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chapter 5 nutrition
Early years, children and young people: nutrition
The Scottish national diet has been the focus of increasing Government attention over the last two decades and has been repeatedly identified as a key priority 56,57,58. This chapter focuses on 2 key areas: Infant feeding and the eating patterns of Scottish school children.
Infant feeding
Good nutrition, particularly amongst 0-2 year olds, is a foundation for future health. This period is critical for infants and the potential consequences of poor nutrition at this time can include death and illness. It can also cause delayed mental and motor development, impaired intellectual performance and future work capacity 59.
Optimal nutrition is exclusive breastfeeding for around 6 months and then continued for up to 2 years and beyond with the appropriate introduction of nutritious weaning foods. Breastfeeding protects the infant from future diseases such as gastroenteritis, otitis media, urinary and upper respiratory tract infections, obesity, type 1 and 2 diabetes and high blood pressure 59,60.
The Scottish National breastfeeding target set in 1994 was that, by the year 2005, more than 50% of women should still be breastfeeding their babies at 6 weeks of life.
The present position of breastfeeding in Scotland
In the Infant feeding survey 2005 61 three-quarters of all mothers had given formula milk by the age 6 weeks rising to 92% by 6 months. Just under half of the mothers were not following key recommendations for preparing formula milk and just under half who were using formula milks were not using the recommended milks. More positively there has been a marked trend towards the later introduction of solid foods.
Most of Scotland's NHS Boards record information on infant feeding as part of a routine child health surveillance system ( CHSP- PS) 62. These Board areas cover 84% of Scotland's pre-school population. The data for 2006 show:
- 44% of mothers were recorded as breastfeeding at the health visitor's first visit (around 10 days) and 36% as breastfeeding their babies at 6-8 weeks. This compares with 45% and 37% respectively in 2005.
- A wide variation in breastfeeding rates, varying in 2006 from 31% in NHS Lanarkshire to 59% in NHS Lothian.
- All breastfeeding rates at 6-8 weeks were lower than the national 50% target.
Older mothers are more likely to breastfeed than younger mothers and breastfeeding rates are higher in more affluent areas.
Breastfeeding 1 at the 6-8 Week Review by NHS Board of Residence and Year of Birth
Breastfeeding 1 at the 6-8 Week Review by Maternal Age and Scottish Index of Multiple Deprivation ( SIMID); 2001-2006
Provisional figures for 2006 show a slight decrease in breastfeeding rates at 6-8 weeks from 2005 levels. However, rates have risen overall since 2001.
Data on infant feeding at 5-7 days of age show a worrying increase in supplementation of breastfeeding by formula and other milks in the early days and a fall in overall breastfeeding rates. The greatest decline in breastfeeding is in the first 72 hours 61 and early supplementation of breastfeeding is strongly associated with early discontinuation of breastfeeding. A recent systematic review found that breastfeeding initiation and duration rates in the UK were amongst the lowest in Europe, particularly in the most deprived socio-economic groups. Reasons suggested include society and cultural norms as well as clinical problems, organisation of health services and lack of preparation of health professionals and others to support breastfeeding effectively 63.
Action to improve breastfeeding rates
Breastfeeding is encouraged at many levels. For example: National health promotion adverts; policies in NHS maternity hospitals and primary care teams working with individual women and community groups. NHS Board Breastfeeding Strategy Groups, in particular, support a wide range of innovative work such as improving capacity and capability of health professionals through training, supervised clinical practice and implementing the UNICEFUK Baby Friendly standards.
Clinicians, health promotion experts, local authorities and voluntary organisations have worked with local communities to train peer volunteers to increase the public's acceptability, knowledge of and confidence in breastfeeding. Other partners in the community deliver projects such as the Glasgow "Breastfeeding Friendly Nursery" that promotes breastfeeding in the pre-5 setting.
National progress
Key areas of a new National Infant Feeding Strategy being developed include:
- Increasing both initiation of and duration of breastfeeding
- Minimise the risks of formula feeding
- Supporting good weaning practices
- Increasing public knowledge and acceptance of breastfeeding
- Raising awareness of legal rights for infant feeding
- Ensuring integrated, multi-sectoral support
- In 1996 only one NHS Board had a breastfeeding strategy, in 2005 only one did not.
- In 1993 there were four breastfeeding support groups - there were 150 in 2005.
- In 1994 there was only one peer support programme, increasing to 11 by 2005.
- 58% of Scottish babies are now born in a UNICEF "Baby Friendly" accredited hospital compared with 34% in Wales and Northern Ireland and 9% in England.
- The University of Paisley is the first University in the World to receive a UNICEFUK Baby Friendly award.
- The Breastfeeding (Scotland) Act 2005 makes it an offence to prevent or stop a person in charge of a child under the age of 2 years, who is otherwise permitted to be in a public place, from feeding milk to that child. This legislation is the first of its kind in the UK and Scotland is one of the few countries worldwide to enshrine such protection in national legislation.
The challenge ahead
There has been a great deal of work on infant feeding over the past 10 years. However, breastfeeding rates are still disappointingly low and we still have a lot to do. If we are to increase breastfeeding rates we need a huge shift in social and cultural attitudes and there is some evidence that this is happening. Research carried out following the first Scottish breastfeeding TV campaign in 2001 showed that people were much more aware of the benefits of breastfeeding and most were able to name some of these benefits. However there are apparent difficulties in translating this understanding into providing optimal nutrition for infants in Scotland.
The eating habits of 11, 13 and 15 year olds in Scotland between 1990 and 2006:
Eating well is a long-term investment in health. Habits formed in childhood and adolescence are thought to track into adulthood influencing the risk of future chronic diseases 64. As children grow older they have more control over their food choices with greater opportunities to choose and buy their own food and drinks outside the home 65. There are many influences on food choices including exposure to foods in the home and at school, taste preferences, affordability, advertising and personal concerns about weight and body image.
This following section describes the eating habits of adolescents in Scotland in their final year of primary school and in second and fourth years of secondary school. They are aged around 11.5, 13.5 and 15.5 years. The data are from the Health Behaviour in School-Aged Children ( HBSC): WHO Collaborative Cross-National Study 66 in Scotland conducted by the Child and Adolescent Health Research Unit ( CAHRU), the University of Edinburgh 67. Scotland has participated in 5 consecutive HBSC surveys carried out every 4 years in the spring since 1990.
International comparisons have highlighted the poor diet of Scottish schoolchildren relative to Europe and North America. Young people in Scotland have high levels of consumption of soft drinks, sweets, chips and crisps 68,69,70,71.
Concerted efforts in Scotland to improve children's experiences of food in school include implementation of Hungry for Success58 and more recently the Schools (Nutrition and health promotion (Scotland) Bill 72. These aim to increase access to healthier food choices within school by setting strict nutritional standards.
The following important findings are examples from the HBSC survey.
Breakfast consumption
Breakfast is recognised as an extremely important meal for young people nutritionally but also for its support of cognition and learning 70. Eating breakfast every school day declines with age. Seventy-seven percent of 11 year olds eat breakfast compared with 51% of 15 year olds. There is no gender difference at age 11 but at ages 13 and 15 girls are less likely to eat breakfast regularly than boys. Between 1990 and 2006 there has been a gradual decline in eating breakfast every day, apart from a small increase between 2002 and 2006 among girls.
Figure 5.1 Eating breakfast daily 1990-2006
Lunch on school days
Pupils were asked what they do for lunch on schooldays for the first time in the 2006 survey. Over 90% of 11 year olds eat a packed lunch or a school dinner and 5% go home for lunch (see Figure 5.2). Among 13 and 15 year olds, the favoured option for lunch is buying it outside school from a local shop, café or van (39% and 42% respectively) followed by eating school lunches (32%; 28%) or a packed lunch (16%; 14%). Four per cent of 15 year olds claim not to eat lunch at all and 10% go home for lunch. A higher proportion of girls (38%) than boys (30%) eat school lunches and a higher proportion of boys (33%) than girls (23%) buy lunch outside.
Figure 5.2 What pupils do for lunch on school days
Figure 5.3 Eat fruit daily
Fruit and vegetable consumption
Fruit and vegetables are vital components of a healthy diet and protect against certain diseases such as heart disease and some cancers. Daily fruit consumption decreases with age especially between 11 and 13 years (51% and 36% respectively). A higher proportion of girls than boys consume fruit daily at all three ages (Figure 5.3).
Daily fruit consumption has increased overall since 2002 for both boys (31% to 36%) and girls (36% to 43%). Among 11 year olds daily consumption of fruit has increased by approximately 10% (boys: 37% to 46%; girls: 45% to 55%). Girls are more likely to eat vegetables daily than boys at all three ages but consumption does not decline with age, unlike fruit. There has been a small increase since 2002 in daily vegetable consumption among 11 year olds (from 34% to 39%) and 15 year olds (from 30% to 36%). A significant increase is found for boys at age 11 (29% to 35%) while for girls increases are found among 13 year olds (38% to 46%) and 15 year olds (30% to 41%). Overall, daily vegetable consumption increased from 33% in 2002 to 38% in 2006.
Sweets consumption
There is a slight increase in the daily consumption of sweets between ages 11 and 13 years. Approximately one-third of young people eat sweets every day and there are no gender differences at any age. Daily consumption of sweets has declined significantly since 2002 from 47% to 34% for boys and 43% to 34% for girls.
Consumption of cola/other sugary drinks
Regular consumption of cola and other sugary drinks can lead to tooth erosion as well as potentially contributing to obesity. It also takes the place of more nutritious drinks and food. Soft drinks are associated with reduced milk and nutrient intake and with increased calorie consumption, body weight, and type 2 diabetes. Sugary drinks are consumed daily by 32% of boys and 25% of girls. While there is a gender difference overall, it is only found in one of the three age groups: the 13 year olds. Daily consumption of these soft drinks does increase between P7 and S2 (23% to 30%) but then remains relatively stable.
Daily consumption of cola and other fizzy drinks has decreased very significantly between 2002 and 2006 from 47% of young people down to 28% of them. The presence of a separate question on diet soft drinks (not in the 2002 questionnaire) may have affected responses but is unlikely to have contributed to the apparent total decrease in daily consumption.
Consumption of diet cola/diet soft drinks
Diet soft drinks are consumed daily by 19% of young people and there are no age or gender differences. No comparisons can be made with 2002 as an item on diet drinks was not included.
Water consumption
Water is consumed daily by 47% of boys and 54% of girls. Thirteen and 15 year olds are less likely to drink water (47% and 50% respectively) than 11 year olds (56%). Overall, girls are more likely to drink water daily than boys. The daily consumption of water is more than double the daily consumption of diet soft drinks and nearly double the daily consumption of sugary soft drinks.
Figure 5.4 Drink water daily
Overall changes
Young people's eating habits have improved with increases between 2002 and 2006 in daily consumption of fruit and vegetables and decreases in daily consumption of sweets and sugary soft drinks. Breakfast consumption declined between 1990 and 2002 but this decline appears to have halted between 2002 and 2006. The uptake of school meals declines significantly between Primary 7 and Secondary School. There will be an opportunity to compare the eating habits of young people in Scotland with those from the 40 other member countries of the HBSC study when the HBSC international report is published in 2008.
Summary
Good nutrition in the first two years of life should be based on effective breastfeeding. The level of breastfeeding in Scotland is much too low and, despite effort and action over the past 10 years, remains low. More concerted action and support at a local level for mothers is needed along with a significant shift in social and cultural attitudes to breastfeeding in Scotland.
It is important to continue to monitor the eating habits of Scotland's school children. The trends to date show a mixed picture with encouraging trends in a number of areas but some worrying trends such as declining uptake of school meals as children progress through school.
"Young people's eating habits have improved with increases between 2002 and 2006 in daily consumption of fruit and vegetables and decreases in daily consumption of sweets and sugary soft drinks."
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