Assignment Scenario

Following the latest report on the nation’s diet by NHS Digital, the Secretary of State for the

Department of Health and Social Care is concerned that fruit and vegetable consumption among

UK children is decreasing despite numerous public health campaigns and nutrition guidelines

being implemented. He is meeting the Secretary of State for the Department of Education to

discuss how the two departments can work together to improve current food policy and design new

intervention to increase fruit and vegetable consumption in children. He is thinking there should be

less focus on health messaging and more emphasis on socio-cultural perspective to target

children’s attention. He is seeking your input for his meeting to understand the socio-cultural

factors that influence fruit and vegetable consumption among children and policy implications on

this issue.

Total word count excluding scenario page: 2181

 MEMORANDUM

To: Matt Hancock, Secretary of State for Department of Health and Social care

CC: Jonathan Slater, Secretary of State for Department of Education

From: Food Policy Advisor, DOH

Date: 3/01/2020

Subject: Socio-cultural factors influencing fruit and vegetable intake among children

1. Introduction

Healthy eating is promoted among children in the belief that positive eating behaviours that

are initiated in childhood, continue over the adolescence years and persist into adulthood

(Lytle et al., 2000). Thus, encouraging children to eat more fruits and vegetables (FV) from

the start could lead to long-term physiological benefits and contribute to healthy cognitive

development (Tandon et al., 2016). Evidence show that children generally do not see it as

their role to be interested in health (EPPI, 2003). Instead, they value eating as a social

occasion and actively seek ways to exercise their own food choices based on food culture

at home and peer influences in school (EPPI, 2003). In order to develop effective

interventions to increase FV consumption among children, it is important to reduce health

emphasis in messaging and focus more on socio-cultural aspects to target children’s

attention.

2. Objectives

The objectives of this memo are to:

 Highlight key socio-culture factors influencing the FV intake among children

 Analyse existing programmes in the UK that promote FV consumption among children

as part of healthy eating initiatives

 Propose specific policy recommendation on how to encourage FV consumption among

children from socio-cultural aspects

3. Issue:

 WHO (2018) recommends that people to eat at least five servings of FV which is

approximately 400g per day and many countries including the UK adopted this into

their national dietary requirements.

 Recent health survey indicates that only 18% of children in the UK aged 5 to 15

ate the recommended portion of FV per day (NHS Digital, 2018).

 Recent data also shows alarming numbers of obese and overweight children with

more than 1 in 5 children are overweight or obese when they begin school, and 1 in

3 children are overweight or obese by the time they leave primary school (Public

Health England, 2019).

 Poor diet and low levels of physical activity are the primary factors to excess weight

(NHS Digital, 2018)

 Diets high in fruit and vegetables (FV) are linked to various health benefits including

a reduced risk of cardiovascular diseases, obesity and cancer (WHO, 2019).

 The Global Burden of Disease Study reported low FV intake is one of the top ten

risks for global mortality (Feigin et al., 2016).

 The WHO estimated that 3.9 million deaths worldwide in 2017 were attributable to

inadequate FV consumption.

4. Timing

Immediate
5. Background:

5.1 Eating pattern among children in the UK

 The fundamental problem behind public health issue for children are the changes in

food habits that have developed mainly due to changes in lifestyle, food industry

advertising and globalisation of fast food over the last few decades.

 The increase in families two working parents, pressure of work, time limitation has

led to ‘convenience revolution’ with pre-packed processed products forming the

basis most of the meals prepared in home (WHO, 2006).

 Many children grow up with out the basic skills of cooking a healthy meal and eating

out may be the only option for feeding themselves, encouraging the consumption of

unhealthy food and snacks with unknown nutrient contents (James, 2002).

 The consumption of snacks products high in fat, sugar and salt may be responsible

for the decline in FV consumption evidenced in recent research, (WHO, 2004)

 Parenting styles are child-centred whereby children themselves influence the

provision of unhealthy snacks, indicating a shifting of power structure within modern

families (Dixon and Banwell, 2004)

5.2 Key Socio- culture factors influencing FV in take among children

i) The culture of Conveniences

 Review of qualitative studies emphasises the importance of conveniences and the

trade-off between time and being healthy. Children prefer snacks like chocolate bar

because these are instantly available, can be eaten immediately, do not require

preparation, easy to carry in backpack without getting squashed or soggy.

 As taste and quality is guaranteed they do not risk wasting money on bad quality or

waiting time (Krølner et al., 2011)

ii) Socially acceptable food among children

 Food choice available in the sporting arena or school compound is determined by

socially acceptable food such as confectionary, crisps and flavoured drinks rather

than FV. (Krølner et al., 2011)

iii) Peer influences

 Peer influences towards easting FV differ by gender because of the symbolic value

of eating FV with respect to image and gender identify (xxxx et al. xxxx)

 A study in primary school in Scotland reported that school girls valued the social

aspects of snacks compared to boys (Ross, 1995). Husby et al. (2009) identified

that girls prefer to swap food with their friends, for example pizza for fruit.

 But another study reports that boys don’t want to swap healthy food (Ross, 1995).

This supports the finding that gender is among strongest determinants of FV intake

where in 14 of 17 reviewed European studies, girls reported as eating more FV than

boys (Brug et al., 2008).

iv) Food Culture in Home environment

 Eating is a social behaviour; children establish eating habits and awareness of type

of food through observing their parents and family. Cox et al. (1998) studied

behaviour of UK households identified that family influence strongly shapes eating

behaviour towards FV.

 This parent-child behavioural modelling effect is widely researched globally, and

evidence indicates that modelling of FV consumption can result in establishing

preference for FV for lifetime (Ong et al., 2017).

6. Current Policy framework relevant to FV consumption among children

Programme Department/ Objectives Impact Analysis

or Policy Agencies
Name
National Department of  Free piece of fruit on Teachers found that

School Fruit Health (DOH) every school day for distributing the fruits in

Scheme children between 4- 6 morning breaks in the

(2004) years individual classes could

 The fruits are delivered encourage a sharing,

to schools 3 times a calm and social time

week (EPPI, 2003)

Healthy Jointly run by Encourage schools to NHSP did not

Schools the DOH, provide education about have a significant

Programme & Department of nutrition with the curriculum positive impact

National Education supported by the provision on pupil

Healthy School of healthy school meals and knowledge or

Standard snacks behaviour (DOH,

(1999) 2011)

Food in DFEE/DOH  Compulsory regulations No programme

Schools (FIS) for school lunches evaluation is available on

(2001)  Practical cookery skills public domain as these a

for Year 6 and 7 children range of various projects

 Breakfast Clubs to implemented separately

ensure children eat

before school

Source: Compiled by authors from various sources (DOH,2011) and (EPPI, 2003)

Although, these programmes have been rolled out nationally to ensure that school children
are able to eat healthily, these interventions do not specifically target to increase FV
consumption to meet the ‘5 A Day’ nutritional guidelines.
7. Policy Recommendation and Considerations

Recommendation A:

Promotion of FV as social snacks in school food environment via school vending

machines or fruit tuck shops to increase availability & accessibility of FV

 Previous research confirms that schools are the most popular way of accessing

children to improve fruit and vegetable intake (WHO, 2006)

 In many schools, vending machines are usually the only source of snacks during

lesson break and sport activities. Vending machines have been criticised for

promoting unhealthy snack foods and soft drinks (xxxx, xxxx)

 Vending machines could be used to sell healthier options for e.g. fruits; apple,

orange, grape, melon sticks and chopped vegetables; tomatoes, carrot,

cucumber, celery sticks with healthy dips like hummus or cheese.

 If there are no facility for vending machines, fruit tuck shops can be set-up by

members of school community (e.g. pupils, staff or parents) in schools

Considerations:

 Since the majority of British Children do not eat school lunches, other

opportunities to increase availability are important for reaching most of the

children (Gregory et al, 2000 - Helen)

 Although children like the taste of FV, they are unwilling to sacrifice time to

wash, dry, peel or cut fruits. This lack of facilitation has been identified as a key

barrier to eating FV in several academic literatures (Reinaerts et al., 2007).

 Many children complain that FV were inconvenient to travel with compared to

pre-packaged snacks that were easy to carry and no preparation was required

e.g. fruit gets bruised in the bag compared to a packet of crisps (Krølner et al.,

2011).

 Evidence shows that children would purchase more FV if it was easily

accessible in readily consumed form in refrigerated vending machines at school

(Kubik et. al., 2005)

 An FSA research investigated the economic viability of selling healthier option

from vending machines in 12 schools. The project demonstrated that children

will buy a range of healthier products from vending machines when available

even though they are the usual brand products (Harvey, 2004)

 Vending machines containing soft drinks, confectionary and crisps should not be

allowed at schools for young children.

 The success of vending machines is mainly depended on the locations of the

machines, their reliability and staff commitment to maintained them regularly

(xxxx et.al, xxxx)

 A few schools in Europe have banned school snack bars from selling soft drinks,

chocolate bars and crisps and replacing them with healthy alternatives such a

FV sticks. (WHO, 2006)

 One UK study examined the impact of a school fruit tuck shop scheme on the

diets of children aged 9-11 years, results suggest that where children are not

allowed to bring unhealthy snacks to school, their willingness to utilise the fruit

tuck shops and eats fruits as snacks in school is greatly enhanced (L Moore,

2008)

 Schools can join FV weekly subscription plan with local producers to ensure

children get access to fresh, local and seasonal FV. School can work with local

producers for weekly supply of FV, delivered to school on a regular basis

 Given exchanging food among peer is an important social event for children, the

emphasis should be placed in messaging FV as tasty and an acceptable social

snack among both genders.

 The programme effectiveness requires detailed assessment to ensure that fruit

provided by schools does not act as a replacement for that normally received at

home.
Recommendation B:

Provide guidance and recommendations to parents via regular Parental newsletter

 The parent newsletter message should aim to increase home availability and

accessibility of FV by repeated exposure to FV in positive contexts, with

reinforcements and suggesting FV preparation skills as family activity

Consideration

 Parents and care givers must be involved actively if school-based initiatives

targeted to increase FV consumption are to have long-lasting effect on

children’s health

 In a study of obesity prevention in children, report shows that including parents

in school food nutrition programme is important as changes in positive eating

behaviours last longer if interventions are aimed at family behaviour and eating

habits rather than individuals alone (Muller et al. 2001)

 In a survey conducted among children and parents in 22 London schools,

results show that the quantity of FV that parents themselves reported eating was

a positive predicator of their children’s higher intake (Cooke et al., 2004).

 To date, it appears that the most effective method to involve parents is by

having materials sent to them directly (Contento & Michela, 1998; Foerster et

al., 1998; Perry et al., 1998; (REF WORK 211)

 WHO recommends that families should be provided with information regarding

school health, food and nutrition initiatives with parents involved in planning

process

 Parents who are not participating actively should be kept up-to date about

progress of iniatives and new programme.

Recommendation C:

Implement both Option 1 and Option 2 together to increase availability and accessibility in

both school and home

Considerations:

 By increasing the availability and accessibility of FV in both school and home, it

provides repeated exposure to FV to children and it became a cultural norm to

snack of FV.

 Children prefer food that they are familiar with and their familiarity is created by

frequent exposure of the food (Horne et al., 1995).

 An experiment by Wardle (2003) revealed that exposure to a specific type

vegetable for 2 weeks continuously could increase children’s liking for that

vegetable.

 Research across 15 countries among children concluded that frequent

availability of FV at home contributes to the increase of FV consumption

(Krølner et al., 2011).

Recommendation D:

Do nothing

Considerations:

 By not implementing specific actions targeting to increase FV consumption,

children may not get easy access to FV and the lack of facilitation will remain as

a key barrier to consume FV

 Children may have to solely rely on their parents to provide FV to meet 5 a day

nutrition guideline which may not be possible given not all parents are aware of

this guideline and the benefits of healthy eating starting from childhood

 FV will not be a popular social snack and may be remain as gendered food

choice

 The alarming obesity levels among UK children may continue to rise due to poor

diets and lack of FV consumption.