Agenda Public health perspectives in the Introduction research of - - PDF document

1

Resea rch Unit for Die tary Studies at Institute of Preventive Medicine w w w .kostforskning.dk

Public health perspectives in the research of children’s food and meals

Ida Husby, Ph.D.

Institute of Preventive Medicine and Institute of Human Nutrition, University of Copenhagen 4th Norplus Course, Copenhagen, March 2009

Agenda

• Introduction

– Public health nutrition – Nutrients, food and meals

• A comparative photo-based interview study

with children

– Method, results and discussion

• Discussion

Public health nutrition

• Public Health is a collective action taken by

society to protect and promote the health of entire populations (Margetts 2004, Mason et al 1996)

– Change – Nutrition epidemiology, recommendations, intervention, policies, education etc.

• New public health and empowerment strategies –

the process through which people gain greater control over decisions and actions affecting their health (WHO 1986)

Evidence based health promotion

• The use of information derived from formal

research and systematic investigation to identify:

– Causes and contributing factors to health – Effective health promotion actions

• Evidence derived from many disciplines
• Formal evidence combined with the expertice of

individual practioners which guides the selection and application of evidence (Smith et al 2006)

Many types of evidence

• Evidence-based public health must rely on a

variety types of evidence, often in combination (Victora et al 2004)

– Randomized controlled trials – Evaluations – Process- and impact indicators

• Important to document theory and central

concepts and principles (Green & Glasgow 2006)

Meals

• Three approaches to meal research

– Format and contents – Meal patterns – The social organisation of meals

• Definitions of meals (Douglas & Nicod 1974, Douglas

1975)

– Meals – structured (food and social relations) – Snacks – unstructured, but some are embedded in social relations (drinks)

2

Children’s diet and health

• The diet are associated with diseases and
• besity (WHO 2003, Hung et al 2004, Swinburn et al 2004, World

Cancer Fund 2007)

• Health behaviours – and health – are

established in childhood (tracking studies)

(Kelder et al 1994, Lien et al 2001, Maynard et al 2003, Baker et al 2007)

• Children’s diet and physical activity are

central elements in strategies to prevent

• besity (Lobstein et al 2004, Müller et al 2005, WHO 2006)

The diet of Danish children

• Too much sugar
• Too much soft drinks
• Not enough fruit and vegetables
• Not enough dietary fibre
• Too much fat (and saturated fat)

(DTU-Food 2008)

Associations between meals and nutrion

• Meal patterns (Anderson et al 1993, Siega-Ritz 1998, Zizza et al

2001, Nicklas et al 2004)

– Skip meals – Eat out – More snacks

• Family meals (Gilman et al 2000, Haapalati 2003, Videon &

Malling 2003, Neumark-Sztainer et al 2003, Feldman et al 2007)

Snacks – children and adolescents

• Increasing prevalens of snacking (Jahns et al 2001,

Zizza et al 2001, Nielsen et al 2002)

• 20-35 % of energy (Ruxton et al 1996, Summerbell et al 1995,

Samuelson 2000, Zizza et al 2001, Fagt et al 2007)

• More snacks – in the afternoon (Cross et al 1994,

Bellisle & Rolland-Chachera 2007)

• Snacks have a poor nutrition quality (Summerbell

et al 1995, Sjöberg et al 2003, Fagt et al 2007)

Meals are embedded in social and cultural meanings

• Family meals – a frame for family life, care,

control and healthy food (Charles & Kerr 1988, DeVault 1991,

Iversen & Holm 1999, Kaplan 2000, Roos 2002, Christensen 2003)

• Snacks – a social community of children of the

same age and of own control (Roos 2002, Sylow 2005)

• Unhealthy food – autonomy, comfort and conflict

(James 1979, Fischler 1986, Charles & Kerr 1988, Chapman & Mclean 1993)

The meal and social context of food

• Food and meals are charged with meanings (Warde,

1997)

• The meal is not only understood by its contents

but by the way it is eaten and what happens during the meal in terms of behaviour (Charles & Kerr, 1988)

• The family need food and need the meal as a

medium to create the family (De Vault, 1991)

• Structured meals help to structure one’s life in
• general. The role, structure and content of a meal

are gradually changing (Mäkelä, 2000)

3

Meals and snacks – the childs perspective

Ida Husby, Berit Heitmann & Katherine O’Doherty Jensen The overall aims of the study are to establish if there are differences among children with a healthier diet opposed to a less healthy diet, and how children experience their food and meals with the intention of using the findings to promote healthy dietaty habits.

Research questions

• How do children experience their food and

meals primarily whilst at home, but also when eating out?

• How do children experience that their food

and meals are controlled?

Population

• In 2002 a dietary survey was conducted
• 17 children were followed up in 2006
• Diet was defined as healthier or less healthy
• Healthier diet (n=9):

Max 10 E% from added sugar 15-25 g/d dietary fibre

• Less Healthy diet (n= 8):

15-25 E% from added sugar Less than 15 g/d dietary fibre

Method

• A comparative design with two groups of children
• Semi structured interviews based on photos taken

by the children

• Interview guide – meal pattern, childrens roles,

control over food and meals

• Interview lasted between 40 and 65 minutes
• Digitally recorded and transcribed

(Kvale 1999, Rasmussen 1999 and 2000, Winther 2004)

Photo based interviews

• The children took pictures of their food and their

meals on different days and at different eating events

• Single-use camera with 37 pictures
• Establish the possibility to interview the children

about concrete situations

• Enable the maintance of details and atmosphere
• Record the childrens own experiences

Analysis

• Index coding, inspired by the procedure of

template analysis (King, 2004)

• Atlas.ti, version 5.2
• Meaning condensation
• Common trait, variation and differences

between the two groups

4

The everyday of the children

• Fourth grade in municipal schools
• After-school activities; club and activities as

football and dance

• Be together with friends and families
• Doing homework, play at the computer,

watch television etc.

• Not very active in tasks in the household

Meal pattern

• Breakfast
• 10 o’clock eating event
• Lunch (packed lunch in school)
• Eating event in the after-school activity
• Eating event late afternoon at home
• Dinner
• Eating event later in the evening

Eating event at school

• ”Coco-Pops are only filling in the morning,

then they stop having a filling effect. They don’t last very long, soon I am hungry again”

(Sofie, Less Healthy Diet)

Lunch in school

• The children brought a packed lunch,

provided by the parents

• Sandwiches, vegetables and maybe

something sweet

• Occasionally some of the children bought

their lunch in the school cantine

Lunch at school, boys and girls

• ”We just eat. And then we can chat a bit and move
• about. At the moment we talk about the football

match I am going to play in Jutland. Otherwise we talk about, what do we talt about? Yeah, all sorts. Football, what we are doing in the club, anything, what we plan to do, or what we have done...”

(Mikkel, Healthier Diet)

• “You don’t just go over and take some food. We

can easily taste each others. If you have a pizza roll: “would you swap a bit for a grape?” or something like that.”

(Camilla, Healthier Diet)

Lunch at school, social context

• ”We are not allowed to sit out there (in the

corridor)... We can’t sit there because he (the teacher) thinks that our class should be a class that eats together. [...] I think that if

• ne sat out there, then I don’t think that

would be a real class.[...] A real class is one that helps each other and is together.”

(Katrine, Healthier Diet)

5

Dinner

• The third main meal of the day, the dinner,

was eaten at home and often in the company

• f their family
• Recreational activities and working hours

could cause irregularity

• Almost all the children told they enjoyed

the family dinner

Eating event later in the evening

• Only one child had an ordinary meal or

eating event after dinner

• Most in weekends the children had sweets

in the evening

• Some had some fruit in the evening

Meal pattern, summing up

• Almost the same meal pattern in the two

groups

• 3 main meals and 2-4 eating events
• Children from the group of Less Healthier

Diet more often had meals and eating events alone

• The parents prepared the main meals

Snacks and the social context

• Both groups of children talked about sweets, chips

and soft drinks

• Healthier diet children: ate sweets and drank soft

drinks in the company of others (with family or friends)

• Less healthy diet children: often ate sweets and

drank soft drinks alone in their room or while being alone in the afternoons

Snacks and the social context

• Healthier diet children: ate sweets and cakes and

drank soft drinks in connection with special

• ccasions. (These could be Fridays, a family

birthday or a special programme on the television)

• Less healthy diet children: ate sweets and cakes

and drank soft drinks even when there were not special occasions (on weekdays, weekends) in addition to times when there were

Snacks and the social context

• ”Generally I eat them (chocolate) when I

am playing with my playstation. In my room I also have games and a computer”

(Mads, Less Healthy Diet)

6

Special occasion - fruit

Ida: Why don’t you get pineapple on other days? No, because mum can’t be bothered to cut I up […] Ida: Why don’t you just cut it up yourself, the pineapple? I can’t […] no, but it’s also because I must not, my big sister says, I should take care with the sharp knives, that’s why I don’t do it, that’s why my mum should do it.”

(Mads, Less Healthy Diet)

Special occasions

• ”Yeah, its (soft drinks) something we get

some times at parties, and when we have a pleasant time. We keep it in the fridge. So if we decide to have a cosy evening, if there is something on the television, which we really want to see. Not just if there is a serial”

(Frederik, Healthier Diet)

• “I think it was when Denmark played

against France” (Jonas, Healthier Diet)

Social context, summing up

• There were differences between the two groups
• The group with healthier diet had sweets and soft

drinks together with their family and friend and in connection with special occasions

• The group with less healthy diet had sweets and

soft drinks alone and without special occasions too

• The parents bought and served sweets and soft

drinks to both groups of children

Control and rules

• In every family there were special practices

about when and what to eat

• The children asked permission before they

took something to eat. In particular the children with a less healthy diet experienced that they most often recieved a yes in reply

• The rules were tied to such subjects as

economy, practical reasons or health

Reasons for rules

• ”I ask my mother ”mum, may I have some

sweets?”, and she says yes. It is rare that she says

• no. That is when we will eat soon [...]. I take as I
• like. She says nothing, she throws it (the box) out

afterwards” (Mads, Less Healthy Diet)

• “Some times, if I have already had ice cream, she

says no […]. It depends on what sort of ice cream it is. If it is a cheap variety then I am allowed. If it is an expensive type … we say it is a sort of Friday ice cream” (Sofie, Less Healthy Diet)

• “Because it is the unhealthy I should ask about”

(Cecilie, Healthier Diet)

Childrens control

• Children from both groups were happy with the

families rules. They didn’t want to change them.

• With respect to their packed lunch, all the children

explained how much control they had and how they exercised it ”If I don’t like what he gives me in my lunch packet, I ask: Can you give me something else? And he says: Yes, I will” (Emma, Healthier Diet)

7

Control and roles, summing up

• All the children were happy with the rules

in their family, they saw no need to change them

• The children could tell about how they

controlled the packed lunch

Discussion

• Findings:

– Snacking – a focus of health promotion initiatives – The social context of snacking – snacks and drinks – Parents are a key to change

• The methodology with photographs yielded a

fruitful, concrete and valid point of departure for gaining insight into eating habits

Public health nutrition and research of food, meals and everyday practices

• This type of research can contribute to

understand and explain the children’s behaviour and practice within the context of their everyday lives

• An important part of knowledge to

evidence-based health promotion