Food Culture and Child Health: How can we understand it What is its impact generally and on children

1
Food Culture and Child Health How can we
understand it? What is its impact generally and
on children with specific difficulties? How
can we influence it at school and at home?

• Dave Rex, Child Health Lead Dietitian, NHS
  Highland
• David.rex_at_hpct.scot.nhs.uk

2
Nutritional Impact of the Modern UK Diet

• The modern diet is largely responsible for high
  rates of heart disease, stroke, some cancers,
  diabetes, poor dental health, obesity and many
  other physical health problems
• The impact of our modern diet on our brain is
  likely to be at least as great
• This means that the food we eat may have
  immediate meaningful impact on how we feel and
  function from day to day
• In short, a good diet should add life to years,
  not just years to life

3
Food culture

• We now have generations of people with little or
  no food literacy
• People are not able to make well informed choices
• Our national mindset is to perceive healthy
  food as unpleasant, and unhealthy food as
  treats
• Health promoting schools represent a massive
  opportunity to change this

4
Food culture

• Our food culture is shaped by many social,
  practical and political influences over many
  years
• Globalisation means that the rate of change in
  food culture is increasing
• This represents a threat and an opportunity

5

• Remember that mince and tatties,
• macaroni cheese and sugar are the result
• of global Trade with Peru, Italy and the
• Caribbean

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• Healthy food is....
• A commodity to be traded and......
• A fundamental Human right

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• Good foods make bad commodities
• Bad foods make good commodities

8
Shelf Life

• Hydrogenation, salt, sugar and preservatives all
  improve the shelf life of food, but shorten the
  shelf life of the person who eats that food

9
Food and its Social Significance

• Food has a functional role but......
• In human society, it has an even bigger social
  role
• This means that food choice is not rational
• Being irrational with food is central to the
  human condition
• This is true for children and adults alike

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Changing food culture

• In order to develop a healthy food culture, we
  must first become for self-aware and understand
  that ours tastes are socially and politically
  constructed
• Schools represent a major opportunity to shift
  food culture in a healthier and more sustainable
  direction

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A healthier and sustainable direction for school
food

• Nutrition
• Fair trade
• Local food
• Sustainable agriculture
• Waste reduction, recycling and composting

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Connections Between Food and Health

• Food and health are not just connected by
  nutrition and food poisoning
• Our choices affect the health and wellbeing of
  the environment and people engaged in food
  production
• Schools can teach children how to be both healthy
  consumers and responsible citizens

13
Nutrition in Schools The National Picture

• The Scottish Executive developed nutrient based
  school meal standards before England
• Extra funding was committed
• Implementation is monitored through school
  inspections by Hmie
• The School Food trust has been set up to oversee
  similar improvements in England
• Parallel initiatives are taking place in Wales
  and Northern Ireland

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What is Happening in Highland Schools?

• Health promoting schools Your Choice to
  Healthy Living
• Hungry for success - nutrient based standards
  tied to school inspections
• Fruit in schools - 3 days a week for P1s and
  2s
• Food, nutrition and health policy for highland
  schools
• Toolkits for tuck shops and packed lunches
• Many promising pilot projects involving cooking,
  growing and learning about food
• Planning and evaluation toolkit

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Toolkits for Snacks and Packed Lunches

• Both toolkits equip pupils parents and
• staff with the skills needed to make an informed
  choice
• Schools, pupils and families can self-evaluate
  rather than being told what to eat
• Both toolkits are based on the principles of
  balance

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Packed Lunch Toolkit

• Rising Star challenge
• Based on eating for health model for a balanced
  diet
• Can apply it to any meal
• Being piloted and further developed by School
  Health Nursing

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How Many Stars in Your Lunchbox?Can You Be a
Rising Star?
1 if at least one high fibre starchy food is
included (e.g. wholemeal bread)
Gain 1 for each portion (handful) of fruit,
veg, or salad included (including pure fruit
juice)
1 if at least one calcium rich dairy food is
included. (milk, yoghurt, cheese)
1 if at least 1 food from the protein group
(e.g. meat, fish, eggs, nuts, pulses
Lose 1 for each fatty or sugary snack (e.g.
crisps, chocolate, cake, biscuit)
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Guidance on Healthy Lunchbox Star Rating

• A balanced healthy meal should contain foods
  from each food group.
• Emphasis on setting personal targets for more
  stars in your lunchbox.
• Fatty and sugary foods lose 1 star for each
  serving included.
• Maximum of 1 star for each of the starchy, dairy
  and protein groups.
• The fruit and vegetable group scores one star per
  portion.
• Lunchboxes scoring 0 stars of less are a cause
  for concern.
• Lunchboxes scoring more than 3 stars are pretty
  good.
• Can be applied to school meals, evening meals or
  breakfast.

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Examples of Lunchboxes Already Scored

• White bread (0s) sandwich with jam (0 s),
  diluting juice (0s), crisps (minus 1 ),
  chocolate bar (minus 1), and yoghurt (1) total
  -1 star
• White bread (0s) sandwich with cheese (1), 2
  biscuits (minus 1),
• Banana (1), cherry tomatoes (1) total 2
  stars
• Wholemeal bread (1) ham sandwich (1), milk
  (1), grapes (1),
• Cake (minus 1) total 3 stars
• Wholemeal bread (1) sandwich with tuna (1),
  pure fruit juice (1), carrot sticks (1), apple
  (1), yoghurt (1), crisps (minus 1) total 5
  stars

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Nutrition and children with additional support
needs

• Most initiatives described above, focus on the
  needs of the whole school population
• When behaviour or learning is poor, teachers and
  parents naturally want to know if the diet could
  be playing a part
• Remember though, many children with a poor diet
  seem to do well, and many children with a good
  diet still can have behavioural problems or
  difficulties in learning
• Eating 5 a day will do solve everything but
  it is a good start!

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The importance of diet for children with specific
difficulties The example of ADHD

• The current situation
• The difference between nutrition and medication
• What are the risks of giving information on diet?
• What are the risks of saying nothing?
• What does the evidence tell us?

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To whom is this relevant?

• Children with ADHD only?
• Children with a neuro-developmental diagnosis?
• People with psychiatric disorders?
• People with a history of offending behaviour?
• People who find learning difficult?
• Everyone?

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Hypothesis

• The right diet is likely to have a small but
  positive impact on most children, and a large
  impact on some of the most vulnerable.
• Children with ADHD are an example of a sub-group
  for whom the impact of a poor diet may be greater
• The best advice is that which is consistent with
  general healthy eating guidelines, but is framed
  by ADHD symptoms
• The possible connections between food, mood ,
  behaviour and learning are more immediately
  meaningful than those of diet and heart disease
• A key principle of health promotion is to start
  from the perspective and priorities of the
  population in question

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The current situation

• Families are often offered stimulant medication
  by the NHS
• Stimulant medication can help, but it is not risk
  free, and does not always work
• Families are offered no advice on diet unless
  they are referred to Dave Rex
• Sometimes they are given negative messages about
  diet by clinicians (a national problem)
• Current SIGN guidelines say nothing positive
  about diet, but plenty about stimulant medication
• Parents and carers often suspect diet has a role,
  and they make the changes that they think are
  likely to help
• Medical practitioners receive very little
  training on nutrition
• Evidence that diet can influence ADHD is heavily
  contested and not clear cut

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Is there evidence that the UK diet is inadequate?

• The UK diet remains
• Too high in empty calories trans fats,
  saturated fat, salt and refined carbohydrates
  and
• Too low in essential omega 3 fats, antioxidants
  minerals and fibre
• 10 year review of the Scottish Diet Action Plan
  No significant improvement in the Scottish diet
  in 10 years

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European 5-a-day Championship - latest score!!!

• Greece 9

Scotland 3
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The difference between nutrition and medication

• Medication is not essential for survival
• Nutrition is essential for survival
• Medication If in doubt, do nothing
• Nutrition If in doubt, do what you think is best
• Evidence for medication must come from good
  quality clinical research trials where there is a
  placebo group and participants and researchers
  are blinded
• Evidence for nutrition comes from clinical
  trials, epidemiology and large cohort studies

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Nutritional Evidence

• Evidence for nutrition includes efficacy and / or
  safety data based on
• Epidemiology (saturated fat and cholesterol)
• Theory (carbohydrate and poor blood sugar
  control in diabetes)
• Cohort studies (fruit juices and Alzheimer's)
• Clinical trials (oily fish and cardiac death)
• Collectively, these types of evidence build a
  picture of what is effective and what is safe

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American Academy of Pediatrics Committee on
Children with Disabilities.Counselling Families
who choose complimentary and alternative medicine
for their child with chronic illness or
disability (2000-2001).

• plans should be made through a process of
  collaborative
• decision making in which the family receives
  complete and
• unbiased information needed to understand and
  make informed
• decisions.
• Avoid therapeutic nihilismdiscussion of a range
  of treatment options may avert feelings of
  frustration and powerlessness that drive families
  to alternative sources of care.

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CSPI 25 Year review of diet, ADHD and behaviour

• Ignoring or denying (or exaggerating) the effect
  of diet on behaviour is not helpful to children
  and their families. The federal government, the
  food industry, organisations concerned about
  children with behavioural problems, and
  psychiatrists, psychologists and social workers
  should recognise that diet can sometimes help
  children with behavioural problems. Centre for
  Science in the Public Interest, 25 Year review of
  Diet, ADHD and Behaviour (1999)
• Government, private agencies and health
  practitioners concerned about children with ADHD
  and other behavioural problems should acknowledge
  the potential for diet to affect behaviour and
  should advise parents to consider modifying
  their childs diet as a first means of
  treatment. Centre for Science in the Public
  Interest, 25 Year review of Diet, ADHD and
  Behaviour (1999)

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Key concept

• In science and medical practice, proof is always
  elusive.
• In nutrition, we often act on the best available
  evidence, even if the evidence is not strong.
• Strong evidence tends to develop if a patentable
  product can be produced as a result of the
  findings.
• The reality is that research is rarely carried
  out if it only serves the public interest
• Bias against nutrition research and in favour of
  drug based interventions
• In this context, we consider the best available
  evidence on diet

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What are the risks of saying nothing?

• A) Some families will make no changes
• B) Some families will make inappropriate changes
  based on their own attempt to evaluate the
  evidence without support
• C) Some families will feel driven to seek
  alternative private sector sources of care and
  advice, and disengage with the NHS

33
Personal View

• The risks of saying nothing, because we do not
• have proof, outweigh the risks of discussing the
  most promising areas of diet.
• We should not underestimate the psychological
  importance of parents being able to do something
  positive and practical to help their child.
• This motivation of parents should be seen as an
  opportunity, not a threat

34
Characteristics of useful interventions

• Is it likely to make any difference?
• Is it affordable?
• Will the diet still be palatable?
• Will it substantially disrupt the rest of the
  diet?
• Will it make the diet deficient in something
  important?
• Does the diet seem obviously very different?
• The ideal intervention would be
• yes to the first 3 questions, and
• no to the last 3 questions!
• This would produce a rating of 6 out of 6

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Example Zinc and ADHD

• Zinc is a mineral that is essential to many
  processes in the body. It regulates appetite,
  immune function, digestion and is very important
  for brain development
• Poor zinc status may render stimulant medication
  ineffective
• Zinc plus medication is more effective than
  placebo plus medication
• Poor zinc status may be more common in children
  with ADHD
• ADHD symptoms may improve if zinc supplements are
  given as monotherapy

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Gregory et al Survey of British School Childrens
Diets 2000, HMSO
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Zinc Wish List

• Children should have their Zinc intake assessed
• Children with a reported poor Zinc intake, could
  have Zinc status measured
• Children with poor Zinc status could be given a
  Zinc supplement
• At the very least, families should be told that
  Zinc is important and which foods are rich in
  Zinc (and Iron)

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Zinc Useful intervention rating

• 5.5

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Other examples where nutrition may be relevant to
ADHD

• Zinc from foods or supplements
• Inclusion of Slow release carbohydrates
• Intolerances to natural substances in food
• Omega 3 fats from oily fish or supplements
• Antioxidants from fruit and vegetables
• Food additives

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Sugar Rush
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Sugar Hushhh!
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Carbohydrate Wish List

• Families who have children with ADHD should be
  told which carbohydrate based foods are slow
  release.
• They should also be advised to eat regularly.
• Slow release sources of carbohydrates include
  Nuts, milk, pears, apples, peas, onions, leeks,
  cherries, lentil soup, pasta, grapes, porridge,
  fruit smoothies, baked beans, chick peas

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Slow release carbohydrates Useful intervention
rating

• 5
• Scores most poorly for efficacy and palatability

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Example Food intolerances to natural ingredients
and ADHD

• Exclusion of gluten, milk protein, and phenol,
  amine or salicylate rich foods is commonly
  attempted
• Evidence of efficacy is limited to theory and
  case studies
• Individual children vary greatly in the foods
  that they are intolerant to
• There are no properly validated measures of food
  intolerance apart from trial exclusion

45
Food intolerance to natural substances Useful
intervention rating

• 3
• Scores most poorly for efficacy, disruption and
  sometimes difference and deficiency

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Food intolerance wish list

• It should be acknowledged that a small number of
  children are sensitive to natural substances
  found in the diet
• Parents decisions should be respected
• Families should be encouraged to seek advice and
  supervision before attempting to remove foods
  that could be providing valuable nutrients

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I know what my child should be eating.

• Many parents and children do understand what a
  healthy diet is and the impact it can have.
• Sometimes, the more a parent tries to improve
  their childs diet, the more the child resists.
• Sometimes, improving the diet involves more than
  an understanding of nutrition

48
Selective Eating Tips What to do if your child
will not eat proper food

• What does selective eating mean?
• How do people become selective eaters?
• What can be done to address this?

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What is selective eating?

• A diet based on only a narrow range of foods
  when compared to either
• A) the majority of people from the same food
  culture
• B) A diet that is varied enough to be sure of
  avoiding nutrient defiencies
• Sometimes, this is called fussy eating or food
  neophobia

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How do people become selective eaters?

• Negative food experiences in the past
• Wanting to be in control
• Fear of the unknown
• Having preferred food options available
• Getting attention from others
• Being afraid of change in general
• Sensory difficulties with smell, taste or
  texture
• Advertising and marketing
• Influences of peers and family members

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How do you know if selective eating is putting a
child at risk of nutritional deficiencies?

• Are all the food groups present?
• How often are protein / Iron / Zinc rich foods
  eaten?
• How often are fruit or vegetables eaten?
• Children who eat vegetables or fruit everyday are
  likely to be OK.
• Children who eat 5 handfuls of fruit or
  vegetables a day are probably OK.
• No one type of fruit or vegetable will contain
  all the antioxidants you need.
• Children who eat red meat once or twice a week
  are at low risk.

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Fruit and veg

• Eating 6 different fruits is as good as 3 fruits
  and 3 vegetables
• Cooked, raw, frozen, fresh, canned, juiced and
  dried versions of fruit and veg all count
• The greater the variety of colours the better the
  mix of nutrients
• Soups, smoothies and pasta sauces still count

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What can be done to address this?

• More of an art than a science
• Need an understanding basic psychology
• Usually an interactional dimension
• Parents and carers often need to change their own
  behaviour first
• Need a good balance of patience and persistence

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Selective Eating among specific diagnosed
disorders

• Separate social from nutritional objectives
• Finger foods can be healthy
• Be specific with instructions, especially for
  small steps
• Exploit visual learning style rather than
  depending on verbal encouragement and instruction
• If rewards are used, make them immediate, and
  makes the rules for the reward clear and
  consistent

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Influence of Siblings and Peers

• Other children can model better eating habits
• This can be
• Siblings at home
• Friends at school
• Friends invited home for tea
• Question
• If you have two children and one eats poorly, who
  gets the attention?

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Control

• Does your child want more control over their food
  choices?
• Does your child feel under pressure to eat the
  right things?
• Do you want to be more in control of what your
  child eats?
• Do you want your child to be motivated to choose
  the right foods?
• It could be time to put them in charge?

57
How to influence food choice whilst allowing the
child to be in control

• Shared plates Help yourselves to anything you
  fancy
• Forbidden fruit This is too good to waste on
  children...
• Shopping What 5 things shall we choose from
  here
• Cooking and preparation Which things shall we
  put in, peppers or carrots...?
• Ultra-rational I wonder which foods contain the
  most vitamin C....

58
Words to be avoided

• Please just try a little bit, for Mummy!
• Youll get ill if you dont eat properly
• You not going anywhere until youve eaten it
  all
• If you are good you can have some crisps
• You can only have your ice-cream if you eat your
  greens
• You need to eat fruit its good for you

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Small steps

• Progress is often slow
• Small steps can be taken in either
• a) Type of food or
• b) level of exposure

60
Small steps Changing the food type

• What are the characteristics of the childs
  favourite foods?
• Write these down, eg
• Cold, crunchy, brown, bland, salty or
• Hot, sweet, soft, smooth, red
• Now try to think of a food that is marginally
  different in only 1 characteristic

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Small steps Changing the level of exposure

• What does it mean to try a new food
• Try often means that someone needs to accept
  the idea, sight, smell, texture, taste.
• New foods can be tolerated at various levels.
• The touch of food, the smell, the feel in the
  mouth, the sensation of biting into a food, and
  the experiences of chewing and swallowing are all
  separate small steps on the way to food
  acceptance.
• Setting specific tasks that reflect these small
  steps can be very helpful.

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Dealing with Selective Eating in the School or
Nursery Setting

• Communicate regularly with parents
• Make use of peer pressure
• Involve in preparation and cooking
• Provide free taster of school meal along side
  packed lunch
• Put target foods foods on table

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Summary

• A diet which provides less than optimal nutrition
  is the norm for UK children
• This is the result of complex social, political
  and practical influences that have shaped our
  diet over many years
• Schools represent a major opportunity to change
  things for the better
• The best advice for children with specific
  difficulties in learning or behaviour, is that
  which fits with general healthy eating advice,
  even though the framing of that advice may be
  different.
• We should be pragmatic about how much evidence
  we need before we give information on the likely
  best diet for a child with ADHD or ASD.
• Tackling selective eating requires skill,
  patience, persitence and support..
• Dont be scared of food like life itself, its
  not risk free. Enjoy it!

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Further Information

• Email me or visit the Food for Thought pages of
  the NHS Highland web site
• Use a search engine and enter the words
• Food for thought NHS Highland
• It should be the first hit
• A copy of the presentation will be on the Touch
  Learn website for the next week or so