Obesity is a major public health concern, with children and young people becoming overweight or obese at earlier ages. In this blog, University of Derby Research Nurse Jessica Jackson discusses her collaborative study with Public Health England, examining interventions to help parents improve the healthiness of their children’s packed lunches.
A 2018 report by Public Health England found that younger generations are becoming increasingly obese and remaining obese through to adulthood. According to 2018 figures from NHS Digital, 22.6% of reception-age children (four and five-year-olds) are overweight and this rises considerably to 34.3% by year six (10 and 11-year-olds).
The health, social and economic impact of childhood obesity
A child who develops obesity into adulthood is at an increased risk of type 2 diabetes, high blood pressure, high cholesterol, heart disease, stroke and asthma, to name a few. This results in the NHS spending £5.1 billion a year to treat these conditions.
Obesity can also have serious consequences for their daily lives, leading to breathlessness, increased sweating, snoring, difficulties doing physical activities, tiredness and joint pain. Obesity can have a major impact on their self-esteem, leaving them feeling isolated with low confidence and increasing their risk of depression. These psychological problems can in turn have an impact on their relationships with family and friends, and affect their quality of life.
This is why the government has set out a plan for action, working together across society to improve the nutritional content of the food and drink children consume, strengthen the information available to parents and change the way that unhealthy food and sugary drinks are promoted to children.
School Food Standards have also been introduced to ensure the food provided by schools is nutritious and of high quality. Compliance with the School Food Standards is a legal requirement, but ensuring that children who bring their own packed lunch also meet these standards is more challenging. When compared to those who eat school meals, children who bring their own packed lunches consume higher proportions of sugar and salt.
The barriers preventing parents preparing healthy lunchboxes
You might think that a simple solution would be to ask parents to provide their child with a healthier packed lunch. The more you look into this, however, you can see it is a complex issue with many contributing factors. Children are substantially more likely to be obese if they are from a lower socioeconomic background. Additionally, children from black or ethnic minority groups or whose parents are overweight are also more at risk.
The term ‘obesogenic environment’ is now often used to describe the role environmental factors play in determining physical and nutritional activities. For example, limited outdoor play spaces and the availability and affordability of fresh fruit and vegetables can limit parents’ choices.
For parents deciding what to include in a child’s pack lunch, additional barriers might include the child’s preferences, and practicalities of the food staying fresh within the lunchbox. If parents are not aware of affordable healthier options, which are child friendly and stay fresh, how can they be expected to provide them for their child?
Public Health England’s packed lunch trial
I was asked by Amanda Bunten, Public Health England’s Principal Behavioural Insights Advisor, to investigate the effects of an intervention designed to help parents improve the healthiness of their children’s packed lunches. Seventeen Derby schools participated in the cluster randomised controlled trial, with half randomly picked to receive the intervention and the other half not.
In the intervention schools, we gave a range of materials to children aged 7-11 who have lunchboxes over a four-week period. The materials were developed using a behavioural insights approach and informed through parent focus groups, and included healthier lunchbox ‘swaps’, infographics on how much sugar is contained in popular lunchbox foods, a meal planner and a reward chart with stickers. Although the intervention was primarily aimed at parents, the materials were designed to be attractive and interactive enough to use with their children.
This approach was based on the theory that interventions aimed at encouraging people to make better choices are more successful if they use insights into how people actually make their decisions – the ‘what’s in it for them?’. Similarly to National Public Health’s Change4Life campaign, the intervention encouraged families to be ‘food smart’ by using behavioural science-framed phrases.
The main aim of the study was to measure how many sugary snacks and deserts were in lunchboxes before the intervention, once the materials had been sent home, and at a three-week follow-up. We were also interested in seeing how often crisps, sugary drinks, fruit and vegetables and ‘swapped’ items appeared, and the amount of sugar and salt present per 100 g/ml.
Together with researcher Dr Dave Giles, we photographed the contents of over 5,000 lunchboxes in total which were then coded for nutritional value. Vicki Staples, Lecturer in Psychology, Life and Natural Sciences, also designed and delivered a follow-up questionnaire to obtain parents’ feedback.
The intervention had some positive effects. When the photographs were analysed, it was found that a higher number of recommended, healthier alternatives in intervention lunchboxes were present immediately after the study. Sugary drinks were also less likely to be found in intervention lunchboxes at the three-month follow-up. Overall, however, the aim of reducing sugary foods in lunches was not achieved.
How can you encourage your child to eat healthier lunches?
The intervention included a number of practical recommendations for parents:
- Swap sweet snacks such as chocolate biscuits or cake with healthier alternatives like malt loaf.
- Replace the sweet treats children love, such as sugary yogurt or yoghurt tubes, with sugar-free jelly or fruit in juice, which are also very popular with children.
- Cereal bars can be replaced with crackers and lower-fat dips and savoury snack ideas such as plain popcorn, rice cakes or vegetable sticks to add bright colours.
- For the main component of the meal, try chicken wraps or soft cheese and cucumber sandwiches as an alternative to ham or cheese on white bread.
- For drinks alternatives, look for ‘no added sugar’ or ‘sugar free’ on labels, or choose water or skimmed milk.
While it is encouraging that a simple, low-cost intervention can help parents identify healthier items for lunchboxes, more work needs to be done to reduce children’s sugar intake.
Future research could use the behavioural insights approach to investigate alternative, more intensive interventions, which can help parents overcome the barriers experienced when preparing healthy packed lunches for their children.
What we do know is that if we are to achieve a sustainable decrease in obesity, it will need to be through ongoing active engagement with schools, communities, families and individuals.
For more information on this study, please get in touch with me on Twitter @JJResearchNurse, or email firstname.lastname@example.org