adjusting for energy intake. Average intakesof all minerals, with the exception of iron, were signifi-cantly lower among boys, but not girls, in households inreceipt of benefits. These differences in intakes persistedfor calcium in boys and calcium, phosphorus and iodinein girls, even after adjusting for energy intake (Gregoryet al. 2000).

Nutrient status

Blood levels of vitamin C and folate were lower inScotland and Northern England than elsewhere; this islikely to be linked to intake of fruit and vegetables. Girlsin London and the South East had higher iron storesthan in any other region and girls from the Northernregion of England had the lowest plasma vitamin Clevels. Lower nutritional status was found in the lowersocio-economic groups for folate, vitamin C, vitamin Dand iron (Gregory et al. 2000).

Alcohol, smoking and drug use

Alcohol intake and drinking habits

Over the last decade, concern about alcohol consump-tion in the UK has mounted, particularly in relation toconsumption among children and young people. Areport published by the Department of Health reportedthat, since 1990, the amount of alcohol consumed bythose 11-to-15-year-olds who drink has doubled and thenumber of children admitted to hospital as a directresult of their alcohol consumption has increased. Byage 15 years, the vast majority of 15-year-olds inEngland have had their first alcoholic drink. Altogether,2.85 million of 11-to-17-year-olds have ever consumedan alcoholic drink, and over 1 million who do so on aweekly basis. Consumption by young people is greaterin the UK than in many other European countries(Department of Health 2009).

In the new NDNS Rolling Programme (Bates et al.2010) children are also asked about their experience ofdrinking alcohol. Table 12 shows the proportion of chil-dren who reported ever having had a ‘proper’ alcoholicdrink (i.e. not just a taste).

Among those aged 13-to-15-years, 3% of boys and1% of girls reported drinking alcohol about twice aweek, 1% of boys and 11% of girls about once a week,8% of boys and 2% of girls about once a fortnight, and16% of boys and 12% of girls about once a month. Therest reported drinking alcohol only a few times a year orthat they never drink. Nobody reported drinking almostevery day. In younger age groups, those who reporteddrinking alcohol said they did so only a few times a year.

Box 1: Differences in average food consumptionover seven days between children in the LowIncome Diet and Nutrition Survey (LIDNS) report(low-income families) compared with children inthe 1997 National Diet and Nutrition Survey(NDNS) report (general population)

Lower consumption by children in LIDNS comparedwith 1997 NDNS:• Wholemeal bread (girls 24 g vs. 42 g)• Buns, cakes and pastries (boys 121 g vs. 166 g;girls 98 g vs. 135 g)• Semi-skimmed milk (boys 634 g vs. 798 g; girls447 g vs. 524 g)• Skimmed milk (boys 9 g vs. 33 g; girls 11 g vs.39 g)• Vegetables (boys 318 g vs. 346 g; girls 380 g vs.411 g)• Fruit (boys 321 g vs. 366 g)• Fruit juice (boys 329 g vs. 380 g)• Carbonated soft drinks (diet) (boys 347 g vs.457 g; girls 339 g vs. 453 g)

Higher consumption by children in LIDNS comparedwith 1997 NDNS:• Pizza (boys 163 g vs. 112 g; girls 107 g vs. 73 g)• Whole milk (boys 873 g vs. 632 g; girls 620 g vs.501 g)• Fat spreads (boys 86 g vs. 52 g; girls 71 g vs. 43 g)• Beef, veal, lamb and pork and dishes (boys 309 gvs. 240 g; girls 282 g vs. 199 g)• Processed meats (boys 449 g vs. 369 g; girls 385 gvs. 280 g)• Oily fish and canned tuna (boys 31 g vs. 24 g; girls31 g vs. 28 g)• Non-carbonated soft drinks (not diet) (boys1652 g vs 913 g; girls 1342 g vs. 755 g)• Carbonated soft drinks (not diet) (boys 1693 g vs.1136 g; girls 1123 g vs. 856 g)Source: (Nelson et al. 2007; Gregory et al. 2000)



Data from the food diaries showed that, on average,1.5% of total energy intake came from alcohol in boysand 0.8% in girls aged 11-to-18-years. The contributionof alcohol to total energy intake in alcohol consumerswas 8.2% and 4.6%, respectively, in girls and boys aged11-to-18-years (Bates et al. 2010).

Smoking and drug use

Other lifestyle factors impacting on nutritional statusinclude smoking and drug use. A survey of smoking,drinking and drug misuse among young people inEngland (NHS 2009) collected information from 7798pupils aged 11-to-15-years throughout England inautumn 2008. Smoking had been tried at least once by32% of the sample; 6% smoked regularly comparedwith around 12% during the mid 1990s. Girls weremore likely to smoke than boys, and the prevalence ofsmoking was reported to increase with age (14% of15-year-olds smoked once a week compared with 0.5%of 11-year-olds). A survey in Scotland reported 4% of13-year-olds to be regular smokers, rising to 15% of15-year-olds (NHS Scotland 2009). As in England, therehas been a dramatic decline in the prevalence of child-hood smoking in Scotland since peak levels in 1996 and1998.

The National Health Service (NHS 2009) report sug-gests drug use has declined, with 22% of pupils inschools reporting that they ever took drugs in 2008,compared with 29% in 2001 (NHS 2009). Cannabiswas found to be the most frequently used drug in bothsurveys. Information from the NHS 2009 survey sug-gested that 3.6% of pupils had taken Class A drugs inthe year before the survey, which had remained at asimilar level since 2001.

3 Physical activity in schoolchildren

The level of physical activity, its frequency, duration,intensity, type and total amount, as well as the time

spent sedentary have a major impact on health at allstages of life. There is concern that many children spendtoo much time undertaking sedentary activity (see ‘Sed-entary behaviour’ at the end of this section). Physicalinactivity has been identified as the fourth leading riskfactor for global mortality (6% of deaths globally). Thisfollows high blood pressure (13%), tobacco use (9%)and high blood glucose (6%). Overweight and obesityare responsible for 5% of global mortality (WHO2010). Being physically active in early life is of particu-lar importance as it impacts not only on current healthstatus but can also influence health in later life. Themany benefits for children and young people of beingphysically active include helping to maintain energybalance and therefore a healthy bodyweight; aidingbone and musculoskeletal development; reducing therisk of diabetes and hypertension; as well as numerouspsychological and social benefits (including improvedpsychological wellbeing, and higher self-confidence andself-esteem) (see Miles 2007). These health benefits willbe explored in more detail in Section 4; this sectionfocuses on physical activity recommendations, on howmuch physical activity children in the UK are actuallydoing, and on the factors that influence physical activitylevels.

Physical activity is defined as ‘any bodily movementproduced by skeletal muscles that requires energyexpenditure’ (WHO 2010). It therefore includes activi-ties ranging from organised sport and exercise, to activeplay (running around outside) or activities undertakenas a part of everyday living (i.e. walking or cyclingto school, housework). Physical activity can take anumber of forms and types, such as moderate or vigor-ous intensity, or activities that convey particular ben-efits, e.g. aerobic or weight bearing activities thatbenefit the cardiovascular system and skeleton, respec-tively (see Miles 2007).

Recommendations in the UK

Within the UK, physical activity recommendations haveexisted in England, Scotland and Wales for more than adecade. Although recommendations for children havebeen similar in the different areas of the UK (no recom-mendations in Northern Ireland), there have been slightdifferences in both the amount and type of activityrecommended. For the first time now, UK-wide guide-lines on physical activity are available (Department ofHealth 2011). The new guidelines, which now alsoinclude recommendations for pre-school children, werepublished by the Chief Medical Officers from the four

Table 12 Percentage of children in the National Diet andNutrition Survey Rolling Programme Year 1 reporting to everhaving had a proper alcoholic drink (i.e. not just a taste)

8–10 years 11–12 years 13–15 years

Boys (%) 9 31* 57Girls (%) 10 21* 52

Source: Bates et al. (2010).*Small sample base.



home countries in July 2011. The recommendations forchildren and adolescents aged 5-to-18-years are pre-sented in Table 13.

The new guidelines mainly differ from the old guide-lines of the UK countries in terms of intensity of physicalactivity, and for the first time a recommendation aboutlimiting physical inactivity is made.

Moderate intensity activity can broadly be defined asthat which raises the heart rate and leaves an individualslightly out of breath, but still able to talk, whereassomebody doing vigorous intensity activity will breathvery hard, be short of breath, have a rapid heart beatand will not be able to carry on a conversation comfort-ably. The recommended amount of physical activity canbe made up of smaller bursts of activity, which reflectsthe typical activity patterns of children (i.e. walking toschool, spontaneous play, as well as structured activitysuch as Physical Education (PE) lessons). Variety isimportant at this age: moderate to vigorous bouts ofactivity will benefit the cardio-respiratory system; activi-ties to improve bone health are those which producehigh physical stress on the bones, and include running,jumping and skipping; active play (e.g. climbing, carry-ing and ‘rough and tumble’) helps to improve musclestrength and flexibility.

Measuring physical activity

Assessment of physical activity levels may be carried outusing subjective or objective measurements. Subjectivemethods typically take the form of questionnairesasking about current or past activity levels, includingphysical activity diaries, logs and recall surveys. Objec-tive methods use physiological measures, such as heartrate monitoring or motion sensors, which provide real-time estimates of the frequency, intensity and durationof physical activity (Miles 2007).

Accurate identification of children’s physical activitylevels by means of subjective methods is made difficult

by both the type of exercise children undertake and theircognitive ability to recall physical activity. Whereasadult activity is more likely to include exercise (a sub-category of physical activity, usually planned, structuredand performed to improve physical fitness), children’sactivity tends to be far more sporadic. An inability torecall past events accurately in younger children furthercompounds this problem (Livingstone et al. 2004).More objective methods generally provide more accu-rate data in children, but the use of these methods isassociated with higher cost and burden on subjects com-pared with subjective assessment methods. Therefore,despite the limitations of subjective assessment of chil-dren’s physical activity levels (either by children or theirparents), this approach is commonly used in large-scaleepidemiological studies because it is a relatively inex-pensive, quick and simple way to obtain data. However,there has been an emergence of studies opting to useobjective assessment methods to identify activity levels,often in a subsample in addition to subjective methods(e.g. used in the 2008 Health Survey for England). Toolsused can range from simple pedometers, which countsteps taken, to more sophisticated accelerometers,which record detailed information about activity pat-terns on a minute by minute basis.

Current activity levels of children across the UK

The 2008 Health Survey for England assessed levels ofout-of-school physical activity (any activity outsideschool lesson time) in children (aged 2-to-15-years)using both self-reporting and accelerometers (Craiget al. 2009b). Data from self-reported questionnairessuggest that 32% of boys and 24% of girls met theprevious physical activity target (at least 60 minutes ofat least moderate intensity physical activity each day).However, as only out-of-school activity was assessed,this is likely to be an underestimation of actual activity.The numbers were considerably lower than the 72% ofboys and 63% of girls who were reported to meet theprevious target in the 2007 survey (also only out-ofschool physical activity) (Craig & Shelton 2008); thiscan partly be explained by major revisions of the ques-tionnaire used in order to obtain more accurate data(Craig et al. 2009b). Changes in the new questionnaireincluded questions about sedentary time and separatequestions on physical activity during break time andtravel. The validity and reliability of earlier question-naires were unknown (Craig et al. 2009b). Levels ofphysical activity varied with age (Fig. 4); among girls,there was a downward pattern in activity associatedwith increasing age, with the proportion meeting the

Table 13 UK physical activity guidelines for children and youngpeople (5-to-18-years)

1. All children and young people should engage in moderate to vigorousintensity physical activity for at least 60 minutes and up to several hoursevery day.

2. Vigorous intensity activities, including those that strengthen the muscleand bone, should be incorporated at least three days a week.

3. All children and young people should minimise the amount of timespent being sedentary (sitting) for extended periods.

Source: Department of Health (2011)



previous government recommendations ranging frommore than 30% in those aged 5 years to only 12%among those aged 14 years. Accelerometer data sug-gested similar activity levels to those obtained by self-reporting, with 33% of boys and 21% of girls meetingprevious government recommendations (Craig et al.2009b). The findings from the government’s HealthSurvey for England are in stark contrast to other studiesassessing physical activity levels of children in Englandusing accelerometry, some of which have suggested just2.5% of children may meet previous government rec-ommendations (Riddoch et al. 2007).

The 2009 Scottish National Health Survey, using self-reported methods to assess out-of-school activity, foundthat 69–72% of boys and 56–60% of girls in Scotlandmet the previous recommendation of at least one hourof moderate activity. When activity undertaken atschool was included, 75–77% of boys and 64–68% ofgirls met the recommendations (Bromley et al. 2010).The large differences between England and Scotlandcan, in large part, be explained by the use of a revisedquestionnaire in the 2008 Health Survey for England,whereas the Scottish Health Survey used a questionnairebased on the physical activity questionnaire used inearlier Health Surveys for England, which reportedsimilar values to the Scottish survey (Craig & Shelton2008; Craig et al. 2009b; see earlier).

The Welsh Health Survey 2009 reported that 47% ofboys and 29% of girls were physically active (physicalactivity that left the child feeling warm or slightly outof breath) for at least 1 hour everyday, and 63% ofboys and 45% of girls were physically active on at least5 days a week – this included physical activity at school(Welsh Assembly Government 2010). Northern Irelanddoes not have a comparable health survey. However,

research has indicated that physical activity levels arelow, with just 15% of 8-to-12-year-olds taking part in60 minutes of activity, which ‘made them out of breathor hot and sweaty’ everyday (Central Survey Unit2008).

Influences on children’s physical activity levels

Many factors influence children’s physical activityhabits and understanding these is the key to ensuring allchildren meet national recommendations. This is par-ticularly important as research indicates that physicalactivity behaviours may track into adulthood (Malina1996; Harro & Riddoch 2000) and, therefore, facilitat-ing physical activity in childhood may be important inhelping set good behaviour early on.

Gender and age

That boys are more active than girls is a common obser-vation and evidence to support this is provided by anumber of studies in school-aged children (Inchley et al.2005; Henning Brodersen et al. 2007; Riddoch et al.2007). In addition to gender, age is also found to affectactivity levels, with the majority of research indicatingthat activity levels decline as children get older. In theHealth Behaviour in Teenagers Study, the number ofdays of vigorous physical activity per week fell over the5-year study period, and more so in girls than in boys. Incontrast, hours of sedentary behaviour increased overthe study period by an average of 2.5 hours per week inboys and 2.8 hours per week in girls (Henning Broder-sen et al. 2007). A series of studies in Scotland foundthat there was a consistent decrease in physical activityin girls with increasing age but no consistent trends

Figure 4 Proportion of English children aged5-to-15-years meeting physical activityrecommendations. Source: Craig et al. (2009b).

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could be observed in boys (Inchley et al. 2005; Bromleyet al. 2010). In the 2008 Health Survey for England, noclear pattern was obvious in boys, but among girls, therewas again a reduction in activity associated withincreasing age (Craig et al. 2009b).

Ethnicity

Henning Brodersen et al. (2007) explored the effect ofethnicity on physical activity levels. Ethnicity was clas-sified, by self-reporting, as either White, Black or mixedBlack, or Asian or mixed Asian. Asian students of bothsexes reported being less physically active than theirWhite counterparts (P < 0.001), whereas for Black stu-dents, lower activity levels were seen only among Blackgirls when compared with White girls. However, Blackstudents of both sexes reported higher levels of seden-tary behaviour than their White peers, the differencebeing greater in girls. Trends in sedentary behaviour alsodiffered in White and Asian girls, with increasing sed-entary behaviour occurring at younger age in Asian girls(Henning Brodersen et al. 2007).

The 2004 Health Survey for England’s report on theHealth of Minority Ethnic Groups also showed thatwith the exception of Pakistani boys and Irish boys andgirls, children in minority ethnic groups are less likely toperform 60 minutes of activity per day than the generalpopulation, although considerable differences betweendifferent minority ethnic groups were seen. Additionally,in most groups, girls were less likely than boys to haveachieved a high level of activity in the week prior to theinterview. The difference was particularly large in theBlack African, Pakistani, Bangladeshi and Indian group,and in Black Caribbean and Irish children it was similarto children of the general population (see Fig. 5). Only

in the Chinese group were girls as likely as boys to haveachieved a high level of activity (Sproston & Mindell2006).

Socio-economic Status (SES)

In the Health Behaviour in Teenagers Study no associa-tion between SES and physical activity was found inboys, but girls from lower SES households were lessactive than those from higher SES households. Seden-tary behaviour levels were greater in boys and girls fromlow socio-economic neighbourhoods, the differencebeing greater in girls than boys (Henning Brodersenet al. 2007). The Low Income Diet and NutritionSurvey (LIDNS) provides information on the diet andlifestyle habits of people on low income in the UK, andinvolved 3728 people (932 children 2-to-18-years) from2477 households from the lowest 15% of the popula-tion in terms of material deprivation. The survey foundthat 28% of boys and 34% of girls aged 2-to-15-yearsreached the previously recommended level of 60minutes of moderate physical activity per day (excludingactivities at school). This is clearly lower than therespective percentages in the 2003 Scottish HealthSurvey [74% of boys and 63% in girls; (Bromley et al.2005)] and the 2002 Health Survey for England [70%boys and 61% girls; (Sproston & Primatesta 2003)],which used an identical questionnaire to assess physicalactivity levels. Inchley et al. (2005) also suggested thatchildren from low-income backgrounds are less activethan their counterparts from higher income families.Data on physical activity levels in different socio-economic groups are however inconsistent. In contrastto the data referred to above, data from the 2008 HealthSurvey for England found that more boys and girls in

Figure 5 Percentage of children aged2-to-15-years to have achieved a high level ofactivity in the 2004 Health Survey for England.Source: Sproston & Mindell (2006).

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the lowest family income quintile met the government’sphysical activity recommendations than those in thehighest income quintile (36% for boys and 30% for girlsin the lowest income families, versus 25% for boys and22% for girls in the highest) (Craig et al. 2009b). Datafrom the Scottish Health Survey 2009 showed no sig-nificant association between boys’ physical activitylevels and SES, but found a significant association forgirls, with more girls from families of lower SES meetingthe recommendations compared with girls from familiesof higher socio-economic backgrounds (Bromley et al.2010). It is unclear why there are such discrepancies inthe data. Research has suggested that the type of activitymay also differ, with children from lower socio-economic background tending to participate in unstruc-tured activities, or free play, while children from higherSES groups are more likely to take part in sports in clubsand structured activities (Brockman et al. 2009).

Family and peer influence

The role of family, in particular parental support, ininfluencing children’s activity levels has received increas-ing attention in recent years. However, the extent ofparental and peer influence is still uncertain.

Parents can potentially encourage activity by rolemodelling, providing support or by facilitating activity,such as providing transport or financial support. Astudy in 180 9-year-old girls examined the extent towhich parents’ activity-related parenting practices influ-enced the girls’ physical activity levels (KrahnstoeverDavison et al. 2003). In families where both parentsprovided a high level of overall support for their daugh-ter’s activities, 70% of girls were classified as beinghighly active, compared with 56% in families whereonly one parent showed a high level of overall supportand 32% of girls in families in which neither parentprovided a high level of overall support. The type ofsupport given differed between fathers and mothers;fathers supported their daughters more through rolemodelling, whereas mothers acted more as facilitatorsby providing logistic support; the impact of both kindsof support on girls’ activity levels seemed to be similar(Krahnstoever Davison et al. 2003). In another study,parent inactivity was a strong and positive predictor ofchild inactivity, whereas scores of parent activity weresomewhat weaker predictors of a child’s vigorous activ-ity and total physical activity level (Fogelholm et al.1999). A study by Brockman et al. (2009) found thatSES of the family may influence the level and type ofsupport given. Children from schools in middle/highSES areas were more assisted through actions such as

logistical and financial support, while parents of chil-dren from schools in low SES areas (lowest third of SESstatus defined by the Index of Multiple Deprivation, aUK government-produced measure of deprivation)mainly restricted their input to verbal encouragementand demands on the children (e.g. ‘Get off the sofa andgo and play’). Participation in family-based activitieswas reported to be higher in children from schools inmiddle/high SES areas than children from schools in lowSES areas. Cost was reported as a significant barrier bychildren from schools in low SES areas (Brockman et al.2009). The Scottish and English health surveys alsolooked at the relationship between parents’ physicalactivity levels and physical activity levels of their chil-dren, resulting in different outcomes. In the 2008 HealthSurvey for England (Craig et al. 2009b), younger boys(2-to-10-years) were more likely to meet the recommen-dations if the parents met the recommended level ofphysical activity, whereas in older boys (11-to-15-years)only the fathers’ activity levels seem to have an influ-ence. Among girls, the activity level of parents maderelatively little difference to the proportion meeting therecommendations. Similarly, for both age groups ofboys and girls, more were in the low activity category iftheir parents were also in this category (Craig et al.2009b). In the Scottish Health Survey, both boys andgirls whose mothers met physical activity recommenda-tions were more likely to meet the recommendationsthemselves, whereas this pattern was not apparent inrelation to the fathers’ physical activity levels (Bromleyet al. 2010). More research will be needed to understandthese discrepancies between studies.

A study carried out in a cohort of 315 9-to-13-year-olds from schools across London sought to determinepeer (friends’) influence on physical activity levels.Activity levels were recorded using a 3-day diary andpedometer. Peer influence was assessed using a SocialSupport and Eating Habits/Exercise Survey. The studyfound there to be a significant correlation betweennumber of steps taken and friends taking part in physi-cal activity or exercise with the study subject, andfriends discussing physical activity or exercise with thesubject (Finnerty et al. 2010). The role of peers in influ-encing activity levels is also described by Jago et al.(2009) who suggest that promoting physical activity viafriendship groups may be one way to increase activitylevels among children (Jago et al. 2009).

Physical environment

The environment in which we live has received increas-ing attention over recent years in terms of the role it



plays in influencing physical activity levels of individu-als. The characteristics of the built environment areoften cited as a cause of inactivity. In particular, anincreasing reliance on car use in place of walking andcycling, concerns over safety, and a lack of green spaceare commonly cited as barriers to being physically active(Dunton et al. 2009). Indeed, busy traffic and a neglectof local play areas have both been identified as barriersto children’s participation in physical activity (Bruntonet al. 2003). However, a recent systematic review com-paring the physical activity levels of children living indifferent built environments did not find major differ-ences between children from rural and urban areas(Sandercock et al. 2010).

In 2008, the National Institute for Health and Clini-cal Excellence (NICE 2008) issued evidence-based guid-ance on how to promote physical activity by creatingbuilt or natural environments which support active lif-estyles. The guidance features advice such as:

• ‘ensure planning applications for new developmentsalways prioritise the need for people (including thosewhose mobility is impaired) to be physically active as aroutine part of their daily life;• ensure pedestrians, cyclists and users of other modesof transport that involve physical activity are given thehighest priority when developing or maintaining streetsand roads (this includes people whose mobility isimpaired).’

Implementation of such advice will help to ensure achild’s environment offers plenty of opportunity to beactive, including ensuring children can participate inphysically active play.

Travel to school

Mode of travel to school may be associated with physi-cal fitness in schoolchildren, as suggested by findingsfrom the East of England Healthy Hearts study. Basedon data from 6085 schoolchildren aged 10-to-16-years,those walking or cycling to school were significantlymore likely to be classified as ‘fit’ compared with chil-dren using passive travel modes (car or public trans-port). This significant difference remained afteradjusting for general physical activity levels in girls, butnot in boys (Voss & Sandercock 2010).

Sedentary behaviour

Sedentary behaviours refer to activities that do notincrease energy expenditure substantially above theresting level; these include screen-based behaviours such

as TV viewing and playing computer games, as well asactivities such as reading, listening to music, sitting andlying down (Pate et al. 2008; British Heart Foundation2009). It has been suggested that not only low physicalactivity levels but also increasing time spent on seden-tary activities may be linked to the increase in over-weight and obesity (Biddle et al. 2004). However, basedon current evidence, some experts conclude that it isdifficult to establish a clear link between sedentarybehaviour and overweight and obesity. It has been sug-gested that this is more likely to be a result of a lack ofevidence rather than because there is no link (Biddleet al. 2004; Reilly 2008), and that despite the lack offirm evidence there are good reasons for believing thatphysical inactivity is causally related to obesity in chil-dren (Biddle et al. 2004). Those suggesting that there isan association between sedentary behaviour and obesitysay it may be complex; it may not be as simple assedentary behaviours directly displacing physicallyactive ones. It has been proposed that inactivity may beindependently associated with Body Mass Index (BMI,see Section 4.1) irrespective of physical activity levels(Fleming-Moran & Thiagarajah 2005). More evidenceis needed in order to draw firm conclusions.

In addition, an increase in sedentary behaviour maynot just mean fewer calories are expended; evidenceindicates that activities such as television viewing areoften associated with negative eating habits, includingthe consumption of energy dense foods and drinks(Vereecken et al. 2006; Reilly 2008), thereby exacerbat-ing the problem. Evidence from intervention studies inchildren show that decreasing sedentary behaviourresults in improvement in weight parameters, althoughthe magnitude of change is modest and difficult to inter-pret (DeMattia et al. 2007). There is a need to under-stand whether tackling sedentary behaviour in publichealth intervention programmes will be effective inreducing overweight and obesity in children.

The 2008 Health Survey for England examined sed-entary time (excluding at school) in children andreported that boys and girls spend an average of 3.4hours on weekdays and 4.1 hours on weekend daysbeing sedentary (excluding school or sleeping time), withthe average time increasing with age (Craig et al. 2009b).A further study on sedentary behaviour in 923 teenagegirls (12-to-17-years) from secondary schools in 15regions within the UK reported that the five most time-consuming sedentary activities occupied on average 4.4hours per weekday and 6.7 hours per weekend day. Thisis in contrast to just 44 minutes per weekday and 53minutes per weekend day devoted to active transport orsports and exercise (Gorley et al. 2007).



The new UK physical activity guidelines include rec-ommendations on physical inactivity. All children andyoung people are advised to minimise the amount oftime spent being sedentary (sitting) for extended periods(Department of Health 2011). In the US, the NationalAssociation for Sport and Physical Education advisesthat children should try to avoid being inactive forperiods longer than 2 hours (Corbin & Pangrazi 2004).

4 Nutrition, physical activity and healthin childhood

4.1 Overweight and obesity

Classification of overweight and obesity

In both adults and children, appropriate weight-for-height is most frequently described using the BMI, deter-mined by dividing weight (kg) by height squared (inmetres). For adults cut-offs for overweight and obesityare 25 and 30 kg/m2, respectively (WHO 2000). Thesecut-offs are not applicable to children because the ratioof velocity of weight gain to that of height gain changesduring normal growth, especially around puberty. Forexample, the BMI of a boy or girl on the 50th centile atage 1 years is 17 kg/m2, then falls to 15.5 kg/m2 at age 6years and climbs to 21 kg/m2 at age 20 years (Cole et al.2000). Therefore, age- and sex-specific reference data(centile cut-off points on charts) are necessary to inter-pret measurements of children. For children in the UK,national reference data for child-specific BMI are avail-able; these are based on a large representative sample ofUK children from 1990 (Cole et al. 1995). These refer-ence values are widely used to assess the weight status ofchildren, and are considered by the Growth ReferenceReview Group, a working group convened by the RoyalCollege of Paediatrics and Child Health, to be the onlysuitable BMI reference for assessing weight relative toheight in children for clinical purposes (Wright et al.2002). In clinical practice, children above the 91stcentile are classed as overweight and children above the98th centile as obese (Reilly et al. 2002; Wright et al.2002). However, in public health settings different cut-off points are generally used. The 85th percentile as thecutoff for overweight and the 95th percentile as thecutoff for obesity are used by both the Health Survey forEngland and the National Child Measurement Pro-gramme, a governmental initiative to measure childrenin Reception (aged 4-to-5-years) and Year 6 (aged 10-to-11-years) to assess overweight and obesity levels(Department of Health 2008; Craig et al. 2009a).

The 85th and 95th percentiles are also used as cut-offpoints for overweight and obesity in the growth refer-ences by the World Health Organization (WHO) forschool-aged children and adolescents (De Onis et al.2007), which are based on data from two large surveys,the Health Examination Survey (European) and theHealth and Nutrition Examination Survey (US). Thereferences were aligned with the growth reference stan-dards for children up to 5 years of age and with the BMIcut-off points for overweight and obesity in adults (DeOnis et al. 2007). The International Obesity Task Force(IOTF) has also put forward an alternative derived fromdata collected among children from six countries. TheIOTF identifies the childhood percentile in the datasetcorresponding to a BMI of 25 or 30 at age 18 (Butlandet al. 2007). These growth references are useful forinternational comparison of overweight and obesity inchildren. However, for studies on the prevalence of over-weight and obesity in the UK, the standards based on asample of UK children are generally still the preferredchoice and are being used in various health surveys asmentioned above.

Prevalence of overweight and obesity

The Health Survey for England provides data on trendsof overweight and obesity in children throughoutEngland from 1995 to 2009. In this survey, overweightwas defined as a BMI between the 85th and 95th per-centiles, and obesity was defined as a BMI above the95th percentile (Craig & Hirani 2010b). Prevalencerates of overweight and obesity in 2-to-15-year-old chil-dren in England in 2009 compared with 1995 are shownin Table 14.

Table 14 and Figures 6 and 7 show that the increase inoverweight and obesity between 1995 and 2009 was

Table 14 Prevalence of overweight (>85th–95th percentile) andobesity (>95th percentile) in English children aged 2-to-15-years1995 and 2009

1995 2009

2–10 years 11–15 years 2–10 years 11–15 years

Boys (%)Overweight 13.1 13.9 16.2 14.0Obese 9.7 13.9 13.7 19.7

Girls (%)Overweight 12.8 14.3 11.5 15.3Obese 10.6 15.5 15.2 15.4

Source: Health Surveys for England (Craig & Hirani 2010a).



mainly due to increasing obesity rates and the overweightrates remained relatively stable. In girls, this trend isobserved to a somewhat lesser degree than in boys. Inboth girls and boys, the rates of overweight and obesityseem to have levelled in the past few years, although therewas a peak in 2008 in boys aged 11-to-15-year (Craig &Hirani 2010a). Mean BMI in girls is associated withhousehold income, with BMI increasing with decreasingincome and those in the highest income quintile being theleast likely to be obese. No clear trends were found forboys (Craig et al. 2009b; Craig & Hirani 2010b).

Another source of data on overweight and obesity inchildren living in England is the school-based NationalChild Measurement Programme, which records heightand weight of children aged 4-to-5-years and 10-to-11-

years; the programme started in the school year 2006/2007. In contrast to the Health Survey for England,where a sample of children representative of the popu-lation are measured, in this programme all children inReception and Year 6 classes are measured. The pro-gramme uses the same cut-off points as the HealthSurvey for England. Data from the latest report fromschool year 2009/10 (Table 15) show that obesity ratesare higher in boys than girls and clearly increase (almostdouble) between Reception and Year 6, in both boysand girls (Department of Health & Department forChildren Schools and Families 2010).

The Scottish Health Surveys use the same cut-offpoints and reference values as the English surveys todefine overweight and obesity in children. Data from

Figure 6 Overweight and obesity rates inEnglish boys aged 2-to-15-years (1995–2009).Adapted from Craig & Hirani (2010a).

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Figure 7 Overweight and obesity rates inEnglish girls aged 2-to-15-years (1995–2009).Adapted from Craig & Hirani (2010a).

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2009 presented in the latest report (Bromley et al. 2010)are shown in Table 16.

Figure 8 shows that whereas the percentage of girlsin Scotland who are overweight or obese has notchanged considerably over the period 1998–2009,there are fluctuations in the total prevalence of over-weight and obesity in boys aged 7-to-15-years. Therehas been a notable difference between the years 2008

and 2009, which the authors of the study suggest mayreflect sample fluctuation rather than a true populationdifference. However, it is still clear that there has beenan increase in the prevalence of overweight (includingobesity) over the past years in boys aged 7-to-15-yearsin Scotland, whereas younger boys show a decline inthe prevalence of overweight (including obesity).

Data from the Welsh Health Survey 2009 show that15% of boys aged 2-to-15-years were overweight and afurther 20% were obese, and 15% of girls were over-weight and 18% obese (Welsh Assembly Government2010). There were no obvious trends in the prevalenceof overweight and obesity between 2007 and 2009(Fig. 9).

Prevalence data for overweight and obesity in North-ern Ireland are available from measurements made inthe Northern Ireland Health and Social WellbeingSurvey in 2005/2006 (NISRA 2007). The survey foundthat, based on UK national BMI percentiles, 18% ofchildren aged 2-to-15-years were obese (20% of boysand 15% of girls). The levels of obesity in boys weregenerally higher than in girls (Fig. 10).

Obesity and ethnicity

Child obesity prevalence has been shown to vary sub-stantially between ethnic groups, with obesity prevalencegenerally being lower in children of White British ethnic-ity. Data from the National Child Measurement Pro-gramme showed obesity prevalence to be especially highamong children of both sexes from Black African and‘Black Other’ ethnic groups, and among children fromsome Asian groups, particularly boys of Bangladeshi,Pakistani and ‘Asian Other’ ethnicity (Department ofHealth & Department for Children Schools and Families2009). Also, the 2004 Health Survey for England found

Table 15 Prevalence of overweight and obesity in Englishschoolchildren in Reception and Year 6 classes, National ChildMeasurement Programme

Overweight (%) Obese (%)

Reception (age 4–5 years) Boys 13.9 10.5Girls 12.7 9.2

Year 6 (age 10–11 years) Boys 14.6 20.4Girls 14.6 17.0

Source: Department of Health & Department for Children Schools andFamilies (2010).

Table 16 Prevalence of overweight (>85th–95th percentile) andobesity (>95th percentile) in Scottish children aged 2-to-15-yearsin 2009

2–6 years 7–11 years 12–15 years

Boys (%)Overweight 14.1 15.1 14.7Obese 8.9 17.6 18.4

Girls (%)Overweight 12.2 12.1 14.7Obese 11.8 14.3 17.3

Source: Bromley et al. (2010).

Figure 8 Total prevalence of overweight andobesity in Scotland for children aged2-to-15-years in 1998, 2003 and 2008. Adaptedfrom Bromley et al. (2010).

29.127.3 26.9 26.4 27.3

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23

33.1

2426.4

34.1

28.227

31.83232.6

0

5

10

15

20

25

30

35

40

45

50

Boys, 2-6years

Boys, 7-11years

Boys, 12-15years

Girls, 2-6years

Girls, 7-11years

Girls, 12-15years

% o

verw

eig

ht

and

ob

ese

1998 2003 2008 2009



differences in obesity levels between ethnic groups, withprevalence rates in boys ranging from 14% in Indian andChinese ethnic groups to 31% in the Black Africangroup. In girls, the rates ranged from 12% in the Chineseethnic group to 27% in the Black Caribbean and BlackAfrican groups (Sproston & Mindell 2006). TheNational Obesity Observatory has summarised UK dataon overweight and obesity in ethnic groups in the UK ina recent report (see Gatineau & Mathrani 2011).

Future trends in children

The Foresight Report on obesity (Butland et al. 2007),produced by the UK government’s Foresight Pro-gramme, published projections on future obesity trendsin children. In this report, the cut-offs suggested by theIOTF were used to define overweight and obesity as thisallows international comparison (see page 318). TheIOTF cut-offs were applied to data from the HealthSurveys for England and were used for projecting futuretrends (see Table 17). Significant increases in levels of

obesity, particularly in boys, are expected shouldcurrent trends not be halted or reversed. Taking theproportion of overweight young people into account,Foresight’s extrapolations suggest that, by 2050, 70%of girls and 55% of boys could be overweight or obese(Butland et al. 2007).

Figure 9 Prevalence of overweight and obesityin Wales for children aged 2-to-15-years in2007, 2008 and 2009. Source: Welsh AssemblyGovernment (2008a, 2009b, 2010).

14

2018

197171

161515

20

15

18

0

5

10

15

20

25

Overweight, boys Obesity, boys Overweight, girls Obesity, girls

% o

verw

eig

ht

or

ob

ese

2007 2008 2009

Figure 10 Prevalence of overweight andobesity in Northern Ireland for children aged2-to-15-years in 2005/2006, by sex and age.Source: NISRA (2007).

1819

13

2119

22

1614

0

5

10

15

20

25

Boys, 2-10 years

Pro

po

rtio

n %

Overweight Obese

Girls, 11-15 yearsGirls, 2-10 yearsBoys, 11-15 years

Table 17 Predicted rates of obesity (International Obesity TaskForce criteria) in 2025 and 2050 among English boys and girls

2004 2025 2050

Boys (%)6–10 years 10 21 >35

11–15 years 5 11 23All under 20 years 8 15 25

Girls (%)6–10 years 10 14 20

11–15 years 11 22 35All under 20 years 10 15 25

Source: Butland et al. (2007).



Factors involved in the development ofchildhood obesity

Obesity is a complex condition and a variety of factorscontribute to rising obesity levels in children and ado-lescents. Obesity occurs when energy intake remainshigher than energy expenditure, for an extended periodof time (Prentice 1999; Moreno & Rodriguez 2007).This means that more energy from food and drinks thanthe body uses has been consumed over a period of timeand, in order to halt weight gain or lose weight, eitherless energy from food and drinks needs to be eaten ormore energy needs to be used by increasing the level ofphysical activity, or a combination of both. However, inreality, obesity has contributing factors on a variety oflevels. Human biology, eating and physical activitybehaviours, people’s beliefs and attitudes, and broadereconomic and social drivers all have a role to play indetermining obesity (Butland et al. 2007). Environmen-tal factors such as the ready availability of energy densefoods and drinks and limited opportunities for beingphysically active can contribute to the development ofoverweight and obesity; this is often referred to as an‘obesogenic environment’. The pattern of growth duringearly life is also a determinant of future risk of obesity.There is evidence that weight gain in early life, particu-larly catch-up growth in low-birth-weight babies, isassociated with a higher risk of overweight and obesityin later life. Also an early so called ‘adiposity rebound’in childhood (the period of time in early childhood whenthe bodyweight for height falls and then rises again)predicts a higher BMI later on (Butland et al. 2007).

To tackle an increase in obesity levels in children andadolescents, the various contributing factors need to betaken into account rather than simply addressing onefactor.

Diet and physical activity

Although it is clear that excess energy intake will resultin weight gain, it is difficult to single out specific dietaryfactors that are related to weight gain. An extensivesystematic review looking at evidence from epidemio-logical studies on associations between diet and physicalactivity and excess weight gain found no associationbetween weight gain in children and intake of any of themacronutrients (fat, protein, carbohydrates) (Summer-bell et al. 2009). There was no single food group,including beverages, that was associated with a higherrisk of obesity in children. The authors also found noassociation between energy intake and weight gain orenergy expenditure and weight gain. An inverse associa-tion between physical activity and sedentary behaviour,

and weight gain and obesity was found in studies withobjective measures of activity and inactivity, but noconsistent associations were found in studies with moresubjective measures (Summerbell et al. 2009).

The findings of this review are in contrast with thefact that a positive energy balance is needed in order togain weight or become obese. This illustrates the com-plexity of the challenge faced in tackling obesity. It ispossible that failure to show associations is the result ofstudy limitations, including the use of self-reported datathat may under-report weight, overestimate height,overestimate activity levels and introduce imprecisionin the measurements of the other relevant factors(Summerbell et al. 2009).

Portion size and energy density

It has been shown that presenting children with largerportions leads to an increased intake of the respectivefood, but also to an increased food and energy intakeoverall (see Benelam 2009). However, this effect was notfound in very young children (3 years or younger),where increasing portion size does not seem to lead toan increased food intake (Fisher & Kral 2007; Benelam2009). One study looked at the effect of increasingportion size as well as the energy density of an entréepresented to children aged 5-to-6-years on total foodand energy intake of one whole meal. In accordancewith earlier findings, the authors found an increasedfood intake when children were presented with a largerportion size, but did not find any influence of energydensity on the total amount of food consumed duringthe meal (Fisher et al. 2007). This suggests that childrendo not compensate for the higher energy density byeating a smaller portion, which in turn can lead to anoverall higher energy intake if energy dense foods areconsumed regularly.

Research so far does not suggest that the tendency toovereat when large portions are presented is specific tooverweight children (Fisher & Kral 2007).

Sugar-sweetened beverages

The consumption of sugar-sweetened beverages (includ-ing carbonated drinks and fruit drinks) has increasedalongside increases in obesity prevalence, particularly inthe US, leading to speculations that these drinks may bepartly responsible for the obesity epidemic (Malik et al.2006). The evidence on the effect of sugar-sweetenedbeverages on bodyweight and body fat, however, seemsto be inconclusive (see Benelam & Wyness 2010). Asystematic review looking at cross-sectional, prospective



cohort and experimental studies concluded that therewas an association between the consumption of sugar-sweetened drinks and weight gain, although the authorspointed out that there are confounding factors that mayhave biased the results as certain lifestyle behavioursmay cluster (Malik et al. 2006). A more recent meta-analysis of evidence from prospective cohort and experi-mental studies in children and adolescents found noassociation between intake of sugar-sweetened bever-ages and BMI (Forshee et al. 2008).

It has been suggested that caloric liquids could leadto excess energy consumption because they fail totrigger satiety compared with equivalent energy intakesfrom solid food. However, a review of the literatureconcluded that studies comparing the effects of equiva-lent amounts of liquid or solid energy on satiety haveyielded inconsistent results and do not consistentlysupport the hypothesis that liquid calories go undetec-ted by appetite control systems (Drewnowski & Bellisle2007).

Meal frequency, snacking, breakfast

The systematic review by Summerbell et al. (2009)looked at evidence from prospective cohort studies onfrequency of eating/snacking and eating/skipping break-fast in children and weight gain. The authors concludedthat there was no epidemiological evidence of a consis-tent association between snacking or breakfast skippingand subsequent excess weight gain and obesity (Sum-merbell et al. 2009). Another systematic review alsoincluded cross-sectional, in addition to cohort, studies.The authors found that 13 out of the 16 included studies(the majority being cross-sectional) consistently showeda protective effect of eating breakfast against becomingoverweight or obese; four studies that reported on theassociation between breakfast and BMI all found anincrease in BMI in breakfast skippers (Szajewska &Ruszczynski 2010). However, the authors pointed outthat as almost all of the data gathered in the systematicreview were from observational studies, causalityshould not be assumed based on these findings.

In summary, there seems to be no single dietary orlifestyle factor that leads to overweight and obesity,but a variety of different often interlinked factors, asillustrated in the Foresight Report on Obesity (seeButland et al. 2007).

Health implications of overweight and obesity

Overweight and obesity are associated with an increasedrisk of various conditions, including cardiovascular

disease, diabetes mellitus, high blood pressure and prob-lems with the muscoskeletal system. Diseases such asheart disease or stroke typically occur in adulthood.However, obese children routinely have been shown tohave many of the changes associated with vasculardisease in adults, including insulin resistance, high bloodpressure, elevated total cholesterol, triglycerides, LDL-Cand oxidised LDL-C, and reduced high-density lipopro-tein cholesterol (HDL-C) (Larson Ode et al. 2009; Shortet al. 2009; Steinberger et al. 2009). Insulin resistance isthe most common metabolic alteration related toobesity and obesity is the major risk factor for thedevelopment of insulin resistance in children and ado-lescents; it represents an important link between obesityand other metabolic as well as cardiovascular compli-cations (Chiarelli & Marcovecchio 2008; Nathan &Moran 2008). It has been suggested to be a key riskfactor in the development of lipid abnormalities; at thesame BMI, adolescents with evidence of insulin resis-tance are more likely to have an abnormal lipid profile(Nathan & Moran 2008; Larson Ode et al. 2009).Recent evidence suggests that waist circumference inchildren is an independent predictor of insulin resistance(Chiarelli & Marcovecchio 2008; Nathan & Moran2008; Steinberger et al. 2009). Considered previously tobe a disease of adults, in the last decade, type 2 diabetesmellitus has become a far more common occurrence inchildren and adolescents. Depending on the ethnic com-position of the population, between 8% and 50% ofnewly diagnosed adolescent diabetic patients have type2 diabetes (Steinberger et al. 2009), the remainder beingtype 1 and other forms of diabetes.

Obese children have also been found to have a higherrisk of impaired endothelial function, lower arterialcompliance and elasticity, and increased intima-mediathickness (Short et al. 2009; Steinberger et al. 2009),which are measures of vascular health and associatedwith adverse cardiovascular events in adulthood.Autopsy studies in children and adolescents have alsoshown that the extent of early atherosclerosis of theaorta and coronary arteries is directly associated withlevels of lipids, blood pressure and obesity (Steinbergeret al. 2009). Obesity is also a well-established risk factorfor hypertension in children (Nathan & Moran 2008;Larson Ode et al. 2009).

In addition to the negative impact of obesity onfactors associated with cardiovascular disease, multiplestudies have suggested that childhood overweight andobesity track into adulthood (Steinberger et al. 2009;Biro & Wien 2010; Lloyd et al. 2010). Overweight chil-dren are more prone to becoming overweight adults,especially at higher BMIs or if they have obese parents



(Steinberger et al. 2009; Biro & Wien 2010). Importantevidence for this comes from a US study (the BogalusaHeart Study) that began in 1972 and has followed manyparticipants from childhood into adulthood; the out-comes of this study show that children who were over-weight at age 2-to-5-years were over four times morelikely to become obese than were those with aBMI < 50th percentile (Freedman et al. 2005). In thisstudy, childhood triceps skinfold thickness, a measure ofbody fat, provided only a slightly stronger associationwith adult adiposity than childhood BMI (Freedmanet al. 2005), which itself does not directly measure bodyfatness. A retrospective school-based cohort study thatfollowed up 1520 men born between 1927 and 1956,from the age of 9-to-18-years, into adulthood (average63 years) resulted in similar outcomes. Childhood BMIcorrelated strongly and positively with adult adiposity,as measured by BMI, waist and hip circumferences(Sandhu et al. 2006). Data from a UK cohort (ThousandFamilies Cohort Study, consisting of 1142 children bornin 1947 and followed up into adulthood) showed amoderate, statistically significant correlation betweenchildhood and adult BMI. At age 50 years, those whohad been above the 90th centile for BMI at age 9 or 13years were between five and nine times more likely to beobese than those in the thinnest quartile in childhood.The association between childhood BMI and adult per-centage of body fat was weaker than that with adultBMI. Most of those in the top quarter for body fat aged50 years had not been overweight as children: 94% hadbeen below the 90th percentile for BMI at age 9 and79% at age 13 (Wright et al. 2001). It has to be consid-ered that around 50 years ago, overweight in childrenwas not as common as today and it is likely that mostchildren were of normal weight. The outcomes of thisstudy indicate that although those who are overweightor obese in childhood have an increased risk of beingoverweight and obese as adults, thinness in childhooddoes not protect from overweight and obesity inadulthood.

Children who are obese are more likely to alreadyhave cardiovascular risk factors, including insulinresistance, lipid abnormalities and high blood pressure,and are more likely to be overweight and obese asadults. However, the question is whether childhoodobesity is an independent risk factor of disease in laterlife. If it is, this would mean that being overweight ata young age automatically increases the risk of diseasein adulthood, even if the weight status changes, andthat thinness in childhood decreases the risk of diseasein adulthood, even if people later become overweightin adulthood. Authors of a recent systematic review

concluded that the evidence so far does not suggestthat overweight and obesity in childhood are indepen-dent risk factors for risk of increased blood pressure,carotid-intima thickness or cardiovascular disease mor-bidity or mortality in adulthood. In fact, those whowere of lower BMI as children and overweight asadults had the greatest risk of having high blood pres-sure as adults (Lloyd et al. 2010). Also, findings of theThousand Families Cohort Study suggested that thosethinnest in childhood but overweight in adulthood hadthe highest overall risk of adult disease (Wright et al.2001).

In summary, evidence does not suggest that over-weight and obesity in childhood are independent riskfactors of adult disease. However, it is important not tounderestimate the potential problems overweight andobesity may cause in later life because of the potentialfor tracking into adulthood. Overweight and obesity inadulthood are established risk factors for various dis-eases, including cardiovascular disease, type 2 diabetes,cancer, aggravation of rheumatic diseases, and asthmaand other respiratory diseases.

Prevention and management of childhood obesity

Prevention of obesity is the key to tackling this majorpublic health problem. Treatment of obesity can provedifficult, and therefore health experts believe that muchmore effort should be put into obesity prevention. ACochrane review on the prevention of childhood obesitypublished in 2005 was not able to demonstrate that dietand exercise interventions are effective in preventingweight gain and obesity in children, but found that theycan be effective in promoting a healthy diet andincreased physical activity levels (Summerbell et al.2005). However, a systematic review and meta-analysisthat considered different settings concluded that nutri-tion and physical activity interventions in schoolchil-dren resulted in significant reductions in bodyweightcompared with control. The authors found combinationintervention, single nutrition intervention and TVreduction intervention to be equally effective. Theauthors also found that physical activity interventionalone did not result in bodyweight reduction (Katz et al.2008).

For the prevention of excess weight gain, it is crucialto emphasise the importance of a healthy balanced dietas well as adequate physical activity levels from an earlyage, with the focus being on general health and wellbe-ing rather than obesity prevention. Schools have animportant role to play here as they provide an environ-



ment where consistent healthy eating messages can beapplied as part of a whole school approach (see Sections6 and 7).

In terms of management of established overweightand obesity in children, a recent Cochrane systematicreview showed that various forms of intervention seemto be effective (Oude Luttikhuis et al. 2009). Theauthors identified 64 randomised controlled trials andreported that while there is limited quality data tofavour one treatment programme over another, com-bined behavioural lifestyle interventions can produce asignificant and clinically meaningful reduction in over-weight in children and adolescents compared with stan-dard care or self-help. They further suggest that in obeseadolescents, consideration should be given to the use ofeither of the drugs Orlistat or Sibutramine, as anadjunct to lifestyle interventions, although thisapproach needs to be carefully balanced against thepotential for adverse effects (Oude Luttikhuis et al.2009). NICE suggested that a small number of interven-tion studies found an effect of non-clinical interventionson bodyweight of children and adolescents, althoughmost studies had major limitations (NICE 2006). In itsguidance, NICE focuses on prevention rather than man-agement of obesity in non-clinical settings (e.g. schools).For management of obesity, NICE suggests that multi-component interventions are the treatment of choice.Weight management programmes should include behav-iour change strategies to increase physical activity levelsor decrease inactivity, improve eating behaviour anddiet quality, and reduce energy intake. Interventionsshould address lifestyle within the family and socialsettings. NICE recommends BMI as a practical estimateof overweight in children and young people, but use ofBMI needs to be interpreted with caution because it isnot a direct measure of adiposity. In terms of manage-ment of overweight and obesity in children, NICE sug-gests that the aim of weight management programmesfor children and young people may be either weightmaintenance or weight loss, depending on their age andstage of growth. NICE also emphasises that if help isoffered at school, confidentiality and building self-esteem are particularly important because treating chil-dren for overweight or obesity may stigmatise them andput them at risk of bullying, which in turn can aggravateproblem eating (NICE 2006a).

4.2 Cardiovascular risk factors

Cardiovascular disease (CVD) is a major cause of adultdeath and ill health. Autopsy studies have revealed firstsigns of atherosclerosis to already be prevalent in child-

hood and it has therefore been suggested that the diseaseprocess begins in this age group (Celermajer & Ayer2006). Autopsy studies have also shown that the extentand severity of arterial fatty streaks or raised plaques isassociated with levels of blood lipids, blood pressure,and obesity in childhood and adolescents (Celermajer &Ayer 2006; Steinberger et al. 2009). Obesity is a majorinfluence in the development of cardiovascular riskfactors in childhood, including hypertension, dyslipi-daemia and diabetes mellitus; and its role is discussed inmore detail in Section 4.1.

A strong positive association between total choles-terol and LDL-C and CVD, as well as an inverse rela-tionship between HDL-C and CVD in adults, has beenestablished in a number of major epidemiologicalstudies. As cholesterol concentrations track over time,it is observed that children with unfavourable choles-terol concentrations are more likely to have unfavour-able cholesterol concentrations as adults (Celermajer &Ayer 2006). Obese children and those with insulinresistance have an increased risk of dyslipidaemia(Steinberger et al. 2009). Although more evidence isneeded to clarify the effect of childhood blood choles-terol concentrations on future CVD risk, public healthstrategies should aim to maintain cholesterol concen-trations at a low level in all children.

Diabetes mellitus

Diabetes mellitus is a metabolic disease that is charac-terised by hyperglycaemia (raised blood glucose) and isassociated with accelerated development of vasculardisease. Hyperglycaemia is the result of either impairedsecretion of insulin (type 1 diabetes), resistance to theeffect of insulin in the liver or muscles (type 2 diabetes),or a combination of these pathophysiological situations(Steinberger et al. 2009). Type 1 diabetes is an autoim-mune disease where the insulin producing cells aredestroyed and insulin needs to be injected. In contrast,type 2 diabetes is mainly found in association withoverweight and obesity and treatment generally includeschanges in lifestyle, including eating a healthy diet,increasing physical activity and losing weight.

The most frequent type of diabetes mellitus in chil-dren and young people is type 1 diabetes, althoughtype 2 diabetes – which is typically a disease of adults– is now being diagnosed in obese adolescents. Theprevalence of both forms of diabetes in children andadolescents has increased during recent decades (Aylinet al. 2005; Haines & Kramer 2009; Hsia et al. 2009).A recent estimate of diabetes prevalence in childrenaged 0-to-17-years is 186 per 100 000 for type 1 dia-



betes and 3 per 100 000 for type 2 diabetes (Haines &Kramer 2009). Most children with diabetes are aged 10years or above; 77% of all children with type 1 and98% with type 2 are in this age group (Haines &Kramer 2009).

Type 2 diabetes is more prevalent in some ethnicgroups than others. A recent study showed that thepresence of type 2 diabetes precursors in children alsodiffers between ethnic groups living in the UK (Whincupet al. 2010). Compared with White Europeans, SouthAsian children have higher levels of type 2 diabetesprecursors; this is also seen, to a lesser extent, in BlackAfrican-Caribbean children (Whincup et al. 2010).

Hypertension

Hypertension is a well-established risk factor for CVDin adults. Evidence shows that children who develophypertension are more likely to have hypertension asadults and hypertension in childhood is a risk factorassociated with early atherosclerotic change (LarsonOde et al. 2009; McCrindle 2010). A well-establishedrisk factor of primary hypertension in childrenand adolescents is obesity (Celermajer & Ayer 2006;Larson Ode et al. 2009; Steinberger et al. 2009;McCrindle 2010). Studies in the US have shown thatthere is an association between the prevalence of bothpre-hypertension and hypertension in children andincidence of overweight and obesity (see Section 4.1;McCrindle 2010). No data on prevalence of pre-hypertension and hypertension in children is availablefor the UK.

Management of primary hypertension in childrenand adolescents should focus on lifestyle changes thathelp with weight loss, including eating a healthy diet,being more physically active and spending less timebeing physically inactive. In terms of diet, a recentmeta-analysis of ten controlled trials, including almost966 children, concluded that a modest reduction insalt intake was associated with significant reductionsin systolic and diastolic blood pressure (He &MacGregor 2006). See Section 1 for target salt intakesin schoolchildren.

4.3 Iron deficiency anaemia

Anaemia is a global public health problem affectingboth developing and developed countries. Globally, themost significant contributor to the onset of anaemiais iron deficiency; it is generally assumed that 50% ofall anaemia cases are due to iron deficiency althoughproportions may vary among population groups and

different areas (WHO 2008). The main risk factors foriron deficiency and iron deficiency anaemia are lowintake of iron, poor iron absorption (from diets high inphytate or phenolics compounds, or low in ascorbicacid and meat/fish), period of life when iron require-ments are especially high (e.g. growth and pregnancy),heavy blood loss as a result of menstruation, and acuteand chronic infections (WHO 2008; Falkingham et al.2010). The presence of other micronutrient deficien-cies, including vitamins A and B12, folate, riboflavinand copper can also increase the risk of anaemia(WHO 2008).

It is estimated that around 25% of the world’s popu-lation has anaemia (around half of which is iron defi-ciency anaemia). The highest prevalence of anaemia is inpre-school children, with an estimated 47% beingaffected worldwide (22% in Europe), whereas theworldwide prevalence of anaemia in older children andadolescents is estimated to be approximately 25% (nodata for Europe) (WHO 2008).

In UK schoolchildren, iron intakes are particularlycritical in girls aged 11-to-18-years, with 46% havingiron intakes below the LRNI (see Section 2) (Bates et al.2010). By comparison, insufficient iron intakes werefound in 7% of 11-to-18-year old boys, 1% of 4-to-10-year old boys and 2% of 4-to-10-year-old girls (Bateset al. 2010).

Around 90% of iron in the diet is present as non-haem iron. The remainder exists as haem iron, which isfound almost entirely in food of animal origin. Haemiron is generally well absorbed in the intestines. Theextent to which non-haem iron is absorbed is principallyinfluenced by systemic iron needs. More iron isabsorbed from the diet in a state of iron deficiency andless is absorbed when iron stores are replete. Evidence,mainly from single meal studies, suggests that ironabsorption is also influenced by the presence of othercomponents in the diet (e.g. vitamin C and meatenhance absorption, phytates and phenolics compoundsinhibit absorption). Evidence from whole diet studiesover a number of days or weeks suggests that the overalleffect of enhancers and inhibitors on iron absorption isconsiderably less than predicted from single meal studies(SACN 2010).

In its report on iron, SACN (2010) compared data onconcentrations of haemoglobin and serum ferritin (thestorage form of iron) from the 2000 NDNS report inchildren (Gregory et al. 2000) with cut-off values sug-gested by the WHO (2008). The data show that theprevalence of anaemia in the UK based on WHO cut-offlevels in 4-to-6-year-old girls was 9–15% (9% if com-pared with cut-off levels for the under fives, 15% if



compared with cut-off levels for 5-to-12-year-olds). Theprevalence of anaemia was lower in older girls and wasapproximately 2–4.5% in 7-to-14-year-olds; in femaleadolescents (15-to-18-years) the prevalence of anaemiawas estimated to be around 9%. In boys aged 4-to-18-years, the prevalence of anaemia was lower than in girlswith around 1–8% having haemoglobin levels below theWHO cut-offs. The prevalence in boys was highest in11-to-14-year-olds (3–8%), followed by 4-to-6-year-oldboys (2.5–8%), and was lowest in 7-to-10-year- (1.4%)and 15-to-18–year-olds (1.1%) (SACN 2010). Anaemiawas particularly common in girls who reported that theyhad tried to lose weight over the past year and amongvegetarians (Gregory et al. 2000). Low serum ferritinlevels according to WHO cut-offs, indicating iron defi-ciency, were found in almost 25% of female adolescentsaged 15-to-18-years. In younger girls the prevalencewas 3–12% and 3–10% in boys. Based on the WHOthresholds for haemoglobin and serum ferritin and datafrom the NDNS, SACN estimates that around 5% ofgirls aged 15-to-18-years have iron deficiency anaemia,and lower prevalence rates were indicated foryounger girls (1.7–2.5%) and all boys (0.6–1.2%)(SACN 2010).

Anaemia carries implications for both mental andphysical performance. Symptoms include fatigue, lassi-tude and breathlessness on exertion (see Buttriss2002a). Evidence from observational studies suggeststhat iron deficiency anaemia is associated with poorcognition in school-aged children. However, iron defi-ciency anaemia is also associated with a number ofsocio-economic and biomedical disadvantages that canaffect children’s development (Falkingham et al. 2010;SACN 2010). Therefore, evidence from observationalstudies is not adequate to demonstrate a causal effectof iron deficiency anaemia on cognition. A recent sys-tematic review and meta-analysis of studies looking atthe effects of oral iron supplementation on cognitionconcluded that iron supplementation improved atten-tion and concentration in adolescents irrespective ofbaseline iron status, and improved intelligence quotientin anaemic children. The authors pointed out that thelimited number of included studies were generallysmall, short and methodologically weak (Falkinghamet al. 2010). SACN also reviewed the evidence fromsupplementation trials in children aged 3 years orolder and concluded that there is evidence for a ben-eficial effect of iron treatment on cognitive develop-ment in anaemic children. However, SACN pointedout that none of the trials reported long termfollow-up of children to determine whether any ben-efits were sustained (SACN 2010).

4.4 Oral health

The Office for National Statistics carried out its fourthChildren’s Dental Health Survey in 2003. This surveyhas been carried out every 10 years since 1973 and aimsto establish the state of dental health of children in theUK, and to monitor change since earlier surveys. Thesurveyed population included children aged 5, 8, 12 and15 years attending state and independent schools. Inaddition to dental examinations carried out by trainedstaff, questionnaires were sent to parents to acquireinformation on children’s oral hygiene and dental care,as well as barriers to dental care (Pendry et al. 2004;Lader et al. 2005).

Dental caries

Data on the prevalence of dental caries in schoolchildrenare available from the Children’s Dental Health Survey,which was carried out for the first time in 1973. Insurveys prior to 2003, dental caries was defined asobvious decay experience, being the sum of teeth withdecay into dentine, filled teeth or teeth that were missingdue to decay (missing primary teeth were not consideredas these are unlikely to have been decayed). The criteriafor assessing dental caries were changed for the 2003survey and, in addition to the above criteria, alsoincluded visual caries (decay on surface and visible tothe observer, but dentine not obviously cavitated).Where comparison to older data was made, the pre-2003 criteria were applied (Lader et al. 2005).

Primary (‘milk’ teeth)

The proportion of children with dental caries in primaryteeth decreased between 1983 and 2003 (Table 18) and,in 2003, there were differences between countries, thehighest proportion being observed in Northern Ireland,followed by Wales. Five- and eight-year-old childrenfrom Wales and Northern Ireland had higher rates of

Table 18 Proportion of children aged 5 and 8 years in the UKwith obvious decay (excluding visual caries) in primary teeth, byyear (1983–2003)

Year5 years(%)

8 years(%)

1983 50 701993 45 612003 43 57

Source: Lader et al. (2005).



decay compared with the UK average (Table 19). Thereare no separate data available for Scotland.

Permanent teeth

There was a clear decrease in dental caries in permanentteeth between 1983 and 2003 in all age groups. Thedecrease was most pronounced between 1983 and 1993and more prominent in permanent teeth than in primaryteeth (Table 20). The proportion of children with decayin permanent teeth was again highest in NorthernIreland followed by Wales, with the prevalence of decayin 8-, 12- and 15-year-olds from these countries beingclearly above the UK average (Table 21).

The prevalence of tooth decay was higher in schools indeprived areas compared with schools in non-deprivedareas for all age groups, and in general more teeth wereaffected in children from schools in deprived areas.

Tooth surface loss (TSL)

TSL is pathological non-carious loss of tooth tissuesresulting from erosion, attrition or abrasion of the toothenamel. This condition, unlike dental caries, is associ-ated with consumption of acidic foods and drinks.Twenty per cent of 5-year-olds showed TSL on thebuccal (outward) surfaces of primary incisors and 53%

showed TSL on the lingual (inward) surfaces of theprimary incisors. Among 8-year-olds, 4% showed signsof TSL on buccal and 14% on lingual surfaces of per-manent incisors, and 10% had TSL on molars. Theproportion of children with TSL on the permanent den-tition increased with age. Among 12-year-olds, 12%had signs of TSL on buccal and 30% on lingual surfacesof permanent incisors, and 19% on molars. The respec-tive numbers in 15-year-olds were 14% on buccal and33% on lingual surfaces of permanent incisors, and22% on molars.

Oral health and hygiene

In 2003, a third of 5-year-olds had some gum inflam-mation (gingivitis), compared with two-thirds of 8- and12-year-olds. In 15-year-olds, the proportion with guminflammation was somewhat lower at 52%. The pro-portion of children with gum inflammation hasincreased since 1983 in all age groups, although in15-year-olds the change was less pronounced than inother age groups. The proportion of children withdental plaque (biofilm formed by colonising bacteria)had also increased since 1983 and was highest in 8- and12-year-olds (76 and 73%, respectively). Fifty per centof 5-year-olds and 63% of 15-year-olds had plaque.Levels of calculus (calcified plaque) rose with age from6% in 5-year-olds to 39% in 15-year-olds, and hadincreased over the previous 20 years.

Children in Wales were less likely than those inEngland and Northern Ireland to have plaque, guminflammation or calculus, although not all differenceswere statistically significant.

Overall, more than three quarters of children in allage groups in 2003 reported brushing their teeth at leasttwice a day, which was higher than 20 years ago.Between 19 and 24% of all children reported brushingonce daily or less. Girls in all age groups tended to brushmore frequently than boys. Generally, more frequent

Table 19 Proportion of children aged 5 and 8 years with obviousdecay (including visual caries) in primary teeth in 2003, by country

Country5 years(%)

8 years(%)

England 41 54Wales 52 71Northern Ireland 61 76United Kingdom 43 57

Source: (Lader et al. 2005).

Table 20 Proportion of children aged 8, 12 and 15 years in theUK with obvious decay (excluding visual caries) in permanentteeth, by year (1983–2003)

Year8 years(%)

12 years(%)

15 years(%)

1983 38 81 931993 19 52 632003 14 34 49


Table 21 Proportion of children aged 8, 12 and 15 years withobvious decay (including visual caries) in permanent teeth in 2003,by country

Country8 years(%)

12 years(%)

15 years(%)

England 17 41 55Wales 26 54 65Northern Ireland 34 73 78United Kingdom 19 43 57




brushing was associated with less plaque and gingivitis,except for 8-year-old children.

Diet and dental caries

Dental caries (dental decay) arises when several factorsoccur simultaneously, in particular a susceptible toothsurface, presence of acid producing bacteria and asource of fermentable carbohydrate (e.g. sugars andstarches). Hence, diet has the potential to influencedental decay. However, the most important strategy isregular (at least twice daily) brushing of teeth with afluoride-containing toothpaste. Because the introduc-tion of water fluoridation (in some parts of the country)and recognition of the importance of fluoridation oftoothpaste (introduced in the mid 1970s), dental cariesprevalence has fallen. For example, in 1973, 12-year-olds had an average of five decayed, missing and filledteeth (DMFT), and in 2003, this had fallen to less thanone DMFT. Fifteen-year-olds had an average of aroundeight DMFT in 1973 and 1.5 DMFT in 2003. Fluoridestrengthens the tooth enamel, providing resistance todecay (British Nutrition Foundation 1999b).

Sugars and other fermentable carbohydrates are fer-mented by bacteria on the tooth surface (typicallylocated in dental plaque). This results in localised acidproduction, which in turn can lead to progressivedestruction (demineralisation) of teeth, particularly ifpH remains low owing to frequent ingestion of ferment-able carbohydrates. Although all fermentable carbohy-drates have the potential to cause dental decay, the maindietary factor is frequency of sugars consumption, thisbeing more important than the total amount consumed.It has also been suggested that limiting sugar-containingfoods and drinks as well as snack food containing starch(e.g. crisps) to meal times is one way to reduce theincidence of caries, as the saliva produced when chewingrestores optimal pH in the mouth. Although sugars andfermentable carbohydrates have been linked to dentaldecay, EFSA recently concluded that available data donot allow the setting of an upper limit for intake of(added) sugars on the basis of a risk reduction for dentalcaries. This is because caries development related toconsumption of sucrose and other cariogenic carbohy-drates does not only depend on the amount of sugarconsumed, but it is also influenced by frequency ofconsumption, oral hygiene, exposure to fluoride, andvarious other factors (EFSA 2010).

Another factor that affects the risk of developingcaries is the retentiveness (stickiness) of the carbohy-drate. Foods such as dried fruit or toffees may stick to

teeth for a longer time than would occur with less stickyfood. Therefore, it is important to brush teeth regularly.

Chewing sugar-free gum, which promotes saliva pro-duction, has been found to reduce dental caries. EFSAhas accepted a health claim related to Xylitol (artificialsweetener) chewing gum/pastilles and risk reduction ofdental decay and has agreed that the wording ‘Xylitolchewing gum reduces the risk of caries in children’reflects the scientific evidence for caries reduction (EFSA2008).

Diet and dental erosion

Dental erosion is the loss of hard tissue by chemicaletching, without bacterial involvement. Acids respon-sible for erosion occur in food and drinks, which caneither lead to loss of hard tissue or to softening of theenamel or dentine, making it more prone to attritionand abrasion. Softened enamel may be rehardened bysaliva, and it is clear that excessive oral hygiene shouldbe avoided after exposure to potentially erosive events.Dietary acids are present, for example, in fresh fruit andfruit juices (e.g. oranges, lemons, limes), and soft drinks(British Nutrition Foundation 1999b).

4.5 Bone development

Optimising bone development during childhood andadolescence is crucial in order to decrease the risk ofosteoporosis later in adult life. Optimum bone develop-ment is also important for the avoidance of skeletalproblems in childhood and adolescence such as rickets,which is a disease where bones are deformed owing toan insufficiency of vitamin D.

Most of the skeletal mass is laid down during child-hood and adolescence. It is estimated that by post-puberty (16 years onwards), approximately 80–90% ofpeak bone mass is achieved (Lanham-New et al. 2007).Throughout early childhood, bone mass increases lin-early with skeletal growth, whereas during the pubertalyears a rapid increase in bone density can be observed(by as much as 40–70%). Bone density continues toincrease for several years after the cessation of growthuntil peak bone mass is achieved. The exact age at whichpeak bone mass is attained remains controversial and isgenerally believed to be between 18 and 35 years of age(Lanham-New et al. 2007).

Beside genetic factors that influence peak bone massand account for roughly 70–75% of the variance seen(Lanham-New et al. 2007), nutrition and physical activ-ity play an important role in bone development. Themain nutrients associated with bone development are



calcium and vitamin D. Calcium is the most abundantmineral in the human body. Bones and teeth account forapproximately 99% of the body’s total content ofcalcium, where it is a main structural component (storedas hydroxyapatite) (Phillips 2004; Theobald 2005).

Calcium

Calcium is essential for bone growth as it is required forthe mineralisation of bone. An adequate intake ofcalcium is one of a number of factors that are importantfor acquiring and attaining optimum peak bone mass.Diets containing insufficient amounts of calcium maylead to a low bone mineral density, which may haveimplications for bone health, notably risk of osteoporo-sis, in later life (Theobald 2005). During puberty, thetotal amount of calcium deposited per day is greaterthan at any other time in life although, expressed per kgof bodyweight, is less than during infancy and child-hood. Therefore, total calcium needs are greater duringadolescence than at any other time in life (Theobald2005) (see Section 1 for DRVs for calcium intake). Datafrom the latest NDNS report show that 11% of girlsaged 11-to-18-years and 6% of boys of this age grouphave intakes below the LRNI, suggesting insufficientintakes. Only 2% of the girls and none of the boys in theyounger age group (4-to-10-years) had intakes belowthe LRNI (Bates et al. 2010) (see Section 2).

A Cochrane review, looking at the effect of calciumsupplementation (including provision in food) on bonedensity in healthy children, concluded that there was asmall effect on total body bone mineral content andupper limb bone mineral density, but no effect at anyother site was found. The authors suggest that theincrease in bone mineral density was unlikely to resultin a clinically significant decrease in fracture risk(Winzenberg et al. 2006). However, the effect of calciumsupplementation on bone development remains contro-versial, with many experts pointing out positive effectsof supplementation in various studies (Prentice et al.2006; Lanham-New et al. 2007). A reason for inconsis-tencies between studies may be the use of different formsof supplementation, including calcium supplements andfood sources of calcium. More studies will be needed toclarify potential effects of supplementation in healthychildren. Calcium is present in a wide range of foods invarying amounts and the bio-availability also variesconsiderably. Dairy products, such as milk, yoghurt andcheese, are plentiful sources of well-absorbed calcium.Fish consumed with soft edible bones (such as whitebait,canned sardines or canned salmon) also contain signifi-cant amounts of calcium, as well as foods fortified with

calcium (e.g. in the UK white and brown flour are for-tified with calcium). Pulses, wholegrains, nuts, seeds,dried fruits and vegetables contain some calcium,although some of these foods also contain substancesthat bind to calcium and inhibit absorption (e.g.phytates in wholegrains and pulses, oxalate in spinachand rhubarb) (Phillips 2004; Theobald 2005). The con-tribution of foods to total calcium (and vitamin D)intakes in UK children is shown in Table 22.

Vitamin D

Vitamin D is critical for bone development and health asit is required for calcium absorption. It is also known tostimulate matrix formation and bone maturation, andenhances osteoclastic activity (osteoclasts are bone-building cells) (Lanham-New et al. 2007). It has beenestimated that gut calcium absorption is increased to30–40% of intake with adequate vitamin D status com-pared with a 10–15% absorption without adequatevitamin D (Holick 2007). Severe vitamin D deficiency inchildren results in rickets (Lanham-New et al. 2007).There has been much controversy among experts aboutwhich cut-off levels should be used to define optimumvitamin D levels (Lanham-New et al. 2011). Vitamin Dis primarily produced in the skin on exposure to sun-light; the amount produced being influenced by latitude,pigmentation of skin and extent of clothing. Someethnic groups living in the UK are particularly prone tovitamin D deficiency due to the dark pigmentation oftheir skin coupled with the level of sun irradiation athigher latitudes, as well as cultural clothing norms thatlimit skin exposure. See Section 1 for more informationon sources of vitamin D and Section 2 for informationon vitamin D status in UK children and adolescents.

Table 22 Foods that contribute to calcium and vitamin D intakesin UK children

Nutrient Food type

Calcium (average intakes740–920 mg*)

Milk and milk products (47–48%); cerealsand cereal products (27%); vegetables andpotatoes (6–7%); meat and meat products(6%); fish and fish dishes (2%); fruits andnuts (1%)

Vitamin D (average intakes2.0–2.2 mg/day*)

Cereals and cereal products (35–37%); fatspreads (21–22%); meat and meatproducts (20–22%); fish and fish dishes(8–10%); eggs and egg dishes (7%); milkand milk products (2%)

Source: Gregory et al. (2000).*See Table 10.



A Cochrane review, summarising the evidence ofvitamin D supplementation on bone mineral density inchildren concluded that although current evidence doesnot support vitamin D supplementation as a means toimprove bone density in healthy children with normalvitamin D levels, supplementation of deficient childrenmay be clinically useful (Winzenberg et al. 2010).

Other dietary factors

Dietary protein intake is also important for bone devel-opment and protein-energy malnutrition can lead toskeletal problems. Positive associations between totalprotein intake, bone mineral content and bone size havebeen reported in children and adolescents (Prentice et al.2006). However, there is some controversy about therelationship between dietary protein, in particular thatderived from animal sources, and calcium metabolism.In adults, excess dietary protein can result in increasedurinary calcium losses and therefore increased bone loss(Prentice et al. 2006; Lanham-New et al. 2007), butlittle is known about the situation in growing children(Lanham-New et al. 2007).

Vitamin K is also important for the skeleton anddeficiency of vitamin K may lead to a reduction in boneformation and decreased bone strength (Lanham-Newet al. 2007). In terms of food groups, a high intake offruit and vegetables has been found to be associatedwith bone development; the exact mechanisms behindthis are yet to be established (Prentice et al. 2006;Lanham-New et al. 2007). High sodium intake and caf-feine consumption have both been suggested to nega-tively influence calcium balance, although the evidenceis inconsistent. There has also been concern that carbon-ated drinks may negatively impact on bone developmentbecause of the perception that such drinks contribute toacid load. However, it has been suggested that pur-ported associations between high intakes of carbonateddrinks and bone development are due to the displace-ment of milk from the diet rather than negative effects ofcarbonated drinks per se (Prentice et al. 2006).

Physical activity

Physical activity is crucial for bone development,particularly high-impact activities that includehopping, jumping and skipping, as well as weight train-ing (Phillips 2004; Hind & Burrows 2007; Lanham-New et al. 2007). For optimal bone development,children and adolescents are advised to follow the UKguidelines for physical activity (see Section 3). However,while weight bearing exercise is known to have a posi-

tive effect on bone mineral density, paradoxically bonehealth is a cause for concern in some girls who areengaged in competitive sports, such as gymnastics ordistance running. This may be due to intensive traininginterfering with growth and development, and efforts tocontrol weight in sports where minimal body fat isperceived desirable. Some highly trained female athletesand ballet dancers have poor bone density as a result oflate onset menstruation or amenorrhoea (see Buttriss2002a).

4.6 Food allergy and intolerance

Food intolerance, which includes food allergy, is anadverse reaction to food that is reproducible and takesplace every time contact is made with a particular foodor ingredient. If the reaction involves the immunesystem, it is known as food allergy (Food StandardsAgency 2008). Non-allergic adverse reactions to foodare mediated by non-immunological mechanisms,including enzyme deficiencies (e.g. lactose intolerance),pharmacological effects and other non-defined idiosyn-cratic responses (Buttriss 2002b; Food StandardsAgency 2008). Most allergic reactions to food are medi-ated by immunoglobulin (Ig) E and are immediate, anexception being coeliac disease which is an allergic reac-tion to gluten that is non-IgE mediated (Buttriss 2002b;Mills et al. 2007). Prior to the manifestation of an aller-gic reaction to a particular food, sensitisation to thefood must occur. However, sensitisation to a food doesnot always lead to clinical reactivity and symptoms offood allergy (Mills et al. 2007). Allergic reactions tofood vary considerably in their severity and the discom-fort they cause, but the majority are not life-threatening.However, some reactions, known as anaphylactic reac-tions, can be very severe and even fatal (Buttriss 2002b;Food Standards Agency 2008). The most common causeof this type of reaction is peanuts. The amount of anallergenic food required to provoke a reaction in a sen-sitive individual varies considerably from person toperson and also over time, depending on a range offactors (Food Standards Agency 2008).

Estimates of the prevalence of food allergy in the UKvary but have been suggested to be around 5–8% inchildren and 1–2% in adults (Food Standards Agency2008). The prevalence in adults is lower as many chil-dren outgrow their allergies, often before they even startschool. The incidence of perceived food allergies andintolerances is usually considerably greater than theactual prevalence. For example, in a robust studyinvolving almost 1000 mothers from the Isle of Wightwith babies aged 3, 6, 9 and 12 months, between 2.2–



5.5% of infants were found to respond to skin pricktests and a subsequent double-blind, placebo-controlledfood challenge (only carried out in those with positiveskin prick test results) during the first year of life. Incontrast, 14.2% of the study population reported thattheir child suffered from adverse food reactions (Venteret al. 2006). Over-reporting of food allergies and intol-erances often leads to an overestimation of the preva-lence rates if measurements are based on self-reporteddata (Madsen 2005; Mills et al. 2007). A meta-analysisof studies has found that the incidence of self-reportedfood allergies in Europe ranges between 3% and 35%,whereas the incidence rates were lower in studies wheresubjects were assessed objectively for food-related sen-sitisation and symptoms (Asero et al. 2006).

Contrary to popular view, the Isle of White Studyresearch team have found that rate of sensitisation tofoods has not increased over the last two decades (FoodStandards Agency 2008). Although higher hospitaladmission rates have been reported (Gupta et al. 2007),this may reflect an increase in the awareness of foodallergies and in their diagnosis.

Despite the small number affected, food allergies canbe life threatening and quality of life can be severelyimpaired. The majority of food-induced allergies arecaused by a small number of foods, namely nuts,peanuts, cows’ milk, gluten (wheat, barley, rye), eggs,soya, fish and shellfish, and avoiding the allergen-containing food is the only way to avoid allergicreactions.

Avoidance of food sensitisation in the first place,and therefore the subsequent risk of allergy, would bethe best way to prevent allergy-induced illness. Forsome time, there has been interest in whether earlyexposure (including in the womb) to particular foodscan influence or disrupt the development of normalimmune system tolerance. This has resulted in adviceon the timing of introduction of foods associated withsevere allergy, such as peanuts and gluten. Untilrecently, pregnant women with a family history ofallergic disease were advised as a precautionarymeasure not to consume peanuts during pregnancyand lactation. However, a recent systematic review(Thompson et al. 2010) has contributed to a change inthe recommendations. The UK government nowadvises that pregnant women who eat peanuts orpeanut containing foods are at no greater risk ofhaving a child with a peanut allergy than those whochoose to avoid such foods (Food Standards Agency2009a). The Department of Health currently recom-mends exclusive breastfeeding for the first 6 months oflife and to begin introducing solid foods at 6 months.

This recommendation is based in part on the assump-tion that early exposure to particular foods can resultin sensitisation, although some experts challenge thisopinion as there is some evidence that there are criticalperiods in early life when exposure triggers normalimmune system tolerance (Du Toit et al. 2008).

An EC-funded project, EuroPrevall, aims to charac-terise the pattern and prevalence of food allergy acrossEurope, and investigate the relationship betweengenetic and environmental factors and the developmentof food allergy (www.europrevall.org). This study, andothers in the area, will hopefully shed more light onthe development and treatment of food allergies inchildren.

4.7 Mental health

Depression and anxiety

Depression can affect people at all life-stages and iscommon in adolescence. Mood shifts in children andadolescents may present as irritability rather thansadness or depression and can interrupt everyday func-tioning, for example the ability to do schoolwork orenjoy spending time with friends (Bamber et al. 2007).

Most of the evidence around the association betweendiet and depression comes from studies in adults andtends to focus on specific nutrients. Nutrients that havebeen associated with depression include n-3 fatty acidsand folate. Observational and intervention studies showthese nutrients to be low in the diets of people who aredepressed, while supplementation leads to improve-ments in symptoms (Bamber et al. 2007). A studycarried out in children aged 6-to-12-years found thatn-3 fatty acid supplementation was associated with adecrease in depressive symptoms (Nemets et al. 2006).Other nutrients associated with depression includevitamin B12, vitamin B6, vitamin C, iron, selenium andzinc (Bamber et al. 2007). A link between obesity,unhealthy eating and depression has also been suggested(Bamber et al. 2007; Oddy et al. 2009; Goldfield et al.2010), although the exact interactions and causationremain unclear. Obesity has been linked to body dissat-isfaction, which in turn can lead to shifting of mood anddepression. On the other hand, depression may lead toincreased energy intake which may lead to obesity.More evidence is needed to explore the relationshipsbetween diet, depression and obesity.

Physical inactivity has been linked to depression andanxiety in young people. A Cochrane review looking atthe effects of exercise interventions in reducing or pre-venting anxiety or depression in children and young



people concluded that exercise seems to have a smallpositive effect in reducing depression and anxiety scores.However, the authors point out that the small number ofstudies and the clinical diversity of participants, inter-ventions and methodology all limit the ability to drawfirm conclusions (Larun et al. 2006). Evidence from lon-gitudinal studies suggests that physical activity is asso-ciated with a reduced risk of depressive symptoms,anxiety and other emotional problems (Sagatun et al.2007; Strohle et al. 2007; Wiles et al. 2008; Jerstadet al. 2010). On the other hand, social physique anxiety(the anxiety about other people’s judgement of bodyshape and body image) has been suggested as a barrierto formal exercise, although the evidence is not conclu-sive (Niven et al. 2009). This could mean that girls whoare less confident about their appearance may avoidtaking part in exercise, which may aggravate emotionalproblems.

Eating disorders

The illnesses anorexia nervosa, bulimia nervosa, bingeeating disorder and their variants are characterised by aserious disturbance in eating, as well as distress or exces-sive concern about body shape or weight (Thomas2000). In addition to their impact on psychological wellbeing, they can have a devastating effect on healththrough the physiological consequences of altered nutri-tional status and/or purging. The epidemiology of eatingdisorders has gradually changed. Eating disorders havetypically been seen in girls and young women, but thereis now an increasing prevalence in males. Of particularconcern is the increasing prevalence of eating disordersat progressively younger ages. A US study found thathospitalisations for eating disorders increased by 119%in children younger than 12 years between 1999 and2006 (Rosen & Committee on Adolescence 2010).

Anorexia nervosa is a serious illness in which peoplekeep their bodyweight abnormally low by dieting,vomiting or exercising excessively, leading to prolongedand extreme weight loss. A major factor in the devel-opment of this disease is anxiety about body shape andweight that originates from a fear of being fat or fromwanting to be thin (NICE 2004). Factors associatedwith the onset of anorexia nervosa include perceivedpressure from the family and the environment, obses-sive desires to be in control of the body, as well asmedia obsession with thinness and the media’s ‘bully-ing’ of fatness (e.g. celebrities being gibed for gainingweight) (Hill 2006). The effects of anorexia nervosainclude loss of muscle and bone strength, cessation ofperiods and, if prolonged and severe, anorexia can lead

to death. Anorexia nervosa in children and youngpeople is similar to that in adults in terms of its psy-chological characteristics, but children and youngpeople may, in addition to being underweight, alsohave stunted growth (NICE 2004).

People who suffer from bulimia nervosa feel that theyhave lost control over their eating, as opposed to obses-sion with control in anorexic people. Bulimia nervosa ischaracterised by a cycle of eating large quantities offood (binge eating), and then vomiting, taking laxativesand diuretics (purging), or excessive exercising andfasting, in order to prevent weight gain. In contrast toanorexia nervosa, the bodyweight of people withbulimia nervosa is often normal. Bulimia nervosa canlead to tiredness, feeling bloated, constipation, abdomi-nal pain, irregular periods, or occasional swelling of thehands and feet. Excessive vomiting can cause erosion ofteeth, while laxative misuse can seriously affect the heart(NICE 2004)

A large number of people with eating disorders do notmeet the strict criteria for anorexia nervosa and bulimianervosa. These eating disorders are often labelled as‘eating disorder not otherwise specified’ and their preva-lence is estimated to be higher than the prevalence ofanorexia and bulimia nervosa. Patients with eating dis-orders not otherwise specified often experience the samephysical and psychological consequences as do thosewho reach the threshold for diagnosis of anorexia orbulimia nervosa. Athletes and performers, particularlythose who participate in sports and activities thatreward a lean body (e.g. gymnastics, running, wrestling,dance, modelling) may be at particular risk of develop-ing partial-syndrome eating disorders (Rosen & Com-mittee on Adolescence 2010).

Although the manifestations of these disorders are viathe diet, they are in fact psychological disorders andunderlying problems need to be treated by trained andexpert multidisciplinary teams. The three main catego-ries of contributors include biological and genetic, psy-chological and socio-cultural factors, which can eitheroccur independently or collectively. Eating disordersappear to run in families. However, whether this is aresult of biological/genetic, socio-cultural or psychologi-cal factors, or a combination of these, is not clear (see(Hooper & Williams 2011)

Cognitive function

There is a widespread belief among experts that nutri-tion and diet may influence cognitive function. The UKgovernment and those involved in education, as well asparents, are likely to have a particular interest in the



association between diet and cognitive function inschoolchildren. A systematic review commissioned bythe Food Standards Agency and published in 2008looked at UK-relevant evidence from controlled trials onthe effect of diet on learning and performance of school-aged children (Ells et al. 2008). Another systematicreview looked at the effect of breakfast on cognitivefunction, including studies from populations that arecomparable with the UK population as well as studieswith non-comparable populations, such as from devel-oping countries (Hoyland et al. 2009).

Breakfast

In the review by Ells et al. (2008), the largest numberof publications on diet and cognitive behaviour exam-ined the effect of breakfast. Three out of four studieson the effect of breakfast clubs in schools found asmall but positive impact on a selection of educationaloutcomes, while one study found no effect. Four out ofsix studies looking at breakfast consumption versusfasting identified some improvements in problemsolving, attention and episodic memory after cerealconsumption and in complex visual display tests afterconsuming breakfast. Two out of six studies wereunable to demonstrate any significant differences. Theauthors of the review pointed out that it was difficultto draw together findings from the different studiesdue to numerous inconsistencies between studies andthe shortcomings of many studies (Ells et al. 2008).

Hoyland et al. (2009) propose that the majority ofstudies looking at breakfast versus no breakfast found apositive effect on cognitive function, which they suggestwas more obvious later in the mornings. Studies indeveloping countries found that cognitive performancefollowing breakfast consumption was better in at-risk orunder-nourished children, with few if any effects in well-nourished and not-at-risk children. The authors foundthat data to show that one type of breakfast was sub-stantially better than another was not evident. Studieslooking at long-term effects of school breakfast pro-grammes and breakfast clubs were mainly carried out inschools with a high proportion of children from lowsocio-economic backgrounds or a high proportion ofunder-nourished and at-risk children. The authors of thereview propose that the studies, taken together, showedimprovement mainly in mathematics or arithmeticscores, which they suggest may be due to increasedattendance or decreased absenteeism. They also suggestthat benefits were no greater in or confined to under-nourished or at-risk groups in most studies that also

included well-nourished controls. The reviewers pointedout that, overall, the quality of studies was rather poor(Hoyland et al. 2009).

Sugars

Six studies included in the systematic review by Ellset al. (2008) considered the effect of sugar intake onlearning and behavioural outcomes, five of which werein a population of children with symptoms of attentiondeficit hyperactivity disorder (ADHD). The authorsconcluded that short-term exposure to sucrose has nodramatic detrimental effects on educational and behav-ioural outcomes in school-aged children, when com-pared with commonly used artificial sweeteners (Ellset al. 2008). A review looking at glycaemic load ofbreakfast suggested that there was insufficient evidenceto demonstrate a consistent directional effect of glycae-mic load on short-term cognitive performance (Gilsenanet al. 2009).

Omega 3 fatty acids

The systematic review by Ells et al. (2008) included fivestudies examining the effect of fish oil supplementationon learning and behavioural outcomes. All studies werecarried out in a population aged 5-to-13-years withsymptoms of neurodevelopmental disorders (dyspraxiaand ADHD). Two studies [supplements rich in docosa-hexaenoic acid (DHA)] found small but statistically sig-nificant positive effects on only a few of a number ofsubjective parental and teacher observations (objectivemeasures not examined). Only one study, using asupplement rich in eicosapentaenoic acid (EPA),reported significant improvements in both objective andsubjective behavioural and educational outcomes. Thereviewers also discussed findings published followingtheir original systematic search that suggest that fish oilsupplements may potentially improve cognitive perfor-mance (Ells et al. 2008). However, the findings of twosubsequent UK studies do not support this proposition(Kennedy et al. 2009; Kirby et al. 2010). One study,giving EPA and DHA to 8-to-10-year-old children for 16weeks, found very few significant differences betweenthe supplemented and placebo groups on learning andperformance measures (one being in favour of theplacebo) (Kirby et al. 2010). A study using DHA for 8weeks in 10-to-12-year-old children found that thetreatment with two different doses (400 mg or1000 mg) had no consistent or interpretable effect onperformance (Kennedy et al. 2009).



Vitamins and minerals

There is evidence that deficiency of some nutrients, e.g.iron deficiency anaemia (see Section 4.3), can lead toimpaired cognitive function. Vitamins and mineralssuggested to be linked to cognitive processes in chil-dren are iodine, iron, zinc and vitamin B12 (Black2003). Low magnesium levels have been reported inchildren with ADHD (Sinn 2008). In the systematicreview by Ells et al. (2008), two studies of low-dosemultivitamin/mineral supplementation over severalmonths were included. One reported a moderate, butstatistically significant, average increase in the non-verbal IQ of children, although this may have beenaccounted for by a substantial net IQ increase in just asmall sub-sample. A study in UK children found nosignificant effect of supplementation on verbal andnon-verbal IQ. Ells et al. (2008) conclude that thesetwo studies alone provide insufficient evidence to drawconclusions about the effects of low-dose vitamin andmineral supplementation on the IQ score of schoolchil-dren (Ells et al. 2008).

5 Factors affecting food choice

Socio-economic and regional factors

Socio-economic status has been suggested to impactupon the dietary and lifestyle habits of people within theUK. Data from the Low Income Diet and NutritionSurvey (LIDNS) suggest that this is only true to a certainextent. Although overall reported diets were poor in thelow-income population, they were only slightly worsethan those of the general population (Nelson et al.2007; Tedstone 2008). Comparing the findings ofLIDNS with data from the 1997 NDNS shows thatnutrient intake levels in children and young people aresimilar in both surveys. However, there were some dif-ferences in consumption of certain foods; for examplelower intakes of wholemeal bread, semi-skimmed milk,fruits and vegetables, and higher intakes of whole milk,processed meat and non-diet soft drinks were found inthe LIDNS (see Section 2) (Gregory et al. 2000; Nelsonet al. 2007).

These findings differ from the 1997 NDNS, a stimulusfor LIDNS, which found that the energy, protein, totalcarbohydrate, NMES and NSP intakes of boys whoseparents were in receipt of benefits was lower than that ofboys whose parents were not. Intakes of some micronu-trients, including vitamin C, calcium and magnesium,have also been found to be lower in children fromhouseholds in receipt of benefits compared with those

from households who were not, even when energyintake was taken into consideration (see Section 2)(Gregory et al. 2000).

The area where a child lives was also shown to havean impact on dietary intake in the 1997 NDNS (noteNorthern Ireland was not included in this survey). Forexample, boys in Scotland were less likely to have eatenall types of fish (including oily fish) than children else-where, and boys and girls in Scotland were also lesslikely to have consumed many types of vegetables thanchildren in other regions (although it is worth notingthere were few regional differences reported for fruitconsumption). Chocolate confectionery was also morelikely to be consumed in boys in Scotland comparedwith London and the South East (94% compared with82%). Boys and girls from Northern England were morelikely to have consumed non-diet soft drinks than inother regions (83% of boys and 82% of girls versus71% of boys and 70% of girls in London and the SouthEast) (Gregory et al. 2000).

Advertising of food to children

The advertising of food to children has undergone con-siderable change since the previous edition of this Brief-ing Paper (see Buttriss 2002a). These changes havestemmed from growing concerns about rising levels ofoverweight and obesity among children, and while it isappreciated that there are likely to be multiple factorsthat have influenced trends in weight gain, food adver-tising has been suggested as one factor which may playa role.

In 2004, Ofcom (the independent regulator of televi-sion within the UK), commissioned by the government,reviewed the evidence on the effect of food and drinkadvertising on dietary behaviour in children and con-cluded that advertising had a modest, direct effect onchildren’s food choices and a larger but unquantifiableindirect effect on children’s food preferences, consump-tion and behaviour (Ofcom 2007). This prompted theDepartment of Health to propose that there was a‘strong case for action to restrict further advertising andpromotion to children of those foods and drinks that arehigh in fat, salt and sugar (HFSS)’ (Department ofHealth 2004b). After an in-depth consultation it wasdecided that restrictions should apply to televised adver-tising of food and drink products aimed at children(Ofcom 2007).

Foods that are HFSS are identified using a NutrientProfiling tool, devised by contractors on behalf of theFSA (Food Standards Agency 2009b). The tool uses ascoring system which identifies the contribution a food



makes to nutrients that are beneficial in a child’s diet(including protein – used as a proxy for calcium- andiron-rich foods in particular–dietary fibre, fruit and veg-etables, and nuts) and compares this (in an algorithm)with the food’s contribution to nutrients currently con-sumed in excess (saturated fatty acids, salt and sugar).The score is calculated on the basis of a 100 g portion ofa food (Ofcom 2007; Food Standards Agency 2009b).

The restrictions of HFSS advertising were imple-mented in a step wise fashion, the final phase cominginto force on 1 January 2009, when all HFSS advertisingwas banned from children’s channels (Ofcom 2010). Incontrast, products low in fat, salt and sugar, includingfruits and vegetables, are not subject to any such adver-tising rules. Ofcom estimated that, as a result of theregulations, children saw around 37% less HFSS adver-tising in 2009 compared with 2005. Younger children(4-to-9-year-olds) saw 52% and older children 22% lessHFSS advertising (Ofcom 2010). It is not yet knownwhat impact this has had on children’s consumption ofHFSS foods.

Other social influences

Body image

Societal influences can strongly influence diet and physi-cal activity habits, particularly during the impression-able childhood and adolescent years. Popular media isthought to have a large influence on young people’sbody image (Hogan & Strasburger 2008), and there isoften a great deal of pressure placed on obtaining an‘ideal’ body shape. For young girls, this typically ‘slim’look is often unobtainable; however, the adoption ofunhealthy practices may occur in a bid to try toconform. These practices may include smoking, mealskipping (notably breakfast), as well as severely reduc-ing intake of foods deemed fattening (often red meatand dairy foods, which are sources of protein, iron, zincand calcium among other nutrients) and the adoption ofvery low energy (and therefore nutrient) diets. As wasshown by a recent survey on the wellbeing of children inEngland, girls tend to be more dissatisfied with theirappearance than boys (Rees et al. 2010); however, datafrom the 1997 NDNS, which found 16% of girls and3% of boys aged 15-to-18-years reported being on someform of diet (Gregory et al. 2000), suggests boys alsofeel such social pressures. Other research has suggestedthe prevalence of dieting may be a lot higher: Frenchet al. (1995) found 26% of adolescent girls to berestricting fat intake in their study, with extreme dietingmethods including fasting and the use of diet pills being

among the methods used to lose weight. Of concern isthe potential for such behaviours to develop into moreserious long term psychological problems (e.g. anorexia– see Section 4.7 for more information) (French et al.1995).

Adopting a healthy attitude to diet and exercise hasbecome increasingly difficult in a society where obesityis endemic and body fat is stigmatised (Hill 2002; Hill2006). Children’s and adolescents’ eating habits arestrongly influenced by the world around them, includingthe attitudes and habits of family, in particular of themother, and friends (Story et al. 2002). It is thereforeimportant that those involved in children’s developmentand upbringing try to instil in youngsters the need todevelop healthy dietary and exercise habits, in the hopethat such behaviours will track through into the adultyears.

Teenage pregnancy

According to a global report, the UK has the highestteenage pregnancy rate in Western Europe (PopulationAction International 2007). Teenage pregnancy hasprofound consequences for those affected, and is‘strongly associated with the most deprived andsocially excluded young people’ in society (Departmentfor Culture Schools and Families 2006). Within theUK, the 1999 government’s Teenage Pregnancy Strat-egy outlined plans to help overcome these statistics, bystating how it would accelerate progress already madetowards the target of halving the under-18 conceptionrate by 2010, from a 1998 baseline (Department forCulture Schools and Families 2006). Progress with thisstrategy is ongoing: the conception rate in 15-to-17-year-olds in England was 44.7 per 1000 women in1999 and had fallen to 41.2 conceptions per 1000 in2007; under-16 conception rate in 2007 was 8.3 per1000. While this is positive news, there is stillsomeway to go if the target is to be achieved. Further-more, geographical disparities in rates still exist acrossthe country, with girls in the North East being themost likely to become pregnant compared with thoseelsewhere in England (see (Department for CultureSchools and Families 2009) for further information).

Pregnancy during the teenage years will affect boththe emotional and physiological status of the mother.Nutritional demands increase to meet the needs of agrowing fetus, at a time when the maternal body stillrequires extra nutrients for growth and development.This is compounded by the fact that a considerablepercentage of young girls have sub-optimal intakes ofsome nutrients (Gregory et al. 2000). Iron is one such



nutrient that is particularly important during preg-nancy, but for which intakes are below the LRNI inover half of teenage girls (see Section 2). Epidemiologi-cal studies suggest that a low haemoglobin concentra-tion during pregnancy is a marker of increased risk oflow birthweight and perinatal mortality, although acausal relationship with iron supply has not beenestablished (SACN 2010). Folate intake is also of par-ticular concern – an adequate intake of folate is essen-tial before and during the first three months ofpregnancy, to help reduce the risk of neural tubedefects in the developing fetus. It is for this reason thatthe Department of Health recommends women ofchild-bearing age to take a 400 mg folic acid supple-ment daily (Department of Health 2004c). However,as the majority of teenage pregnancies are unplanned,consumption of folic acid supplements prior to con-ception and during the first trimester of pregnancy isunlikely.

6 Food provision in school

The provision of food in schools has seen major devel-opments over recent years, with new school food stan-dards being introduced in all four areas of the UK. Themain aim of these standards is to ensure that childrenreceive a healthy, balanced and nutritionally adequatemeal at lunchtime when in school, to provide them withthe nutrients needed for healthy growth and develop-ment. For decades, school meals have been seen as ameans by which to ensure children receive adequatenutrition [see (Passmore & Harris 2004)]. However,evidence began to emerge that the choice of food avail-able was resulting in many children selecting a meal ofrelatively low nutritional value and therefore schoolmeals were failing to meet children’s nutritional needs(Nelson et al. 2004; Nelson et al. 2006). This, coupledwith statistics showing that obesity levels were rising inall age groups and patterns of micronutrient deficiencieswere common especially in older children (see Sections 2and 4.1), led the governments of all four UK countries totake action to improve food served within the schoolenvironment. With a reported 3.5 million meals beingserved every day in schools in England and Wales alone(LACA 2004), this action was urgently needed.

Nutritional guidelines for school meals produced in1992 by the Caroline Walker Trust (The CarolineWalker Trust 1992) have been used as a reference toolfor the development of many of the school meal stan-dards in use today. School food standards in placethroughout the UK are compulsory and comprise

nutrient-based standards as well as food-based stan-dards that are compatible with the government’sEatwell plate (see Fig. 11).

In order to promote a consistent message abouthealthy eating to children, in most parts of the UKschool food guidelines extend beyond school lunches tocover other food served throughout the school day (seeTable 23). Nutrient-based standards are compulsoryonly for school lunches, and compulsory food-basedstandards cover not only school lunches but also foodavailable from tuck-shops, vending machines, breakfastclubs, mid-morning/afternoon catering, and after schoolclubs.

School food standards across the UK

England

A school meals review panel was set up in 2005 by theDepartment for Education and Skills to review anddevelop nutrition related standards for school meals. Itsreport ‘Turning the Tables: Transforming School Food’(School Meals Review Panel 2005) called for radicalchanges to school meals, which included restrictingfoods high in total and saturated fatty acids, sugar andsalt, as well as foods made with poor quality meat. ThePanel’s recommendations formed the basis of newschool standards for all food served within Englishschools, which were launched in three parts. Firstly,interim food-based standards for school lunches cameinto force in September 2006, followed by food-basedstandards for school food other than school lunches inSeptember 2007. Finally, nutrient-based standards forschool lunches were developed, which were required bylaw to be implemented in all primary schools by Sep-tember 2008, and all secondary schools, special schoolsand Pupil Referral Units by September 2009. When thenutrient-based standards became law, the interim food-based standards for school lunches were replaced withthe final food-based standards, whereas the food-basedstandards for school food other than lunches remainedthe same. All standards are legal requirements and applyto all local authority maintained primary, secondary,special and boarding schools and Pupil Referral Units inEngland (School Food Trust 2008a). The School FoodRegulations detail all of these standards (Departmentfor Children Schools and Families 2008).

Food-based standards (see Table 24) apply to allschool lunch services, including hot, cold and packedlunch services provided on a school day. The food-based standards for school food other than lunch applyto all food provision (except lunch) up to 6 pm, includ-ing breakfast clubs, mid-morning break services,



vending machines, tuck-shops, and after school snacksand meals. Independent schools and academies areexempt from the standards but are encouraged tocomply.

The food-based standards can help increase intakes offruit, vegetables and oily fish, but they may not besufficiently comprehensive to impact on intakes of fat,salt and sugar. The nutrient-based standards were set inparallel to increase the vitamin and mineral content ofschool lunches, and to decrease contents of fat, satu-rated fatty acids, NMES and sodium. Standards for thecontribution of macronutrients to energy intake fromschool lunches (Table 25), and maximum and minimumlevels for absolute amounts of macronutrients andmicronutrients (Table 26) were put in place. The contri-butions of macronutrients to energy from schoollunches are the same as recommended for total energyintake throughout the day (see Section 1). Maximum

levels were set for sodium, NMES, fat and saturatedfatty acids, and minimum levels were set for carbohy-drate, protein, fibre, vitamin A, vitamin C, folate,calcium, iron and zinc. The standard for energy is basedon an average value, rather than a minimum or amaximum value (Table 26). The standards are differentfor primary and secondary schools, reflecting differentnutritional needs at different stages of development(School Food Trust 2008a). The standards are designedto be achieved across the food offered at lunch timerather than meals consumed by individual children.

The School Food Trust carried out a national surveyof primary schools in England to assess the impact ofthe standards on catering provision and pupil foodselection and consumption (School Food Trust 2009;Haroun et al. 2010). The researchers found that com-pared with 2005, caterers now provide a more healthylunch that meets food-based and most nutrient-based

Figure 11 The Eatwell plate. Source: Department of Health (www.dh.gov.uk).



Tabl

e23

Aco

mpa

rison

ofsc

hool

mea

lsta

ndar

dsan

dsc

hem

esin

the

four

UK

area

s

Engl

and

Nor

ther

nIre

land

Scot

land

Wal

es

Are

scho

olfo

odst

anda

rds

inex

isten

ce?

Yes

Yes

Yes

Yes

–m

inim

umst

anda

rds.

Mor

est

ringe

nt(b

utno

tco

mpu

lsory

)gu

idel

ines

avai

labl

ein

Appe

tite

for

Life

Actio

nPl

an.

Do

thes

eco

mpr

ise?

Nut

rient

base

d-st

anda

rds

for

scho

ollu

nch?

Yes

No

Yes

No.

How

ever

,gui

delin

esav

aila

ble

(but

not

com

pulso

ry)

inth

eAp

petit

efo

rLi

feAc

tion

Plan

.Fo

od-b

ased

stan

dard

sfo

rfo

odot

her

than

scho

ollu

nch?

Yes

Yes

Yes

No.

How

ever

,gui

delin

esav

aila

ble

(but

not

com

pulso

ry)

inth

eAp

petit

efo

rLi

feAc

tion

Plan

.A

reth

ese

stan

dard

sco

mpu

lsory

?Ye

s–

stan

dard

sap

ply

toal

lloc

alau

thor

itym

aint

aine

dpr

imar

y,se

cond

ary,

spec

iala

ndbo

ardi

ngsc

hool

san

dpu

pilr

efer

ralu

nits

.

Yes

–st

anda

rds

appl

yto

all

gran

t-ai

ded

nurs

ery,

prim

ary

and

post

-prim

ary

scho

ols.

Yes

–st

anda

rds

appl

yto

all

stat

efu

nded

scho

ols.

Yes

–m

inim

umst

anda

rds

appl

yto

all

mai

ntai

ned

nurs

ery

scho

ols,

com

mun

ity,

foun

datio

nan

dvo

lunt

ary

prim

ary

and

seco

ndar

ysc

hool

san

dco

mm

unity

and

foun

datio

npr

imar

yan

dse

cond

ary

spec

ial

scho

ols.

Free

-frui

tsc

hem

e?Ye

s,al

l4-t

o-6-

year

-old

sre

ceiv

ea

free

piec

eof

frui

tor

free

vege

tabl

esda

ily.

No

natio

nalp

rogr

amm

e,ho

wev

era

varie

tyof

initi

ativ

esex

ist.

No

natio

nals

chem

ecu

rren

tlyin

exist

ence

,ins

tead

itis

upto

loca

laut

horit

ies

tode

cide

ifpu

pils

shou

ldre

ceiv

efre

efr

uit.

No

natio

nalp

rogr

amm

eex

ists.

For

mor

ein

form

atio

nab

out

scho

olm

eals

tand

ards

see:

ww

w.sc

hool

food

trus

t.co.

ukw

ww

.den

i.gov

.uk

ww

w.sc

otla

nd.g

ov.u

kw

ww

.phy

sical

activ

ityan

dnut

ritio

nwal

es.o

rg.u

k



standards, with substantial increases in fruit and veg-etable consumption (60% on average) and a 32%decrease in sodium intake. Improvements in relation tothe standards still need to be made for some nutrients(e.g. iron and zinc). By limiting the range of foods avail-able to healthier options, pupils now receive and eathealthier lunches. The average meal taken now containsover two portions of fruit and vegetables, and is lowerin fat, sugar and salt. Primary school pupils were foundto be responding positively to changes that had beenmade, which suggests that handled correctly, the intro-duction of healthier food in school is not a barrier toincreasing take up in primary schools. Indeed, in both

Table 24 Summary of food-based standards for school lunches and school food other than lunches in England

Food-based standards for school lunchesFood-based standards for school foodother than lunches

MO

REO

F Fruit and vegetables Not less than two portions per day per pupil, atleast one vegetable and one fruit

Fruit and/or vegetables must be provided at allschool food outlets

Oily fish Oily fish must be provided at least once every 3weeks

No standard

Bread Bread with no added fat or oil must be provided ona daily basis

No standard

Drinking water Free, fresh drinking water should be freely available at all times

Healthier drinks The only drinks permitted are plain water, low-fat milk, fruit juice, vegetable juice, plain soya, rice or oatdrinks enriched with calcium, plain fermented milk drinks, combination drinks, flavoured low fat milk;tea, coffee and milk containing less than 5% added sugars or honey

REST

RIC

TED Meat products A meat product (manufactured or homemade) from each of the four groups below may be provided no

more than once per fortnight across the school day, providing the meat product also meets thestandards for minimum meat content and does not contain any prohibited offal:

Group 1: Burger, hamburger, chopped meat, corned meat;Group 2: Sausage, sausage meat, link, chipolata, luncheon meat;Group 3: Individual meat pie, meat pudding, Melton Mowbray pie, game pie, Scottish (or Scotch) pie,

pasty or pastie, bridie, sausage roll;Group 4: Any other shaped or coated meat product

Starchy food Starchy food cooked in fat or oil should not be provided more than 3 times a week across the schoolday

Deep-fried food No more than two deep-fried food items in a single week across the school day

Salt and condiments No salt shall be available to add to food after cooking

Condiments may only be available in sachets or in individual portions of not more than 10 g or1 teaspoonful

Snacks Snacks such as crisps must not be provided. Nuts, seeds, vegetables and fruit with no added salt, sugar orfat are allowed. Dried fruit may contain up to 0.5% vegetable oil as glazing agent

Savoury crackers and breadsticks can only beserved with fruit, vegetables or dairy food

Savoury crackers and breadsticks must not beprovided

Cakes and biscuits Cakes and biscuits are allowed at lunchtime butmust not contain any confectionery

Cakes and biscuits must not provided

NONE Confectionery Confectionery must not be provided

Source: School Food Trust (2008a).

Table 25 Standards for contribution of macronutrients to energyfrom school lunches in England

Not less than 50% fromcarbohydrate

Predominantly starch andintrinsic/milk sugars

Not more than 11% fromnon-milk extrinsic sugars

Not more than 35% from fat Predominantly unsaturatedfatty acids

Not more than 11% fromsaturated fatty acids

Protein Protein

Source: School Food Trust (2008a).



the primary and secondary sectors, take up hasincreased since the introduction of the final versions ofthe standards (Nelson et al. 2010). A report on anational survey in secondary schools in England is dueto be published on the School Food Trust website inDecember 2011. For more information on school foodprovision in England see Nelson (2011) in this issue ofthe Nutrition Bulletin.

The School Food Trust oversees school food inEngland; for more information see: www.schoolfoodtrust.org.uk.

Scotland

Scotland led the way in the UK in terms of transformingschool food. Hungry for Success (2002), the report ofScotland’s Executive Panel on School Meals, set out awhole school approach to school meals, based aroundthe introduction of nutrient-based standards for schoolmeals, to which all state funded schools were recom-mended to comply. Adoption of these standards wasrecommended in all special and primary schools in Scot-land by 2004 and in all secondary schools by 2006(Expert Panel on School Meals 2002). The Schools(Health Promotion and Nutrition) (Scotland) Act 2007(The Scottish Government 2007) builds on the successof Hungry for Success and, together with provision ofthe Nutritional Requirements for Food and Drink inSchools (Scotland) Regulations 2008 (The Scottish

Government 2008b), forms part of a wider health pro-moting schools approach. The Regulations comprise (1)nutrient standards for school lunches, (2) food anddrink standards for school lunches and (3) food anddrink standards for school food and drinks other thanschool lunch, served in breakfast clubs, tuck-shops,vending machines, mid-morning services, communitycafes and after school clubs. The Regulations apply tolocal authority schools, grant-aided schools and hostelsfor pupils maintained by a local authority. The Regula-tions came into effect in August 2008 for primaryschools and in August 2009 for secondary schools. Thenutrient-based standards comprise minimum andmaximum levels for the same nutrients included in theEnglish standards: minimum levels were set for protein,carbohydrate, fibre, iron, calcium, vitamin A, vitamin C,folate and zinc; maximum levels were set for total fat,saturated fatty acids, NMES and sodium (The ScottishGovernment 2008a).

A summary of the food standards for school lunchesin Scotland is presented in Table 27, these differ slightlyfrom the English standards. Separate drink standardsfor schools are included in the Regulations. These,together with food and nutrient standards, can be foundin the Healthy Eating in Schools guide from the Scottishgovernment, which aims to support schools in imple-menting the Regulations (The Scottish Government2008a). A supplementary guide for children and youngpeople was published in 2010 (The Scottish Govern-ment 2010b).

Table 26 Minimum and maximum levels of nutrients in school lunches in England

Nutrient Minimum or maximum Primary Secondary

Energy (kJ) 2215 � 5% (111) 2700 � 5% (135)Energy (kcal) 530 � 5% (26.5) 646 � 5% (32.3)Carbohydrate (g) Min 70.6 86.1NMES (g) Max 15.5 18.9Fat (g) Max 20.6 25.1Saturated fatty acids (g) Max 6.5 7.9Protein (g) Min 7.5 13.3Fibre (g) Min 4.2 5.2Sodium (mg) Max 499 714Vitamin A (mg) Min 175 245Vitamin C (mg) Min 10.5 14.0Folate (mg) Min 53 70Calcium (mg) Min 193 350Iron (mg) Min 3.0 5.2Zinc (mg) Min 2.5 3.3

Source: School Food Trust (2008a).NMES, Non-Milk Extrinsic Sugars.



Wales

Within Wales, the Education (Nutritional Standards forSchool Lunches) (Wales) Regulations 2001 provide a setof minimum standards with which school lunches mustcomply (Welsh Assembly Government 2003). Theyapply to maintained nursery schools, community, foun-dation and voluntary primary and secondary schools,and community and foundation primary and secondaryspecial schools. As these are minimum standards, localauthorities and schools can adopt their own more strin-gent standards if they choose to do so. However, in a bidto further improve food and drink served throughoutthe school day, Appetite for Life, produced by the Foodin Schools Working Group in 2006 set up by the Welshgovernment, sets out the strategic direction and actionsrequired to improve the quality of school lunchesin Wales (Welsh Assembly Government 2008b). Thisincludes the setting of more stringent food- andnutrient-based standards for school lunches. These stan-dards are applied to all food, not just set menus, pro-vided in school cafeterias and dining rooms atlunchtime. The nutrient-based standards include thesame nutrients as in the Scottish and English standards.

The food-based guidelines outlined in the Appetite forLife Action Plan are presented in Table 28. Separatestandards for drinks provision were also developed;these as well as the nutrient- and food-based guidelinesare outlined in the Appetite for Life Action Plan reportby the Welsh Assembly Government (2008b).

Uniquely to Wales, the Welsh Assembly governmenthas made a commitment to provide all children ofprimary school age in maintained schools in Waleswith a free, healthy breakfast, as part of their PrimarySchools Free Breakfast Initiative. For more informa-tion about this, see (Welsh Assembly Government2008c).

Northern Ireland

Nutritional standards for school lunches in NorthernIreland have been produced under the School food: topmarks programme, which is a joint venture betweenthe Department of Education, the Department ofHealth, Social Services and Public Safety, and theHealth Promotion Agency for Northern Ireland. Fol-lowing a pilot in 2004/2005, new nutritional standards

Table 27 Summary of food standards for school lunchesin Scotland

Fruit and vegetables A choice of at least two types of vegetablesand two types of fruit (not including fruitjuice) must be provided every day as partof the school lunch

Oily fish Oily fish must be provided at least onceevery three weeks

Variety of extra bread Additional bread must be provided everyday as a meal accompaniment, with avariety of bread, which must includebrown or wholemeal, being provided overthe week

Oils and spreads Only oils and spreads high inpolyunsaturated and/or monounsaturatedfatty acids can be used in foodpreparation

Deep-fried foods Menus must not contain more than threedeep-fried items in a single week

Chips, if served must be served as part of ameal

Table salt and othercondiments

Additional salt cannot be providedCondiments must be dispensed in no more

than 10 ml portionsConfectionery No confectionery can be providedSavoury snacks No savoury snacks can be provided except

savoury crackers, oatcakes or breadsticks

Source:The Scottish Government (2008a).

Table 28 Summary of recommended food standards for schoollunches in Wales as outlined in the Appetite for Life Action Plan

Fruit and vegetables Not less than two portions per day perchild, at least one vegetable or salad andone fruit; a variety should be providedover 1 week

Oily fish On the school lunch menu at least onceevery 2 weeks

Deep-fried potatoproducts

Potatoes and potato products cooked infat/oils in the school kitchen or duringmanufacture must not be served morethan twice a week

Deep-fried products Other food items cooked in fat/oils in theschool kitchen or during manufacturemust not be served more than twice aweek

Manufactured meat products Should not be reformed/reconstituted foodsBread (without spread) Available throughout lunch, a variety of

breads should be encouraged includingwholemeal bread

Confectionery andsavoury snacks

Not to be made available

Salt Not added to vegetables during cooking,restrict or remove salt from recipes andreplace with appropriate and acceptableherbs and spices, not available at lunchtables or at the service counter

Source: Welsh Assembly Government (2008b).



for school lunches were introduced and made compul-sory from September 2007 (School Food Top Marks2009a). In April 2008, the nutritional standards wereextended to include all other food and drinks providedin school, such as via breakfast clubs, tuck-shops andvending machines (School Food Top Marks 2009b).The nutritional standards are food-based and aresimilar to those in other UK countries and aim toensure that more fruit and vegetables are available inschools, and that fresh free drinking water is available.Furthermore, many high fat, high sugar or saltedsnacks have been replaced with healthier options suchas fruit, bread-based snacks, milk and water. Nutrient-based standards for school lunches are not available inNorthern Ireland. For more details see School FoodTop Marks (2009a) and School Food Top Marks(2009b).

Free school meals

Providing free school meals to children from low-income families is an important public health measure.Children from all areas of the UK are eligible for freeschool lunches if their parents receive various forms ofassistance, including Income Support, Income-relatedJobseekers Allowance and support under Part VI of theImmigration and Asylum Act 1999 (for full informationsee www.Direct.gov.uk). It is estimated that about 1.8million children and young people are entitled to freeschool meals; however, approximately one in five chil-dren fail to take up this provision in primary schoolsand about a quarter in secondary schools (LACA 2004).One commonly cited reason for this is the perceivedstigma associated with receiving free school meals,which prevents parents signing up for free meals, as wellas eligible children taking up their entitlement (Harper& Wood 2009).

Packed lunches

Uptake of school meals in primary schools in Englandduring 2008/2009 was around 40%, with the vastmajority of the remainder bringing a packed lunch(School Food Trust 2009). In contrast to lunch andother food provided by schools, for which clear guide-lines exist, there are no official guidelines for packedlunches brought to school from home. While someprimary schools have introduced packed lunch policiesto support healthier eating and offer clear guidance andan opportunity to improve food consumed by all pupils,there is little evidence of their effectiveness (School FoodTrust 2009), and school lunches generally remain the

healthier option (Pearce et al. 2011). The School FoodTrust and the British Nutrition Foundation provide tipsfor healthy school lunch boxes on their websites(www.schoolfoodtrust.org.uk/schools/projects/packed-lunches and www.nutrition.org.uk/healthyliving/healthyeating/healthy-packed-lunches).

The Primary School Food Survey 2009 found thathealthier food and drink items were chosen and eatenmore frequently by pupils taking a school lunch com-pared with those bringing a packed lunch, and packedlunches often included items now restricted in schoollunches (School Food Trust 2009) . Two thirds of pupilstaking school lunches took servings of vegetables andsalad compared with only 8% of pupils bringing packedlunches. Similar trends were seen for water. Far fewerpupils taking school lunches ate confectionery, non-permitted drinks and snacks. Average nutrient intakesfrom school lunches as eaten were more often in linewith healthy eating recommendations than intakes frompacked lunches. The nutrient content of an averagepacked lunch contained more carbohydrate, NMES, fat,saturated fatty acids, vitamin C, sodium, calcium, andless protein, fibre and zinc compared with the averageschool lunch (School Food Trust 2009; Pearce et al.2011).

A recent meta-analysis of studies comparing schoollunches with packed lunches found that differences innutrient provision were larger for all nutrients after theintroduction of food-based standards compared withthe period of no standards, with school lunches pro-viding a more favourable nutrient composition thanpacked lunches (Evans et al. 2010a). Evans and col-leagues also carried out a randomised intervention trialnamed ‘SMART’ to improve the food and nutrientcontent of children’s packed lunches. The researchersprovided the intervention group members with aSMART lunch box (two plastic food boxes and a lunchbox cooler bag) and supporting materials, includingwall charts with ideas for packed lunches, a few weeksof menus, reward stickers and information leaflets onhow to encourage children. The control group onlyreceived a simple one-page leaflet on how to improvechildren’s packed lunches. The results showed that, inthe intervention group, moderately higher weights offruit, vegetables, dairy and starchy foods and lowerweights of savoury snacks were provided to children.Children in the intervention group were also providedwith slightly higher levels of vitamin A and folate.Levels of fats, sugars and sodium did not improve, anddespite an emphasis on starchy foods and drinkingwater, the weight of sandwiches and sweetened drinksdid not change (Evans et al. 2010b).



Schemes encouraging fruit andvegetable consumption

Despite the fact that there are clear public health mes-sages throughout the UK encouraging the consumptionof fruits and vegetables, research consistently shows thatchildren do not eat enough, with the latest NDNSsurvey (using disaggregated data) reporting 11-to-18-year-olds eat on average less than half the 5 A DAYrecommendation (no data yet available for younger chil-dren) (Bates et al. 2010). Providing free fruit to school-children is seen as a way to tackle health inequalities andto help ensure all children get a healthy start in life.However, the provision of free fruit in schools is highlyvariable across the UK and mainly restricted to youngerage groups.

Within England, four- to six-year-old children whoattend a Local Education Authority maintained infant,primary or special school are eligible to receive a freepiece of fruit or free vegetables each school day. Whileparticipation in the School Fruit and Vegetable Scheme(SFVS) is voluntary, schools are encouraged to partici-pate. The roll out of the SFVS was complete in Englandby late 2004. It was initially funded by National Lotterymoney and is now funded by the Department of Health(Department of Health 2010). The most recent evalua-tion of the scheme found that children receiving theSFVS ate more fruit and vegetables in 2008 comparedwith 2004 when the scheme was initiated, althoughchanges may partly be explained by the introduction ofschool food standards. It was suggested that effects ofthe intervention do not carry over into the home envi-ronment (Teeman et al. 2010).

While Wales does not have a national fruit and veg-etable scheme in schools, the Fruit Tuck Shop initiativeis one which encourages pupils, parents and staff to setup fruit tuck-shops in schools to provide fresh fruit,dried fruit or fruit juice to schoolchildren throughoutthe school day (Physical Activity and NutritionNetwork Wales 2009). A study evaluating the impact ofthe Fruit Tuck Shop initiative in schools in deprivedareas found that, in isolation, fruit tuck-shops were noteffective in changing children’s snacking behaviour inschools, but that fruit tuck-shops had a greater impactwhen reinforced by school policies restricting the typesof foods students were allowed to bring to school(Moore & Tapper 2008).

Schools in Northern Ireland can select from a varietyof initiatives that focus on healthy snacking duringbreak time. Examples include the Boost Better Breaksaward and the Smart Snack award, both of which statethat for schools to gain membership they must only

offer milk (and/or water) and fresh fruit and vegetablesat break times. Information about these and otherschemes in Northern Ireland can be found in the Learn-ing to Eat Well Report (Health Promotion Agency forNorthern Ireland 2001).

Within Scotland a free fruit scheme was in existenceacross all publicly funded schools between 2003 and2006, and formed part of the Scottish Executive’sHealth Improvement Programme. As part of thisscheme, all children in primaries 1 and 2 (ages 4-to-7-years) received free fruit 3 times per week. This schemehas now ended but The Schools (Health Promotion andNutrition) (Scotland) Act 2007 gives local authoritiesthe power to decide whether they choose to provide freefruit during the school day (The Scottish Government2007). An evaluation of the original scheme, publishedin 2005, found that authority professionals and schoolstaff members perceived that the initiative had been verysuccessful. For example, 90% of school respondentsthought that the initiative had brought about animprovement in general eating habits and almost 60%perceived that pupils were consuming more fruit andvegetables as part of their school meals (MacGregor &Sheehy 2005).

Breakfast clubs

There has been a trend over recent years for schools tointroduce breakfast clubs, particularly in primaryschools. This has been driven by concerns that a sub-stantial proportion of pupils are not eating breakfastand arrive at school hungry, which may impact nega-tively on school performance (see Section 4.7). In addi-tion to the provision of food, breakfast clubs can alsohelp develop social skills and provide opportunity foradditional learning through ‘play’ activities, or providetime to complete homework.

The School Food Trust carried out a study looking atthe potential benefits of breakfast clubs, comparing 13primary schools with breakfast clubs to 9 schoolswithout, all located in deprived areas of London. Oneyear after introduction, average Key Stage 2 resultswere statistically significantly higher by 0.72 points inthe schools with breakfast clubs compared with a non-significant 0.27 point increase in the schools withoutbreakfast clubs. This difference was sustained over thenext few years with no further increases. Schoolsbelieved that they had reaped significant benefitthrough the introduction of breakfast clubs, especiallyin the case of the most socially deprived. The benefitsincluded improvement of social skills, of punctuality ofchildren who were frequently late and of children’s



health and concentration levels (School Food Trust2008b). A recent review on breakfast clubs concludedthat there are benefits to mental performance andsocial development, although it is unclear whether suchbenefits are derived from the consumption of breakfastper se, the environment or a combination of the two.The authors also suggest that benefits of breakfastclubs are more pronounced in deprived areas (Defeyteret al. 2010).

Nutritional guidelines for breakfast clubs as well asother resources that support schools in setting up break-fast clubs are provided by ContinYou, a UK communitylearning organisation (www.continyou.org.uk).

7 Food in the curriculum

The UK comprises four countries, each of which has itsown independent curriculum.

England

Reviews of the primary and secondary curricula, readyfor teaching from September 2014, are underway.While the review process takes place, schools shouldfollow the current curriculum in place (http://curriculum.qca.org.uk/). In primary schools (5-to-11-years) food is taught as a compulsory part of thecurriculum – mainly through the subjects of Designand Technology (D&T); Science; and Personal, Socialand Health Education (PSHE). Each of these threesubject areas specifically highlights aspects of foodeducation for children. Combined, they provide oppor-tunities for children to learn how to cook, understandand apply healthy eating messages and learn about theunderpinning scientific principles of food science andfood safety.

In secondary schools, food is taught mainly throughD&T: food. Within this subject, pupils learn abouthealthy eating, ingredients, equipment and cooking.Nutrition and digestion are also taught in Science, andtheoretical aspects of healthy eating and general healthare built into PSHE. The curriculum for this age rangewas updated in 2007. Food education aspects wereemphasised in D&T, with specific references being madeto cooking, healthy eating, food safety and nutritionalneeds. To support this change, schools were able to offerthe Licence to Cook programme as a non-statutoryentitlement. The contract for this project has nowended. The British Nutrition Foundation was part of aconsortium contracted by government to develop theresources for this initiative. The project website, devel-oped by the British Nutrition Foundation, had over

650 000 registered student users. Food education,through the D&T curriculum, is optional.

Northern Ireland

The primary curriculum in Northern Ireland is set out insix areas of learning, with aspects of food being taughtthrough different areas in a multi-disciplinary fashion.Food education is supported in primary schools (ages5-to-11-years) through the subjects of The WorldAround Us (Science and Technology, Geography) andPersonal Development and Mutual Understanding. InNorthern Ireland references to specific understandingor practical cooking activities are not generallyhighlighted. However, guidance documents are availableto help teachers plan appropriate activities for the chil-dren they teach.

At secondary school, food is taught through threemain areas of learning: Learning for Life at Work(Home Economics); Science and Technology (Science);and Learning for Life and Work (Personal Develop-ment). Home economics is compulsory for all second-ary school-aged pupils (ages 11-to-14-years), and istaught through 3 themes: Healthy Eating, Home andFamily Life, and Independent Living. The concept is tohelp all young people learn practical skills in foodsafety and preparation, as well as the opportunityto explore real issues that they may face as familymembers, citizens and consumers. It is hoped that thisapproach will help support them for future indepen-dent living. The primary and secondary curricula areavailable at www.nicurriculum.org.uk.

Scotland

The curriculum in Scotland (www.ltscotland.org.uk/curriculumforexcellence) has been through a compre-hensive review, with Curriculum for Excellence beingpublished in 2009. The curriculum, for children agedfrom 3-to-18-years, shows the progression for differentaspects of food education, known as lines of develop-ment. Food aspects are most explicitly highlighted forteaching through three of the curriculum areas: Healthand Wellbeing; Science; and Technologies. However,with a strong emphasis on inter-disciplinary (cross-curricular) learning, links can be made (and are activelyencouraged) with other curriculum areas.

The curriculum clearly highlights food educationlearning, for both primary and secondary schools –all of which is statutory. For example, Health andWellbeing includes the study of energy and energybalance (Physical Activity and Health), as well as



nutrition, safe and hygienic practices, and food and theconsumer (Food and Health). In Science there are linksto body systems and cells, and to the properties anduses of substances. Lastly, Technologies provides thefood contexts for developing technological skills andunderstanding.

Wales

The curriculum in Wales (www.learning.wales.gov.uk), which was updated in 2008, ensures that childrenin primary and secondary schools experience learningabout food. The three areas of the curriculum wherefood is mainly featured are: D&T: food; Science; andPersonal and Social Education. The area where mostchildren learn about food, particularly undertaking andlinking practical cooking work to elements of nutrition,is D&T: food. This is a compulsory component of thecurriculum, for children aged 7-to-14-years, coveringaspects of cooking skills, food safety and hygiene, andapplication of healthy eating, as well as consideringissues surrounding sustainability and the science behindfood.

Supporting the curriculum

The British Nutrition Foundation runs an educationprogramme for UK schools, entitled Food – a fact of life(FFL), which provides a range of free resources. In 2010the FFL website (www.foodafactoflife.org.uk), wheremost of the resources are available, received over onemillion visits. FFL provides teachers with a comprehen-sive collection of resources to support the education ofchildren and young people aged 3-to-16-years. Broadlyit provides information in the following topic areas:healthy eating; diet and health; cooking; food safety;and farming. FFL supports the curricula throughout theUK and has been developed to provide a progressiveframework to support and inspire all those involved infood and nutrition education. In addition, continuingprofessional development for teachers is also offered.

Except for a small range of printed posters aboutnutrients and cooking, the resources are available in arange of digital formats. These include worksheets,videos, podcasts, excel templates, differentiated onlinetutorials, recipes, interactive whiteboard activities, Pow-erPoint presentations and information pages. A series ofeSeminars is also provided for students and teachers.

8 Promoting healthy lifestyles in children

In recognition of the growing problems of obesity andphysical inactivity among today’s children, many initia-

tives have been developed, both at national and locallevel, to try to halt and even reverse these trends. It isrecognised that the solutions to such problems are farfrom simple. The initiatives discussed below all outlineways to support children and their families to leadhealthier lives.

Examples of governmental initiatives across the UK

Healthy Weight Healthy Lives

Healthy Weight Healthy Lives was a cross-governmental strategy for England by the previousgovernment that aimed to support people to maintain ahealthy weight and encourage physical activity, therebycreating a healthy society (HM Government 2008). Pub-lished in January 2008, the document set out a strategyto make England ‘the first nation to reverse the risingtide of overweight and obesity’. The initial focus of thecampaign was on children, with the aim of reducing theproportion of overweight and obese children in 2020to 2000 levels. In order to do this, the programmelaid out immediate plans to, among other things, investin an evidence-based social marketing campaign(Change4Life); ensure all schools are Healthy Schools;and develop tailored programmes to increase participa-tion in physical education.

Change4Life and SmallSteps4Life

Change4Life is a society-wide movement that has con-tinued under the Coalition government and that encour-ages people to ‘eat better, move more, and live longer’.The campaign began in 2009, with the aim of makingweight and physical activity ‘hot-topics’. Launched in anumber of phases, it began by addressing the issue ofobesity, before going on to personalising it to individu-als and families, and then inspiring and supportingpeople to change their behaviour. The campaign, ini-tially targeted at families with young children, looked attopics including ‘me size meals’ and ‘snack swaps’.Smallsteps4life is a school focused approach addressinghealthy eating, exercise and emotional health of school-children. It provides material for teachers, and includeschallenges for students and pledges from students. Formore information see www.nhs.uk/Change4life andsmallsteps4life.direct.gov.uk.

Healthy Schools

The Department for Health and the Department forChildren, Schools and Families (DCSF) set up the



Healthy Schools initiative in England as a key deliverymechanism to help achieve targets outlined in HealthyWeight Healthy Lives (HM Government 2008) andThe Children’s Plan from the DCSF [see (Departmentfor Children Schools and Families 2007)]. The Pro-gramme was based around four themes, relating toboth the curriculum and the school environment: (1)Personal, Social, Health and Economic education; (2)Healthy Eating; (3) Physical Activity; and (4) Emo-tional Health and Wellbeing. The previous governmentset a target for all schools to be participating inthe Healthy School Programme, with 75% tohave achieved Healthy School status, by the end of2009.

In July 2010, the new Coalition government con-firmed that Healthy Schools will continue, recognisingthat the initiative plays an important role in helpingchildren and young people reach their full potential.However, the programme organisation is changing toreflect new health policies and priorities. The HealthySchools website was archived in April 2011 and a newHealthy Schools toolkit went live on the Department forEducation website. The toolkit is based around a healthand wellbeing change model. It is designed to enableschools to ‘plan, do and review’ health and wellbeingimprovements for their children and young people. Formore information about Healthy Schools visit www.education.gov.uk.

Food and Fitness – Promoting Healthy Eatingand Physical Activity for children and youngpeople in Wales

This five-year implementation plan, launched in 2006,aimed to build upon the many national strategiesalready in existence in Wales (including ClimbingHigher – the Welsh Assembly Government Strategy forSport and Physical Activity, and Food and Well Being:Reducing Inequalities Through a Nutrition Strategy forWales), as well as local programmes, and provide aframework for integrating action on nutrition andphysical activity for children and young people in Wales(Welsh Assembly Government 2006). The plan wasbased around seven key actions, which look at nutritionand physical activity both within and outside the schoolenvironment, in a bid to provide a co-ordinatedapproach to food and fitness to improve the health ofthe Nation’s children. One such action focused onextending the Welsh Network of Healthy Schoolsscheme, which is similar to the Healthy Schools schemein operation in England.

Healthy Eating, Active Living – An action plan toimprove diet, increase physical activity andtackle obesity

This action plan from the Scottish Parliament stateshow the country aims to improve the diet and physicalactivity habits of the nation set over the period of2008–2011, in a bid to establish a base from which totackle the Nation’s obesity problems (The ScottishGovernment 2008c). In this action plan the Scottishgovernment sets out commitments aimed at improvingthe health of Scottish people. The commitments aretargeted at various population groups, including chil-dren, and address various issues, including diet andphysical activity.

Preventing overweight and obesity in Scotland: aroute map towards healthy weight

This Route Map, developed by the Scottish Govern-ment and the Convention of Scottish Local Authorities(COSLA), outlines a plan to ‘reduce the rate of increasein the proportion of children with their Body MassIndex outwith a healthy range by 2018’ (The ScottishGovernment 2010a). The policy directions set out inthis document are aimed at central and local govern-ment decision-makers working with their partners inagencies, the third sector, NHS Scotland and businessto develop and subsequently deliver the long-term solu-tions to this problem. The preventative actions outlinedin this report are grouped under four categories: (1)Energy consumption – controlling exposure to, demandfor and consumption of excessive quantities of highcalorific foods and drinks; (2) Energy expenditure –increasing opportunities for and uptake of walking,cycling and other physical activity in our daily lives andminimising sedentary behaviour; (3) Early years –establishing life-long habits and skills for positivehealth behaviour through early life interventions; and(4) Working lives – increasing responsibility of organi-sations for the health and wellbeing of their employees.A joint governmental leadership group, including Min-isters, COSLA leaders and key stakeholders includingthe NHS and the public health community is scheduledto be the visible focus of the Route Map and to ensureits implementation by holding decision-makers toaccount.

Investing for Health

Investing for Health is the public health strategy forNorthern Ireland (Department of Health Social Servicesand Public Safety 2002). Published in 2002, this action



plan focuses primarily on reducing health inequalitieswithin the population, and therefore focuses on lowerincome groups rather than setting targets for the popu-lation as a whole. It does, however, include childrenfrom low-SES backgrounds. By setting out aims toimprove the dietary habits of this group, it hopes toreduce commonly seen problems of this populationsubset, including dental decay.

A Children’s Environment and Health Strategyfor Europe

The Children’s Environment and Health Action Planfor Europe (CEHAPE) is an initiative led by the WHORegional Office for Europe. Launched in June 2004,it was signed by all 53 member states of the WHOEuropean Region, including the UK. Within the UK theHealth Protection Agency became responsible forevaluating children’s environmental health, and recom-mending how the UK can protect the health of childrenand young people from environmental hazards (HealthProtection Agency 2009). Priorities outlined in thisinclude reducing the prevalence of overweight andobesity, and reducing morbidity from a lack ofadequate exercise, by implementing health promotionactivities that focus on diet, physical activity andhealth, and providing safe, secure and supportive envi-ronments for children to be active within. The UKstrategy builds on and complements policies and activi-ties already undertaken by government departments,devolved administrations, local and regional authoritiesand the NHS.

Examples of other schemes in existence withinthe UK

MEND

Mind, Exercise, Nutrition. . . . Do It! (MEND) is asocial enterprise, whose aim was to ‘enable a signifi-cant, measurable and sustainable reduction in globalchildhood and family overweight and obesity levels’.MEND claims to be the first clinically proven commu-nity based child weight management programme.MEND 5–7 and MEND 7–13 are offered to thosechildren aged 5-to-13-years considered to be above ahealthy weight, and their families, and are free toattend. These MEND programmes consist of two-hoursessions run twice a week over a 10-week period, inwhich parents and children are taught about food andnutrition and what encompasses a balanced diet; areencouraged to become more active; and are also taught

techniques to help keep them motivated and ensure thenew lifestyle changes taught are adhered to. MEND2–4 focuses on encouraging children aged 2-to-4-yearsand their parents to adopt healthy habits early on, andcan be attended by children of any weight. A ran-domised controlled study evaluating the effectivenessof the MEND programme on obese children aged 8-to-12-years found that participation in the programmewas effective in reducing adiposity in children andeffects were sustained 9 months after the intensive partof the intervention. The authors also pointed out thatthe programme was one of the few paediatric obesityinterventions which conforms to expert recommenda-tions (Sacher et al. 2010). For more information on theMEND programmes, see www.mendprogramme.org.

Let’s Get Cooking

Let’s Get Cooking is a national network of cookingclubs for children, families and their communities acrossEngland. The programme started in 2007 and during itsfirst five years, Let’s Get Cooking is using £20 millionfrom the Big Lottery Fund to set up the first 5000 clubs.Let’s Get Cooking has three key targets: (1) by the endof the 5-year programme more than one million chil-dren, family members and members of the local com-munity will increase their food preparation or cookingskills as a result of Let’s Get Cooking; (2) 70% ofparticipants who learn a new healthy eating skillthrough Let’s Get Cooking will replicate that skill athome; and (3) 50% of children, young people and fami-lies who participate in Let’s Get Cooking will increasetheir intake of nutritionally healthy food. Let’s GetCooking has already exceeded these targets with morethan a year still to run. Cooking clubs that join Let’s GetCooking receive funding for cooking equipment andclub-running costs, training for adult helpers and arange of resources. Let’s Get Cooking resources includea start-up pack for each club, wall charts, food safetyadvice, child-friendly versions of recipes, a termly activ-ity and newsletter. All clubs have their own club page onthe website and have access to downloadable resourcesand advice. The aim is that Let’s Get Cooking clubs willbe sustainable and that they continue to run afterfunding has ended. For further information visit www.letsgetcooking.org.uk.

Food Dudes

Food Dudes is a healthy eating school-based interven-tion targeted at primary schoolchildren. This pro-gramme (undertaken in the school environment) uses



influential role models (food dudes) to encourage chil-dren to repeatedly taste fruits and vegetables. During the16-day intervention children are shown six short FoodDudes video episodes and letters of encouragement areread to them. Home packs are also provided to ensurehealthy behaviours learnt in the classroom are contin-ued in the home environment. After this initial phase,children continue to be encouraged to eat fruit andvegetables with the use of tools such as classroom wallcharts to record consumption. The children are pre-sented with fruit and vegetables during break time andlunch. In 2007, the Irish government made the FoodDudes programme available to all primary schools inthe country. The programme has also been rolled-out inselected areas of England (~130 schools), with a view toeventually making it nation-wide.

Studies in the UK and Ireland have shown that theFood Dudes programme significantly increased con-sumption and liking of fruits and vegetables in children,both during (Lowe et al. 2004; Horne et al. 2009) andafter the programme (Lowe et al. 2007; Horne et al.2009). In the Irish study, the effect of intervention wascompared with a school where fruit and vegetables werepresented but no intervention was conducted. Both inthe short and long term, fruit and vegetable consump-tion was increased only in the intervention group. Oneyear after the programme, the fruit and vegetablecontent of lunch boxes packed by parents was signifi-cantly increased in the intervention group, which sug-gests an overall positive influence of the programme onfruit and vegetable intake in children, even outside theschool setting (Horne et al. 2009). For more informa-tion visit www.fooddudes.co.uk.

Walk to school initiative

The aim of this campaign, which started in 1996, was toencourage parents, children and young people to makewalking to school part of their daily routine. The cam-paign is run by the national charity Living Streets. Aspart of the campaign, two national awareness events arerun each year: Walk to School Week in May and Walk toSchool Month in October. A year-round walking pro-motion scheme called Walk Once a Week is aimed atprimary schools and Campaign-in-a-box and Free yourFeet are aimed at secondary schoolchildren. For moreinformation visit www.walktoschool.org.uk.

Acknowledgements

The Foundation wishes to thank the members of theFoundation’s Scientific Advisory and Industrial Scien-

tists Committees who have kindly commented on thecontents of this Briefing Paper. We are also grateful toKellogg’s for financial assistance to support some of thetime spent writing this paper, and to Heather Yüregirwho contributed to an early draft whilst working at theFoundation.

Conflict of interest

The Foundation is grateful to Kellogg’s for financiallysupporting some of the time spent on the preparation ofthis Briefing Paper. However, the views expressed in thispaper are those of the authors alone and Kellogg’s havenot been involved in writing or shaping its contents.

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