The Opportunity for School Food to Influence a Child’s Dietary Intake

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Abstract

Childhood obesity is a common public health problem all over the world. Obesity is linked to negative health upshots such as heart disease, type 2 diabetes, high blood pressure and certain malignancies. Common causes of these health issues include physical inactivity, too much screen time, inadequate sleep and poor eating habits. The purpose of this study was to conduct a nutritional analysis of the dietary intakes of children aged between 4 and 11 years in Northern Ireland (NI) compared to the rest of the United Kingdom (UK). Data were collected from the National Diet and Nutrition Survey Rolling Programme (NDNS RP).

Information on the dietary intakes of children between 4 and 11 years was obtained from the NDNS website and subjected to data analysis. Independent sample t-tests and analysis of variance were used to compare the mean consumption of different nutrients and food groups between NI and the rest of the UK as well as across various ethnicities and socioeconomic standing. Least Significant Difference was used as post-hoc tests.

There were significant differences in the consumption of energy (p=0.02), fibre (p=0.00), vitamins A (p=0.02), B6 (p=0.02), riboflavin (p=0.02) niacin (p=0.04), calcium (p=0.01), potassium (p=0.03), zinc (p=0.04), phosphorous (p=0.04), sodium (p=0.03), processed red meat (p=0.01) and total fruits and vegetable portions (p=0.00) between NI and the rest of the UK with NI reporting higher values for most of the nutrients.

The impact of ethnicity on dietary patterns was also statistically significant for (p=0.00). Socioeconomic status also had an important influence on food habits with the consumption of macronutrients, micronutrients, fruits and vegetables, oily fish and processed red meat decreasing with a decline in the social or economic status. School caterers should consider supplementing menus with fibre-rich foods, oily fish, fruits and vegetables to improve the availability of deficient nutrients. Parents should also shape their children’s eating habits.

Introduction

Childhood obesity poses several immediate and long-standing health risks in addition to a number of psychological health problems. Approximately 33.5% of children in the United Kingdom (UK) between the ages of 10 and 11 years are either obese or overweight (Wilkie et al. 2016; Wilkie et al. 2018). Bodyweight is determined by four major adjustable lifestyle behaviours such as sleep, physical activity, eating habits and screen time (Baidal et al. 2016; Cattuzzo et al. 2016; Simmonds et al. 2016; Ekelund et al. 2017).

Dietary patterns play an important role in a person’s current and future health standing. Eating diets that are predominated by fruits and vegetables lowers predisposition to cardiovascular disease, diabetes, obesity and some forms of cancers such as colorectal and breast malignancies (Turati et al. 2015). Conversely, diets containing high levels of sugars and saturated fats elevate the risk of these lifestyle-related diseases (Jones-McLean et al. 2015).

Studies also show that the risk of obesity and cardiovascular disease develops in the early stages of life (Ayer et al. 2015; Rovio et al. 2017). Therefore, it is necessary to eat a healthy diet throughout the life course, which means that appropriate dietary patterns and behaviours should be cultivated early in life. Furthermore, childhood is characterised by rapid growth and development as well as physical activity, which implies that the effects of childhood nutrition are likely to be felt later during adulthood. Conversely, healthy eating behaviours can form during early childhood and affect subsequent growth and development. Consequently, efforts to prevent chronic diseases should focus on inculcating positive dietary habits from an early age (Baidal et al. 2016; Simmonds et al. 2016).

Nutrition education is a crucial constituent of nutrition intermediation to enhance dietary patterns, food choices and to avert nutritional deficiencies. The effectiveness of nutrition education programs is determined by their appropriateness and suitability for target populations. Thus, their benefits in developing lifelong healthy eating behaviours can be realized in the future (Llewellyn et al. 2016).

In the UK, particularly in Northern Ireland (NI), local evidence indicates that children’s diets are not balanced (Gibson & Francis 2015). No more than 15% of children between the ages of 11 and 16 years consume five or more servings of fruit or vegetables per day (Gaal et al. 2018). Conversely, approximately 25% of children in this age category eat biscuits, candies or chocolate bars once a day, whereas about a third of children in the same age group eat these sugary foods more than once daily. These observations are to be expected in the light of the findings of the Hastings report authorised by the Food Standards Agency (Bugge 2016; Gilmore et al. 2010).

The commentary showed that television advertising was the most common method of creating awareness about children’s food. The most publicised foods included sweets, pre-sugared breakfast cereal and soft drinks. Additionally, newly opened or existing fast food outlets were also promoted. The negative effects of such advertising are witnessed as poor health in children, specifically the rising cases of overweight and obesity (Kelly et al. 2015; Norman et al. 2018).

As a result, a cross-departmental task force known as Fit Futures was formed to point out areas of priority to reduce the incidence of obesity and overweight in young people in NI (Evensen et al. 2017; Evensen et al. 2019). The taskforce underscored the importance of knowledge, skills and attitudes of key individuals in shaping children’s nutritional choices. These included school workers, teachers, parents and children themselves. A point of concern was that the choice of foods available within the school setting undermined the possible positive influence that teachers may have on children’s food habits.

Examples included food items present at tuck shops, within the school meals and vending machines. The Fit Futures report recommended that schools should initiate authorised programs to start food and nutrient-based benchmarks for all school food (Fit Futures 2005). The proposed nutritional standards were implemented and evaluated in 105 schools between 2004 and 2005 (Sand, Emaus & Lian 2015; Evensen et al. 2017). The evaluation concluded that approximately 23% of children in NI were obese. Six policy areas were recommended for action, including providing real choice, supporting early years of development, creating healthy schools and communities.

Other regions of UK have applied strategies such as England’s Obesity Strategy between 2008 and 2011 (Hawkes, Ahern & Jebb 2014). The Healthy Weight Healthy Lives (HWHL) initiative under this program made positive strides towards addressing obesity by improving knowledge, attitudes, engaging stakeholders and provoking change. However, it did not fully realise change across all government sectors. Therefore, it is uncertain whether these standards have led to a substantial improvement in the dietary habits of school children in NI and the rest of the UK over the years.

The purpose of this study is to conduct a nutritional analysis of the dietary intakes of school children aged between 4 and 11 years in Northern Ireland (NI) compared to the rest of the United Kingdom (UK). With this information, it is possible to identify areas of inadequacy to develop appropriate interventions to mitigate the situation. This paper describes the dietary habits of NI children compared to the rest of the UK. Differences in nutritional intakes due to ethnicity and socioeconomic status are also described together with possible strategies of improving the children’s dietary habits.

Methodology

Survey Sample

All data used in this study were collected from the National Diet and Nutrition Survey Rolling Programme (NDNS RP). NDNS is a cross-sectional survey that runs continuously to evaluate the diet, nutrient consumption and nutritional standing of the UK population aged 36 months and above in private households (Bates et al. 2019). The NDNS RP is funded by Public Health England (PHE) in addition to the NI Food Standards Agency (FSA).

Partakers of the survey were enrolled through a random sampling approach from Primary Sampling Units (PSUs) of the Postcode Address File (Gaal et al. 2018). Data were collected from 1,425 children between the ages of 4 and 11 between years 5 and 9 of the survey. The initial stage of the survey involved the collection of demographic, anthropometric, physical activity and socioeconomic standing data by interviewers.

Dietary Assessment

Dietary consumption data were gathered in the initial phase of the during home visits by interviewers. Food diaries estimating the consumed food within the last 4 days (including weekdays and weekends) were used to measure the intake of food.

The approximation of portion sizes was facilitated by the use of common household measures, photographs and weights indicated on food labels. Parents or guardians completed food diaries for children younger than 11 years. The interviewers conducted food diary checks to ensure that exhaustive information was provided by each participant. Variables of interest included macronutrients, micronutrients and food groups. The mean energy, macronutrient and micronutrient consumption were evaluated using the Diet In Nutrients Out (DINO) appraisal structure together with food constituent data retrieved from the Department of Health (DH) NDNS Nutrient Databank (Bates et al. 2019).

Socioeconomic Status

Socioeconomic status (SES) was established through the National Statistics Socio-Economic Classification (NS-SEC), which was developed to facilitate the accurate measurement of employment relations and circumstances of occupations to elucidate the impact of socio-economic ranks on social conduct and other experiences (Office for National Statistics 2019). The main factor that was used to determine SES was employment.

Data on occupation and employment status were collected as described by NS-SEC. The ensuing NS-SEC categories were allocated by combining facts about occupation coded to occupation unit group, size of organization (>25 employees as large organizations and <25 employees as small organizations) and employment status (employer, self-employed, or employee). The three-class version of SES was used, which consisted of higher managerial, administrative and professional occupations in the high SES, intermediate occupations in the middle SES and routine and manual occupations in low SES (Office for National Statistics 2019).

Ethnicities

The grouping of the participants based on ethnicity led to five main groups: “White, Mixed (White and Black Caribbean, Black African, Asian), Black or Black British (Caribbean, African), Asian or Asian British (Indian, Pakistani, Bangladeshi) and any ‘other’ ethnic group” (Gaal et al. 2018, p. 4). White/non-white groupings were formed by clustering all people of Caucasian ethnicity as white. People of mixed ethnicity, Asian or Asian British, Black or Black British and any other ethnicity comprised non-whites.

Statistical Analyses

Data from 5 to 11-year-old children were collected from years 4 to 9 of the National Diet and Nutrition Survey. Statistical analysis was conducted using IBM SPSS version 25 software. Independent-sample t-tests were used to compare the means of macronutrient, micronutrient and food group intakes between NI and the rest of the UK. Dietary patterns with respect to mean macronutrients, micronutrients and food group intakes were compared between White and Non-white ethnicities using independent-sample t-tests. One-way analysis of variance (ANOVA) was done to compare the micronutrient, macronutrient and food groups across five ethnic groups as well as dietary patterns across different socioeconomic groups. Fisher’s Least Significant Difference (LSD) was used as a post-hoc test to identify groups with significant difference. All p-values <0.05 were considered statistically significant.

Results

Table 1 shows there was a significant difference (p=0.02) in the intake of energy (EAR) in MJ between NI (mean=7.60 g, SD=0.78) and the rest of the UK (mean=7.46, SD=0.76). However, there was a significant difference in the intake of fibre between NI (mean=13.15 g, SD=3.59) and the rest of the UK (mean=14.23, SD=4.45) at p=0.00. NI was higher than UK for EAR but lower for fibre. There were no significant differences in the intakes of food energy (kcal), proteins, fat, saturated fatty acids, cis n-6 fatty acids, cis n-3 fatty acids, trans-fatty acids and carbohydrate between NI and the rest of the UK.

Table 1: Macronutrient intake according to region (Northern Ireland vs. rest of UK).

Data presented as mean (SD).* Significant differences in nutrient intakes to region (Northern Ireland vs. rest of UK were analysed using Independent Samples T-test.

Table 2: Micronutrient intake according to region (Northern Ireland vs. rest of UK).

Table 3: Food group according to region (Northern Ireland vs. rest of UK).

Table 4: Macronutrient intakes across the 2 ethnic groups.

Data presented as mean (SD).* Significant differences in Macronutrient intakes across the 2 ethnic groups were analysed using Independent Samples T-test.

Table 5: Micronutrient intakes across the 2 ethnic groups.

Table 6: Food group intakes across the 2 ethnic groups.

Table 7: Macronutrient intakes across the 5 ethnic groups.

Data presented as mean (SD).* Significant differences in nutrient intakes across the 5 ethnic groups were analysed using One-way ANOVA Test.

Means sharing a letter in their superscript are not significantly different at the 0.05 level according to LSD test.

Table 8: Micronutrient intakes across 5 ethnic groups.

Means sharing a letter in their superscript are not significantly different at the 0.05 level according to LSD test.

Table 9: Food group intakes across 5 ethnic groups.

Means sharing a letter in their superscript are not significantly different at the 0.05 level according to LSD test.

Table 10: Macronutrient intakes across socio-economic classification (NS-SEC).

Data presented as mean (SD).* Significant differences in nutrient intakes across Socio-economic classification (NS-SEC) were analysed using One-way ANOVA Test.

Means sharing a letter in their superscript are not significantly different at the 0.05 level according to LSD test.

Table 11: Micronutrient intakes across socio-economic classification (NS-SEC).

Means sharing a letter in their superscript are not significantly different at the 0.05 level according to LSD test.

Table 12: Food group intakes across socio-economic classification (NS-SEC).

Means sharing a letter in their superscript are not significantly different at the 0.05 level according to LSD test.

Table 2 indicates that there were significant differences in the consumption of vitamin A in retinol equivalent between NI and the rest of the UK. The retinol level in retinol equivalents was higher in the rest of the UK (mean=560.37, SD=414.95) than NI (mean=486.82, SD=261.65), which was statistically significant (p=0.02). There were statistically significant differences in the intakes of vitamins B6 (p=0.02), riboflavin (p=0.02), niacin (p=0.04), calcium (p=0.01), potassium (p=0.04), zinc (p=0.01), copper (p=0.03), iodine (p=0.03), phosphorous (p=0.02) and sodium (p=0.03) between NI and the rest of the UK. The intakes of these micronutrients was higher in NI than the rest of the UK.

Table 3 shows there were significant differences in fruit intake (not including juice or smoothies) and vegetables portions (80g per portion) between NI (mean=1.95g SD=1.20) and the rest of the UK (mean=2.44g SD=1.45, p=0.00). Similarly, the total fruit and vegetable portions consumed (fruit, veg, juice and smoothies) was higher in the rest of the UK (mean=2.89g SD=1.54) than in NI (mean= 2.35, SD=1.31, p=0.00). However, the difference in the intake of fruit juice (from composite dishes) and fruit from smoothies between the two regions was not statistically significant. Processed red meat was eaten more in NI (mean=15.24g, SD= 15.36) than the rest of the UK (mean=11.89g, SD=14.69).

This difference was statistically significant (p=0.01). The average portion of processed red meat for this age group was 50g. Processed red meat included foods such as sausage, bacon and ham. Given that a sausage is approximately 75g, this difference translated to a about one-fifth of a sausage between the two regions. Figure 1 shows the consumption of macronutrients and two food groups in NI compared to the rest of the UK and the government recommendations.

The intake of protein exceeded the government recommendations. However, the consumption of oily fish, fibre and processed red meat were less than the levels endorsed by the UK government. Figure 2 compares the intakes of sodium and calcium between the two regions and shows that the intake of calcium exceeded the maximum dietary requirements and were higher in NI than UK. Conversely, the sodium intake was lower than the recommended level but was higher in NI than the rest of the UK.

Clustering the ethnic groups as white and non-white revealed a significant difference in the dietary intakes. (Table 4) across various ethnicities showed that there were significant differences in the consumption of cis n-3 fatty acids (p=0.02), cis n-6 fatty acids (p=0.04) and total sugars (p=0.00) between whites and non-whites. However, there was no significant difference in the intakes of food energy, protein, fat and carbohydrates between the two ethnic groups.

Figure 3 shows that the intake of processed red meat did not exceed the maximum recommended level of 70g per week. However, the consumption of oily fish was still lower than the endorsed levels of 140g per week. The protein intake in both ethnicities exceeded the government recommendations, whereas the intake of total sugars which was higher in whites than non-whites, was below the dietary recommendations. Figure 4 showed that the intake of calcium and sodium were higher in whites than non-whites and exceeded the government recommendations.

Table 5 shows that there were significant differences in the intakes of vitamin E (p=0.02), thiamine (p=0.00), riboflavin (p=0.02), calcium (p=0.01) and sodium (p=0.00) between whites and non-whites. Nonetheless, there was no significant difference in the consumption of vitamin A, vitamin B6, vitamin B12, vitamin C, vitamin D, niacin, folate, potassium, iron and zinc.

There were statistically significant differences between the consumption of processed red meat (p=0.00) and oily fish (p=0.00) between whites and non-whites (Table 6). The intake of processed red meat was higher in whites (mean=13.69g) than non-whites (mean=5.03g), whereas the consumption of oily fish was higher in non-whites (mean=4.11g) than whites (mean=1.81g). Conversely, there was no difference between the consumption of fruit juice (p=0.31) and smoothie portions (p=0.22) between whites and non-whites. However, there were statistically significant differences in the consumption of plain fruit and vegetable portions (p=0.01) as well as total fruit (p=0.03) between whites and non-whites.

Further grouping of the various ethnicities into five cultural groups showed a significant difference in dietary intakes (p=0.00) between groups. (Table 7) shows that there were significant differences in the consumption of cis-n-6 fatty acids across the five cultural groups (p=0.04) and total sugars (p=0.00). Post-hoc tests showed that the difference in cis-n-6 fatty acid intake existed between Whites and Asian or Asian British ethnicities as well as between mixed ethnic groups and Asian/Asian British. The difference in total sugar intake existed between Whites and Black or Black British as well as between Whites and Asian or Asian British.

There was also a difference between Asian/Asian British and mixed ethnic groups as well as between Black/Black British and mixed ethnic groups at p<0.05 (Table 8), there were significant differences in the intakes of vitamin E (p=0.01), thiamine (p=0.00), calcium (p=0.04) and sodium (p=0.00) across the five cultural groups. LSD post-hoc test showed that differences in vitamin E was between White and Asian/Asian British (p=0.00) as well as between Asian/Asian British and any other group (p=0.03). The difference in thiamine intake was between Whites and Asian/Asian British (p=0.00) as well as Whites and Mixed ethnic group (p=0.04).

For calcium, the difference existed between Whites and Black/Black British (p=0.04). The intake of sodium differed between Whites and Mixed ethnic group (p=0.02), Whites and Black/ Black British (p=0.00) and between Whites and Asian/ Asian British (p=0.00).

A comparison of the intake of different food groups across the five cultural classes (Table 9) showed statistically significant differences in the consumption of fruit and vegetable portions (p=0.01), total fruit and vegetable (p=0.03) processed red meat (p=0.00) as well as oily fish (p=0.00). The highest consumption of red meat was reported in whites (mean= 13.69g), whereas the lowest intake was Asian or Asian British (mean=2.20g). LSD test revealed that the intake of fruit and vegetable differed between Whites and Asian or Asian British (p=0.02), between Whites and any other group (p=0.01), as well as between Blacks/black British and any other group (p=0.02).

The effect of socioeconomic standing (SES) on dietary patterns was demonstrated in Tables 10, 11 and 12. It was noted that there were significant differences in the consumption of 6 out of 7 macronutrients (Table 10). There were statistically significant differences in the intakes of food energy (p=0.00), protein (p=0.00), fat (p=0.01), carbohydrates (p=0.00) and total sugars (p= 0.00) across the three socioeconomic classes. The highest levels of these micronutrients were recorded in people of high SES, followed by middle SES and finally low SES. LSD test showed that the differences were significant between high SES and low SES for all nutrients that differed (p=0.00).

A similar trend was observed in Table 11 for the micronutrients. Statistically significant differences were observed in the consumption of vitamin A (p=0.00), vitamin B6 (p=0.00), vitamin B12 (p=0.00), vitamin C (p=0.00), vitamin D (p=0.01), thiamine (p=0.00), riboflavin (p=0.00), niacin (p=0.00), folate (p=0.00), potassium (p=0.00), calcium (p=0.00), iron (p=0.00) and zinc (p=0.00). For these nutrients, post-hoc tests showed that statistically significant differences existed between high SES and low SES.

Table 12 showed that the consumption of fruits and vegetables (p=0.00), fruit juice (p=0.00), fruit smoothies (p=0.00), total fruit and vegetables (p=0.00), and oily fish (p=0.00) was statistically significant between the three SES. LSD test showed that significant differences existed between low SES and high SES (p=0.00), low SES and middle SES (p=0.00) as well as middle SES and high SES (p=0.00). The impact of SES on the consumption of processed meats as well as portions of fruits and vegetables was not statistically significant.

Discussion

The UK government recommends that the daily consumption of protein should be at least 28.3 grams per day, whereas the fibre content should not be lower than 20 grams a day. Table 1 shows that the intake of fibre was lower than recommended while the consumption of protein exceeded the maximum daily limit in NI and the rest of the UK. The UK government recommends that people aged 11 years and older should have at least 5 portions of fruits and vegetables per day, which is equivalent to 400 grams (Public Health England 2016). This stipulation aligns with NI dietary recommendations.

Conversely, children and adults should restrict their intake of red and processed meat to at 70 grams per day, whereas adults and children should have at least 140 grams of oily fish (Kranz, Jones & Monsivais 2017). However, Table 3 shows that the consumption of fruits and vegetables was below the recommended levels in NI and the rest of the UK to the same extent. This observation could be attributed to a variety of factors such as cost and preference.

Diets that are rich in fruits and vegetables are often more expensive than normal ones (Monsivais et al. 2015; Conklin et al. 2016). Hayter et al. (2015) reported that SES influenced what parents fed to their children. Most parents with low SES understood the importance of fruits and vegetables but were unable to provide them because of their financial circumstances. This observation suggests the need for implementing food price policies to promote the intake of healthier, diverse diets.

Similarly, the consumption of oily fish was less than the recommended range of 7 to 17 grams per day in NI and the rest of the UK, even though the levels were slightly lower in NI. Studies show that the commonly eaten food in the UK is fish and chips, which are energy dense (Lentjes et al. 2016; Wrieden, Mangwende & Goffe 2016). A similar trend is replicated in NI, which is part of the UK (Neville et al. 2018). Fish is a good source of protein as well as omega-3 and omega-6 oils.

From these patterns, it would be expected that the consumption of oily fish would meet the government recommendations. However, since that was not the case, there is a likelihood that the type of fish consumed did not have large quantities of fish oil. Mardle and Metz (2017) reported that cod, haddock, tuna, salmon and prawns are the ‘big 5’ fish species consumed in the UK, particularly through fish and chips shops all over the country. Of these five species, cod and haddock, which do not have high quantities of fish oil, are commonly eaten. Therefore, this problem can be resolved by promoting the consumption of oily fish such as trout, salmon, sardines, herring, mackerel, eels and tuna.

These results suggest that the key nutritional needs of NI children are fruits and vegetables, oily fish and vitamin A, which should be increased in their diets. Nonetheless, the consumption of saturated fatty acids, processed meats and red meat are higher than recommended and need to be reduced. It was not possible to deduce the exact differences in a food context given that diverse foods were consumed, and some food data were obtained through estimations from pictures and food atlases.

SES plays a vital role in the nutrient intakes of a population. Miller, Spiro and Stanner (2016) reported that calcium, folate, iron, vitamin D and iodine were often deficient in specific categories of the UK population, including teenagers, ethnic minorities and economically challenged. In this study, there were significant differences in the macronutrient, micronutrient, and food group intakes between the three the SES, particularly between low SES and high SES. Low financial status makes balanced diets unaffordable (Darmon & Drewnowski 2015). Furthermore, people of low SES have limited access to fresh fruits and vegetables (Burgoine et al. 2017) as well as whole grains (Mann et al. 2015). These factors explain the observed disparities in the intake of different nutrients across the three SES.

Ethnicity had a significant impact on nutritional intake. The growth of immigrant populations in developing and developed countries is mainly responsible different dietary patterns as observed by Dekker et al. (2015). Overall, areas predominated by Asians had carbohydrates (rice) and white meat as the commonly eaten food groups. In this study, Asian or Asian British comprised only 7.6% of the total population, which could explain why the influence of noodle/rice and white meat consumption was not substantial enough to shift the patterns of the whole population.

The impact of ethnicity on dietary patterns reflects an interaction of numerous factors such as poverty income ratio and average nutrient requirements for each ethnicity. For instance, Malek et al. (2019) examined the effect of race and income differences on achieving the reference dietary intakes in a US population. Data from 24-hour recalls were collected and evaluated. It was noted that significant differences existed in the percentage estimated average requirements for 15 nutrients, including vitamin A, vitamin B12, B6, C, D, zinc, calcium, iron and folate. The requirement for riboflavin and vitamin B12 differed substantially between Hispanics, non-Hispanic blacks and other ethnic groups when likened to non-Hispanic whites.

Similarly, the supplementation of foods with vitamin D resulted in a reduced need for the micronutrient in Hispanics compared to non-Hispanic whites. The tolerable upper intake levels of also differed from one ethnic group to another. These findings suggest the involvement of a genetic or biological component in the requirement and intake of various nutrients and micronutrients and have informed the need for nutrient supplementation to meet the dietary requirements of various groups (Blumberg et al. 2017).

The latest NDNS data compare the consumption of various nutrients in NI and the UK. The observed findings in this study are in line with past data. For example, Syrad et al. (2016) observed that the daily energy intake, protein and most micronutrients surpassed the UK dietary reference values in children at 21 months of age, thereby predisposing them to obesity. Conversely, the intake of vitamin D and iron in the UK did not meet the stipulated standards despite supplementation efforts. In this study, the intakes of vitamin D was approximately 2 micrograms per day for UK and NI children, which is significantly less than the recommended levels of 10 micrograms a day.

However, the iron intake was within the expected limits of 6.1 to 8.7mg per day for children between 4 and 10 years (Public Health England 2016), which showed an improvement in iron consumption from previous data.

Breakfast is linked with higher general dietary sufficiency compared to other meals (Gaal et al. 2018). The most abundant nutrients in breakfasts included iron, iodine, calcium, B vitamins, magnesium and vitamin D. However, some of these nutrients, particularly vitamin D, was inadequate in UK and NI children, which suggested that breakfast composition may have influenced the available nutrients and that these micronutrients were inadequate in typical breakfasts in NI and the rest of the UK.

Eating habits can also determine the consumption of different food groups. Studies show that Belfast, which is the capital of NI, has the unhealthiest eating habits (Davison et al. 2015). Approximately half the population admitted to eating junk food, which in most cases contain high levels of sugars, fats, and salt (sodium). In this study, the mean sugar, fat and sodium consumption was higher in NI than the rest of the UK, which could be explained by the love for junk food in most parts of NI including its capital.

Personal preferences can also influence the nutritional status of an individual. For example, children do not like food items such as grains, milk, butter, pulses and green leafy vegetables (Johnson 2016; Iftikhar et al. 2019). Taylor et al. (2016) investigated the consumption of micro and macronutrients among picky and nonpicky eaters between the ages of 2 and 5.5 years and noted that the former had higher average iron, carotene and zinc intakes than the latter.

Additionally, fish, vegetables and meat were consumed in lower quantities among picky eaters. However, the intake of sugar exceeded the recommended levels in picky eaters. This observation probably accounted for the observed low consumption of oily fish, cis-6 and cis-3 fatty acids among the children and suggests that parents and school workers should find ways of presenting such foods to children attractively to motivate picky eaters.

Overall, from the data collected in this study, the main nutritional requirements of children in NI are fruits and vegetables, oily fish and micronutrients such as vitamin A, B vitamins, calcium, potassium, zinc, copper, iodine and phosphorus, which were lower than recommended levels. Inadequacies in these nutrients also exist in the UK. Nonetheless, the intake of saturated fatty acids, processed and red meat are high in both regions and ought to be cut down. The nutritional status of children in NI can be improved by addressing various factors that affect dietary habits.

Food patterns are outcomes of intricate associations between a number of factors such as food choice as determined by taste, appetite, availability, cost, earning potential, time, meal patterns, stress, mood, attitude, education and knowledge of food (Iftikhar et al. 2019). Failing to strike a balance between these factors often leads to poor dietary habits. Parents should guide their children towards the attainment of healthy energy and nutrient levels for young children and teenagers (Taylor et al. 2016).

Given that eating habits play a significant role in the intakes of various nutrients and food groups, there is a need to address this issue to improve the nutritional status of children in NI. Parents of picky eaters should expand their children’s diets to incorporate more fruits and vegetables. In contrast, parents should monitor the quantities of sugary foods. The findings by Gaal et al. (2018) suggest that breakfast is a viable target when attempting to enhance the consumption of specific nutrients.

The best way to teach and promote healthy eating habits in children and adolescents is through schools, which can target many students cost-effectively. Furthermore, children in the NI spend a significant amount of their time at school, which implies that schools are powerful ways of encouraging healthy eating habits in children. Studies show a direct association between the academic performance of a child and their health standing (So & Park 2016; Faught et al. 2017). For these reasons, it is important to create a positive, healthy environment that is conducive for learning as well as the wellbeing of schoolchildren.

School canteens in NI can adopt strategies such as incorporation of deficient nutrients and food groups such as vitamin D, oily fish, and fibre to their daily menus. This approach would ensure a constant supply of the inadequate nutrients and remedy the situation. Additionally, graphical representations of the nutritional rating on the front of food packaging has produced satisfactory results in promoting healthy food purchases (Reilly et al. 2018) and can also be adopted in NI.

Pricing and promotion strategies can also be employed to create awareness of healthy foods and make them affordable to the student population (Yoong et al. 2015). The school administration should implement nutrition policies such as banning fatty and sugary foods and promoting the sale of fruits and vegetables (Nathan et al. 2016; Yoong et al. 2016).

Fruits and vegetables play a vital role in human nutrition and health (Rodriguez-Casado 2016). The fact that the consumption of fruits and vegetables in NI and the rest of the UK was lower than the recommended five servings per day implies that there is a need for serious interventions to improve the consumption of this food group. Iftikhar et al. (2019) suggests nutrition education lectures highlighting the importance, benefits and consumption of fruits and vegetables.

These lectures should target middle-school children aged between 7 and 10 and have been reported to cause significant improvements in the knowledge, attitudes and practices associated with the consumption of fruits and vegetables. The findings of this study suggest that school-based nutrition intervention is an effective way of modifying the dietary habits of school-aged children and should be considered for children in NI.

School food manufacturers have an important role to play in influencing the dietary habits of children. The first aspect that should be considered is the advertising of food items meant for schoolchildren. Studies show that advergames have a significant short-term and long-term effect on children’s food preferences, particularly when they concentrate on food items with high levels of salt, fat, or sugar that form the bulk of advertising (Chambers et al. 2015). Additionally, a link between marketing strategies and obesity has also been established (Clarke & Svanaes 2014; Boyland & Whalen 2015; Mazur et al. 2018). Therefore, there is a need for NI to impose restrictions concerning the advertising of food items rich in salt, fats and sugar to limit their consumption by schoolchildren.

Ultra-processed foods have high quantities of salt, fat and sugar but low levels of fibre, healthy protein and micronutrients. Their ease of manufacture and cost has displaced freshly prepared and minimally processed healthy foods in most developed countries including the UK (Monteiro et al. 2018). School food manufacturers in NI should also cut down on the production of ultra-processed foods and adopt the United Nation’s NOVA food classification system to ease the identification of these commodities by the public.

Limitations of the Study

The main limitation of the study is that there no data that calculated the total fruit and vegetable intake of children aged 11 years and below. Therefore, it was necessary to work out the respective intakes from the available NDNS data. Additionally, NDNS coded -5 in the dataset, meaning that no data were available for this age group, which yielded negative results during the comparisons. Furthermore, the NDNS data did not include the intakes of fruit juice and smoothies.

Given that the dataset used in the compilation of this study relied heavily on NDNS data, all limitations associated with the survey as well as other methods that use the same approach apply to this report. For example, the accuracy of the survey outcomes depends on the memory of the subjects when providing data through the 24-hour recalls. Additionally, the reliability of the portion size information was dependent on the age and memory of the participants, which contributed to variations. Poor memory has been cited as a prevalent shortcoming when using 24-hour recalls to collect food intake data (Subar et al. 2015). Food atlases and pictures used to guide the estimation of portion sizes sometimes contain limited pictures which complicate the estimation of indigenous foods (Gemming et al. 2015).

Conclusion

This study demonstrates that there exist significant differences in the nutritional intakes of children in NI and the rest of the UK in most nutrients and food groups. NI was better than the rest of the UK in the intake of most nutrients and food groups even though the government recommendations were still unmet for certain nutrients such as fibre, vitamin D, oily fish, fruits and vegetables in both regions. Other factors that had a significant impact on food habits included cultural affiliation and socioeconomic standing. There were significant differences in nutrient intakes across the three SES with majority of the differences being noted between high and low SES.

Given the role of schools in developing and promoting healthy nutritional behaviours, school caterers in NI should incorporate appropriate foods such as whole grains, fruits, vegetables, and fish in the school diet to meet the required intake of these nutrients.

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