December 3 2001 - Village Hotel, Coryton, Cardiff

Welcome and Introduction

Mrs Ann Hemingway, Welsh Member of the FSA Board and Chair of the Agency’s Advisory Committee for Wales reviewed progress made thus far by the Steering Group in terms of establishing the basis for action, and set out the reasons for selecting infants, children and young people as a priority group. One issue of concern is the effect of advertising and promotion of foods on children’s diets.

Results of research commissioned by the FSA has shown parents are concerned about misleading health claims made for foods targeted at children, and feel bombarded by conflicting advice about healthy eating. They respond by ignoring much of this, although they do recognise fruit, vegetables and milk as part of a healthy, balanced diet. Furthermore, fathers were more likely then mothers to give in to their children’s demands for certain products. These findings highlight the need to work with industry on communicating accurate health messages through advertising and labelling of food promoted to children. It was hoped the discussion groups would look at barriers such as these, experienced by children in accessing a healthy diet, and come up with a range of practical and workable solutions to tackle them.

Roy Ballam, senior education officer from the British Nutrition Foundation, described how food and nutrition fit into the school curriculum, and the way organisations such as BNF and the FSA can provide support in getting the key messages across. Food is a cross-curricular theme covered in Design and Technology (DT), Science, Physical Education (PE), and Personal and Social Education (PSE). Of these, much of the practical application such as food safety, cooking skills, manufacturing processes, labelling and budgeting is included in Food Technology. These are essential life skills which young people need to make informed decisions about their diet in adulthood. There are a number of initiatives already in place to assist schools in the promotion of diet and health and include Healthy Schools Schemes; Fruit Tuck shops; breakfast clubs; Nutritional Standards for schools meals and School Nutrition Action Groups. These initiatives are representative of a whole school approach and therefore reinforce messages taught in the curriculum.

BNF have produced a range of educational materials to support the curriculum, and also actively promote the role practical work, such as making fruit salads and tasting exotic foods as a means to raising awareness of the cultural basis of food. Encouragingly, HMI research shows that 60% of Design & Technology work is practically based, although there is a need to acknowledge constraints on time and facilities often faced by teachers. Teacher training and continued professional development is also fundamental in supporting young people studying Food Technology, and BNF’s website and various CD applications, produced in association with FSA, provide advice to supplement this.

Teachers and pupils rarely receive praise in response to their efforts in food related areas of the curriculum and this does little to raise the profile and increase uptake of food sciences amongst pupils at Key Stage 4. Given the ethos that celebration is the key to success, various initiatives have been undertaken by FSA, BNF and other organisations, for example BNF’s ‘Taste of Success’ which offers pupils certificates in recognition of excellent practical work with food.

In conclusion, government support is needed for food education in the curriculum, through making it compulsory beyond Key Stage 3 and encouraging collaboration with various agencies in the delivery of consistent and accurate messages. Furthermore, promoting a whole school approach ensures the school environment supports messages delivered within the curriculum. Finally, teachers and pupils efforts in food related subjects should be recognised and rewarded.

Dr Katy Tapper, project manager of the food research unit at Bangor University, described the main elements and results of an intervention programme developed at the research unit to encourage nursery and primary school children to consume more fruit and vegetables.

The ‘Food Dudes’ programme, comprises a series of Videos showing older children as role models eating and enjoying fruit and vegetables and offers rewards as a means of getting children to start tasting the fruit and vegetables presented to them. The ultimate aim is to stimulate longer-term behavioural change after cessation of the reward system. The programme was first trialled using nursery school children, and researchers noted a marked increase in percentage fruit and vegetable consumption between baseline and intervention phases even when they were presented alongside ‘unhealthy’ sweet and savoury snacks, and the effect was maintained some 15 months later.

The team at Bangor University then extended the study to four Primary schools in England and Wales. The study design involved a 12-day baseline phase during which children were presented with fruit or vegetables at snacktime and/or lunchtime and amounts eaten measured by either weighing foods before and after consumption or by rating the amount consumed. Home consumption of fruit and vegetables was measured by means of a 4-day parental recall in one of the selected schools only. Following this baseline phase, the ‘Food Dudes’ intervention was introduced and run for 16 days. This was then followed by a maintenance phase during which rewards became more intermittent, and at the end of this, measures were taken at both snacktime and lunchtime. Good increases in fruit and vegetable consumption were evident at both snacktime and lunchtime in all schools, and these increases in consumption extended to the home context (see slides, Annex B).

Two of the schools selected were matched for experimental and control conditions (Brixton and Lambeth) and the efficacy of the intervention assessed. Under control conditions, where additional fruit and vegetables were provided but without the intervention programme, the average percentage of fruit and vegetables consumed remained constant, whereas, in the experimental school, where additional fruit and vegetables were supplemented by the ‘Food Dudes’ programme, average percentage consumption increased.

The success of the programme relies on repeated exposure of the children to the taste of fruit and vegetables with a view to their developing a liking for it even when this is no longer reinforced by rewards. Ultimately, it is hoped this will be subject to social and cultural reinforcement with children considering themselves as ‘fruit and vegetable eaters’ and continuing to maintain consumption over the longer term. In summary, the researchers are convinced of the efficacy of the ‘Food Dudes’ intervention programme and would like to see it introduced on a national basis.

Barry Doughty, Curriculum Policy Manager, explained the background to the establishment of the Wales Youth Agency (WYA) in 1992 by the Secretary of State for Wales. This was a service directed at the 11-25 age range, but particularly for 14-19 year olds, set up with the purpose of promoting, supporting and assisting youth services in voluntary and maintained sectors in Wales. It receives funding through grants from the National Assembly and the lottery, is responsible to Estyn, and has developed a Youth Work Curriculum with a quality kitemark system. The agency operates training courses for youth workers and provides an information service for voluntary, school-based, outreach and issue based youth groups. There are a number of youth workers in each Local Authority in Wales offering an ‘alternative’ curriculum of informal and non-formal qualifications for young people who are disaffected with the standard education system.

Advice about healthy lifestyle is one of the Curriculum areas, and the current priority issues are smoking and sexual health. Siobhan Williams, a youth worker and lecturer from the WYA outlined some of the problems experienced by young people in accessing a healthy diet. Many of the young people WYA deal with have opted out of the education system, and have therefore missed out on the vital skills and information needed to select and prepare healthy food. Also their priority is often more concerned with procuring food regardless of its nutritional value.

In attempting to get the healthy eating message across, and help these young people to make informed choices and decisions about their diet, the WYA approach is to gain their trust and confidence before involving them in sessions to give them practical cooking, food hygiene and budgeting skills. This is supplemented by literature to support these activities. Accreditation of such courses has a major motivational influence for young people who might then able to use them in securing employment. Siobhan ended the presentation with a series of questions aimed at stimulating thought and discussion on how we might better provide for the needs of young people in our attempts to educate them about the benefits of healthy eating.

Following on from the presentations, delegates were given the opportunity to pose questions to the speakers on issues arising from their presentations and of a more general but related nature. The following section attempts to capture the main themes arising from this session:

Q: Frequent reference was made to ‘cooking skills’ in the presentations. As these are taught within the curriculum area ‘food technology’, why don’t we refer to this instead?

A: Food technology aims to equip pupils with the skills they need to be informed consumers. Whilst it is a wide ranging subject covering such topics as scientific understanding of food and manufacturing processes, product labelling, organic production methods, genetically modified crops etc., practical application is necessarily the core element. In lay terms this equates with ‘cooking skills’, and whilst it may be perceived to be loose terminology, it is less open to misinterpretation, particularly by the media.

Q: Whilst the success of the ‘Food Dudes’ project has been discussed, there are issues associated with practical management of such schemes which need to be considered e.g. should children have to bring in their own fruit, and if a school has no kitchen how are food safety regulations observed?

A: These issues have not arisen in the context of ‘Food Dudes’ as it has only been piloted. During the study, no children were required to supply their own fruit, and as catering services funded provision of the fruit, food safety regulations were observed. The ‘Food Dudes’ package will be available from April 2002, and it is hoped that Government will take on its funding.

Q: Could vending machines such as those that sell coke, be used to sell milk in schools?

A: It was recognised that vending machines often generate much needed income for schools, and whilst it would obviously be desirable to replace these with machines selling milk as the ‘healthier option’, there was a need to be realistic perhaps by offering the choice of both. There were similar arguments surrounding school meals as efforts to promote their nutritional content were jeopardised by availability of machines selling confectionery. It was emphasised that whilst it was obviously not desirable to promote chocolate and fizzy drinks, they were acceptable so long as the rest of the diet was balanced.

Q: If we want to achieve a whole school approach to healthy eating, there is a need to gain support from head teachers. How might we go about this?

A: The Meat and Livestock Commission have successfully conducted a workshop involving head teachers, however, in view of teacher shortages and competing pressures, there was potential for exploration of alternative lines of communication e.g. through professional associations and journals. Generally, head teachers do not require convincing of the benefits of healthy eating, but their concerns more often lie with policing unhealthy practices e.g. ice cream vans, rather than promoting good diet.

Q: Whilst there have been various initiatives directed at increasing fruit and vegetable intake by children in the primary sector, this doesn’t seem to be followed through to Secondary schools. Shouldn’t we be striving to deliver consistent messages?

A: The ‘Food Dudes’ programme has been designed specifically for nursery and primary school aged children, however, it should be possible to adapt it using the same principles but perhaps using different role models. With regards to practicalities, there was concern that the onus would fall to food technology teachers to buy, store and sell the fruit, unless Senior Management Teams were convinced of the virtue of such a programme, in which case it might be implemented through the catering services.

Age Limits/Priorities

Whilst the general consensus on the upper age limit was 25 years to reflect transition of young people to independent adulthood, there was a range of views on where the line should be drawn at the lower end, from conception to 1 year old. It was accepted that foetal nutrition would be considered as part of the planned workshop on pregnant women and women of childbearing age. The Breastfeeding Strategy for Wales addresses the needs of very young children, however, it was seen as essential that a healthy diet be implemented from the start of weaning, as this is when children are first introduced to appropriate foods.

With regards to identifying specific sub-groups within this overall target group which demand particular attention, there was agreement that the dietary habits of teenagers were of particular concern, and most of the current initiatives were directed at primary school children with little intervention at the secondary level. Children from low-income families, who experience vulnerability through illness or disability or who are in care might also require further consideration.

Given the overall aim of the nutrition strategy as applied to children and young people is necessarily to empower and educate children to make appropriate food choices, groups were asked to formulate a series of short and longer-term targets, which might progress towards improving their diets. In the light of their responses, it was decided that these would be better defined as short-term processes working towards long term aims.

An integrated approach was seen as essential with targets being practical, achievable, and applicable across the principality. Whilst the focus of attention was principally on school based action in line with their statutory duties, there was a perceived need to extend this to the wider community setting as a prerequisite to changing social attitudes. Also consistency in communicating the healthy eating message was vital, using resource materials which were simple, not overly detailed, and written using language appropriate to the group being tackled. This would help avoid some of the confusion parents and their children express over conflicting advice. The following attempts to summarise the feedback from the various groups presented at the plenary session.

Short-term

• Increase consumption of fruit and vegetables and uptake of free school milk.
• Set up a directory of approved resources/literature on healthy eating which those working in the fields of education and health promotion can make use of in communicating the healthy eating message.
• Collect more baseline data, particularly qualitative data, on the barriers to healthy eating.
• Make 'Food Technology' compulsory at Key Stage 4 and review course content, to reflect emphasis on practical application such as cooking skills and budgeting.
• Work 'basic skills' such as literacy and numeracy into healthy eating activities in schools.
• Encourage establishment of more fruit tuck shops in schools.
• Make advice/instruction on healthy eating fundamental to teacher training courses, parenting classes for prospective and new mothers, and training for carers and other key workers.
• Strive for an advertising policy, which reflects promotion of a healthy balanced diet.
• Link strategy into targets forming basis of 'Better Health: Better Wales'.
• Provide additional finance to schools as a means to creating a supportive environment.
• Build on 'good practice' seen in Primary school sector and adapt to suit Secondary level.
• Establish consortia to bring together local experts on diet and nutrition and ensure action is directed where it is needed in an integrated fashion with cross-community involvement.
• Enhance the role of dieticians with respect to delivery of the healthy eating messages in schools.
• Increase coverage and uptake of the Welsh Healthy Schools Network.

Longer-term targets

• Reduce obesity through delivery of joined up and consistent messages regarding diet and exercise.
• Reduce incidence of dental caries.
• Reduce incidence of chronic diseases such as coronary heart disease, cancer and diabetes.
• Make healthy eating the easy choice through school meals provided and by removing reliance by schools on vending machines to supplement funds.
• Explore the potential of new settings to deliver healthy eating message e.g. parent and toddler groups.
• Conduct surveys/mapping exercises to monitor dietary status and progress on a rolling basis.
• Commission research to study the impact of dietary intake on pupil behaviour in the classroom.

Given the wide age range being considered, their accessibility through the education system, and age-specific issues in relation to diet, it was decided to assign each syndicate group a particular defined age group for discussions relating to obstacles to healthy eating, and how these might be overcome:

Pre-school Children

Barriers:

• lifestyle and inequality resulting from socio-economic circumstances.
• Vulnerability to advertising.
• Lack of access through availability and cost of transport.
• Inconsistency of information provided by health and other professionals to parents.
• Disability or long-term illness in family.

Solutions:

• Seek to promote political change as a means of tackling inequality e.g. through targets included in Better Health: Better Wales and organisations like Surestart.
• Secure co-operation of local media to convey the right messages.
• Encourage food co-operatives and fresh food vans.
• Improve the quantity, quality and availability of information directed at parents on healthy eating.
• Provide additional training and monitoring of childcare providers to inform on diet and the importance of healthy eating.
• Provide new parents with a ‘healthy eating’ information pack.
• Encourage parents to make and maintain positive choices through networking and provide community support and improved services for families affected by illness or disability.
• Improve access to shops through better transport systems.

Primary School Children

Barriers:

• parenting skills and knowledge of what constitutes a healthy balanced diet.
• Parental resistance to adopting healthy eating principles despite being aware.
• Disproportionate advertising of ‘unhealthy’ foods.
• Lack of co-operation from influential officials e.g. Director of Education, Head Teachers and
  School Advisors.
• Nutritional balance of school meals and reduction in their popularity and uptake.

Solutions:

• Instigate multi-agency food and health groups, and identify key individuals who operate within schools to co-ordinate action.
• Engage parents and their children from the outset in any initiative to promote healthy eating e.g. opinions of parents were sought as a means of gauging support for the ‘Free School
• Milk’ project prior to its initiation.
• Secure support of and endorsement for any healthy eating initiative by Directors of Education/ Head Teachers through consultation.
• Publish details of uptake of school milk by Education Authorities in Wales.
• Operate a reward system for Schools who ‘buy into’ healthy eating initiatives and use this to raise their status through publicity.
• Introduce all-Wales policies to implement school milk and fruit tuck shops.
• Adopt innovative approaches to marketing school meals.
• Pilot a scheme whereby school caterers provide healthy eating choices as ‘loss leaders’
• Improve dissemination of healthy eating resources to schools.
• Set up more School Nutrition Action Groups (SNAG) which involve caterers, pupils, and teachers from several schools in decisions on how barriers to healthy eating might be tackled.

Secondary School Children

Barriers:

• Inappropriate role models that give the wrong messages about body image.
• Peer pressure that precludes individuals from eating food perceived to be healthy and nutritious, even though it might be their preferred choice.
• Facility to obtain meals off-site at lunchtime, and the relative unattractiveness of the environment where school meals are taken.
• Relatively late timing of lunch encourages children to snack on chocolate and crisps to tide them over to this time.
• Queuing for school meals.
• Advertising of convenience food, confectionery, snacks and fizzy drinks. Also products, which are marketed through adverts which suggest them to be ‘healthy’, when they are actually of poor nutritional value.

Solutions:

• Enlist the help of sports personalities to increase awareness of the role good nutritional plays in health and physical well-being.
• Set up focus groups to gather opinions of young people on what would make healthy eating more appealing to them.
• Introduce a healthy ‘hot bag’ take away alternative to standard school meals. This would also avoid the necessity to queue for any significant length of time.
• Ensure School Meals Services have access to the best quality produce.
• Revamp menus available at lunchtime to include innovative options.
• Give children who eat school meals at lunchtime a free piece of fruit at breaktime.
• Educate pupils to be informed consumers thereby enabling them to make appropriate judgement about what they eat in the face of pressures from advertising and through knowledge of food labelling.
• Make healthy eating an interdisciplinary venture between parents, pupils and teachers and strive to make it an enjoyable option for all concerned.
• Secure the support of the food industry in effecting change, and encourage their investment in activities that promote healthy eating.

Young People/ Post Compulsory Education

Barriers:

• Lack of knowledge of budgeting and cooking skills particularly for lone parents for whom food might not be a priority in the face of other financial pressures.
• Parental choice determining/governing diet whilst residing at home but also carried through into adulthood.
• Promotion of ‘unhealthy’ foods through advertising.
• Peer pressure and role models that encourage unsound eating habits/disorders.
• Relative availability of fast food such as burgers/fish and chips compared to healthier options.
• Lack of facilities and appliances to prepare healthy balanced meals.

Solutions:

• Promote healthy eating through Universities, Colleges and Youth Organisations e.g. by running information days during Fresher's Week covering food budgeting, labelling and cooking skills, to enable young people to make informed choices.
• Use catering kitchens in colleges after hours for outreach projects e.g. to show young people how to acquire food, store it and cook healthily.
• Increase levels of benefit to allow those on a limited budget to access a healthy diet.
• Improve the nutritional content of mass catering available in Colleges and Universities.
• Get young people involved in healthy eating community projects such as lunch clubs to increase their skill base and give them an opportunity to try healthy food.
• Invite supermarkets to research and market healthy lunches that would appeal to young people.
• Encourage smaller local shops supplying healthy affordable food through planning systems.
• Invest in community schemes to provide second-hand appliances such as cookers, fridges and microwaves to young people on low-income.
• Set up networks of young people e.g. young mums, and work towards gaining their trust before introducing activities such as ‘cook and taste sessions’ to bolster their confidence in applying healthy eating principles in their own homes.
• Provide long term sustainable funding to support healthy eating initiatives.
• Explore innovative ways of engaging single young men as this group is often nomadic and are frequently overlooked by other schemes.

Children/Young People with Special Needs

Barriers:

• Information which is often only available in written format and can convey inconsistent messages.
• Special dietary requirements resulting from disability or medical conditions e.g. diabetes, and medication that requires certain dietary adjustment or that interferes with absorption of nutrients.
• Lack of knowledge by carers of healthy eating practices, and a dearth of information to specifically address this need.

Solutions:

• Make healthy eating information available in alternative formats such as Braille, audiotapes, signing and pictures to enable access by children with special needs. Manufacturers could also apply this to food labelling.
• Use taste substitutes for foods which are not allowed e.g.soya milk, and encourage whole family to use these alternatives.
• Ensure those in the medical profession review diet prior to and as an adjunct to prescribing.

Monitoring and Evaluation

A variety of mechanisms for assessing the success of these actions in changing dietary habits and progressing towards targets were suggested. These could be informal, based on self-monitoring through portfolios/diaries, to a more formalised structured approach at the local and national level e.g. dietary surveys. There was much information that could be derived from systems already in place, and these should be used together rather than in isolation to give an insight into the bigger picture. Appraisal of processes was judged to be as important as evaluation of outcomes, and acknowledgement of effort would be of enormous benefit in maintaining levels of motivation. Specific ideas for monitoring progress could be divided into consumer and health related measures thus:

Consumer Related Measures

• Surveys to monitor fruit/ vegetable and milk sales.
• EPOS data from supermarkets.
• Feedback from schools, health visitors, and Surestart.
• Dietary surveys such as the National Diet and Nutrition Survey (NDNS) but with more emphasis on the Welsh perspective.
• Surveys to determine behavioural change and shift in attitudes/values.

Health Measures

• Pharmaceutical dispensing of relevant drugs e.g. to reduce lipids.
• Epidemiological and morbidity data from GPs, school nurses and other health professionals dealing directly with children.
• Dental screening

Organisations Involved

Government, NHS, Local Health Groups, Unitary Authorities, education and primary care professionals, the voluntary sector, community nurses, health visitors, charitable organisations, social services, school meals services, Environmental Health Officers, Trading Standards Officers, youth organisations, Guide/Scout movements, retailers, manufacturers.

Summary and Closing Remarks

Ann Hemingway drew the workshop to a close by reflecting on and summarising the main threads of the day’s discussions. There was broad agreement that the age range for consideration should span from pre-conception (although this was to be considered at the next workshop as a separate priority group) to 25 years old. Given the different problems and solutions associated with different age groups, there was a perceived need to sub-divide this group further, and there was good consensus on 0-5 years, 5-11 years, 11-14 years, 14-19 years and 19 years and beyond. This would need to be taken back for consideration by the Steering Group as it would have implications for the development of a strategy for children and young people.

In devising a list of targets, it was apparent that many of the short-term targets could actually be regarded as actions and it was therefore constructive to view these as short-term processes working towards longer term health related goals. There was also a need for more consistent baseline data to facilitate targeting of action where it would produce the most benefit, and broader thinking on how the nutrition strategy might overlap with other strategies e.g. to increase physical activity. This highlighted the need to work in partnership with other organisations such as the Sports Council striving towards similar aims.

There was already a certain amount of good practice in existence, and the action planning will take account of and look towards developing this in addition to generating whole host of new ideas. In taking the strategy forward, smaller, achievable milestones needed to be put in place to provide opportunities to celebrate success. This was essentially a joint venture involving a many different organisations, but crucially Government, community agencies and the NHS, the latter being of particular significance in view of the current NHS review. Finally, the role parents play in their child’s nutrition should not be overlooked, and there was a strong case for working with them to help their children make healthier food choices.

Ann acknowledged the hard work put in by participants which had demonstrated good, consistent thinking with a number of key messages getting through. She thanked speakers for their presentations which had provided a launching point for discussions over the rest of the day, and paid tribute to the efforts of the FSA team and Steering Group for organising the event.