A repeated cross-sectional survey assessing changes in diet and nutrient quality of English primary school children’s packed lunches between 2006 and 2016

Objective: Mandatory school meal standards were introduced in 2006 in England; however, no legislation exists for packed lunches. This study analyses provision of foods and nutrients in packed lunches in 2016 to highlight differences in diet and nutrient quality since 2006. Design: Two cross-sectional surveys of children’s packed lunches were conducted in 2006 and 2016. Data were analysed using multilevel regression models taking into account the clustering of children within primary schools. Setting: Data were collected from 1148 children who attended 76 schools across England in 2006 and from 323 children attending 18 schools across England in 2016. Participants: Children were included if they regularly ate a packed lunch prepared at home (approximately half of children take a packed lunch to school) and were aged 8–9 years (in year 4), for both surveys. Outcome measures: Data collected in both years included provision of weight and type of food, nutrients and proportion of lunches meeting individual and combined school meal standards. Results: Frequency of provision and portion size of some food types changed substantially between surveys. Frequency of provision of confectionery in lunches reduced by 9.9% (95% CI −20.0 to 0.2%), sweetened drinks reduced by 14.4% (95% CI −24.8 to −4.0%), and cakes and biscuits not containing chocolate increased by 9.6% (95% CI 3.0 to 16.3%). Vegetable provision in lunches remained low. Substantial changes were seen in the percentage of lunches meeting some nutrient standards: non-milk extrinsic sugars (19%, 95% CI 10 to 29%), vitamin A (−8%, 95% CI −12 to −4%), vitamin C (−35%, 95% CI −42 to −28%) and zinc (−8%, 95% CI −14 to −1%). Conclusions: Packed lunches remain low quality with few meeting standards set for school meals. Provision of sugars has reduced due to reductions in provision and portion size of sugary drinks and packaged sweet foods; however, provision of some nutrients has worsened

National nutrition surveys in Europe: a review on the current status in the 53 countries of the WHO European region

Objectives: The objectives of this study were (1) to determine the coverage of national nutrition surveys in the 53 countries monitored by the World Health Organization (WHO) Regional Office for Europe and identify gaps in provision, (2) to describe relevant survey attributes and (3) to check whether energy and nutrients are reported with a view to providing information for evidence-based nutrition policy planning. Design: Dietary survey information was gathered using three methods: (1) direct email to survey authors and other relevant contacts, (2) systematic review of literature databases and (3) general web-based searches. Survey characteristics relating to time frame, sampling and dietary methodology and nutrients reported were tabled from all relevant surveys found since 1990. Setting: Fifty-three countries of the WHO Regional Office for Europe, which have need for an overview of dietary surveys across the life course. Subjects: European individuals (adults and children) in national diet surveys. Results: A total of 109 nationally representative dietary surveys undertaken post-1990 were found across 34 countries. Of these, 78 surveys from 33 countries were found post-2000, and of these, 48 surveys from 27 countries included children and 60 surveys from 30 countries included adults. No nationally representative surveys were found for 19 of 53 countries, mainly from Central and Eastern Europe. Multiple 24hr recall and food diaries were the most common dietary assessment methods. Only 22 countries reported energy and nutrient intakes from post-2000 surveys; macronutrients were more widely reported than micronutrients. Conclusions: Less than two-thirds of WHO Europe countries have nationally representative diet surveys, mainly collected post-2000. The main availability gaps lie in Central and Eastern European countries, where nutrition policies may therefore lack an appropriate evidence base. Dietary methodological differences may limit the scope for inter-country comparisons

Portion Size of Energy-Dense Foods among French and UK adults by BMI Status

Evidence links consumed food portion size (FPS) and excess weight via increased energy intake. Policies to regulate on-pack serving sizes may be needed; determining consumed FPS of popular energy-dense foods for normal weight and overweight or obese (OWOB) adults, as reported here, may provide evidence to assist this. Data were analysed from national cross-sectional surveys, the French Étude Individuelle Nationale des Consommations Alimentaires2 2005–2007 (n = 2117), and UK National Diet and Nutrition Survey 2008–2014 (n = 3413). The impact of body mass index (BMI) on FPS is also investigated, adjusting for age, sex and under-reporting. Effects of under-reporting on relationships between FPS and BMI; and BMI on consumption frequency (UK only) were explored. OWOB reported larger FPS than normal-weight individuals in many, but not all food subgroups; however, there were only two significant FPS differences. In adjusted analyses, French individuals consumed 1.0 g (99% CI 0.01–2.1 p = 0.01) greater FPS in cakes for 1 point difference in BMI. ‘Other cakes’ and ‘dark chocolate’ were also significantly positively associated with BMI. High-fat bar snacks, but no UK main food groups, were positively associated with BMI. There was limited evidence of links between FPS and BMI in UK and French national cross-sectional data, possibly due to data limitations such as under-reporting. Future work should explore this and relationships between consumed FPS and on-pack suggested serving sizes to provide evidence to assist obesity-prevention policies

Inequalities in education and national income are associated with poorer diet: pooled analysis of individual participant data across 12 European countries

Background: Malnutrition linked to noncommunicable diseases presents major health problems across Europe. The World Health Organisation encourages countries to conduct national dietary surveys to obtain data to inform public health policies designed to prevent noncommunicable diseases. Methods: Data on 27334 participants aged 19-64y were harmonised and pooled across national dietary survey datasets from 12 countries across the WHO European Region. Weighted mean nutrient intakes were age-standardised using the Eurostat 2013 European Standard Population. Associations between country-level Gross Domestic Product (GDP) and key nutrients and nutrient densities were investigated using linear regression. The potential mitigating influence of participant-level educational status was explored. Findings: Higher GDP was positively associated with total sugar intake (5·0% energy for each 10% increase in GDP, 95% CI 0·6, 9·3). Scandinavian countries had the highest vitamin D intakes. Participants with higher educational status had better nutritional intakes, particularly within lower GDP countries. A 10% higher GDP was associated with lower total fat intakes (-0·2% energy, 95% CI -0·3, -0·1) and higher daily total folate intakes (14µg, 95% CI 12, 16) in higher educated individuals. Interpretation: Lower income countries and lower education groups had poorer diet, particularly for micronutrients. We demonstrate for the first time that higher educational status appeared to have a mitigating effect on poorer diet in lower income countries. It illustrates the feasibility and value of harmonising national dietary survey data to inform European policy regarding access to healthy diets, particularly in disadvantaged groups. It specifically highlights the need for strong policies supporting nutritional intakes, prioritising lower education groups and lower income countries

Comparison of consumed portion sizes and on-pack serving sizes of UK energy dense foods

Studies indicate a 'portion size effect' association between increased portion size and energy intake, but direct links with obesity remain unproven. UK portion size guidance is outdated and evidence suggests that on-pack serving-sizes have increased in some energy-dense foods. Serving-sizes are compared with consumed portion sizes in popular energy, fat and sugar-dense foods, and patterns explored. Data was analysed for adults aged 19-64y (excluding under-reporters) from the UK National Diet & Nutrition Survey 2008-2014 (n = 2377) for consumed portion sizes and a commercial product database of major UK retailers provided serving-sizes. Popular energy-dense food groups were split into 45 product-based subgroups. Means of consumed portion size and on-pack serving-size were calculated and compared and nutrition per 100 g and per serve was explored. Just 57% products had serving-size compared to 97% with pack-size information. Serving-size ranges were wide and varied across food groups. Consumed portion sizes were significantly higher than on-pack serving-size in all main food groups and most subgroups. The greatest difference between consumed portion size and on-pack serving-size was Crisps (44%), and within this, 'popcorn' (151%). In Chocolate and Crisps, food subgroups with the largest on-pack serving-sizes were also the most macronutrient dense. Serving-size was unavailable for many products. However, where available, consumed portion sizes were higher than on-pack serving-size in all main food groups and most subgroups. The results could inform updated portion size guidance of energy-dense foods. Further work is needed to clarify whether smaller serving and pack sizes lead to lower total consumption and energy/nutrient intake

Assessing diet in European populations using national dietary surveys

The WHO encourages countries to conduct national dietary surveys (NDS) to inform preventative policies targeting malnutrition and noncommunicable diseases. Previous reviews have found inadequate nutrient intakes and survey provision across Europe. This research is the first to provide an updated review of NDS provision within the whole WHO European Region, across the lifecourse, with reference to disadvantaged groups, obesity and nutrients of concern. Over a third of WHO European countries, mainly Central and Eastern European countries (CEEC), had no identifiable NDS. Where countries reported nutrient intakes, poor WHO recommended nutrient intake attainment was Europe-wide across the lifecourse, particularly in CEEC. Lower educated individuals had poorer diet quality. However, heterogeneity in age group sampled, dietary assessment method, nutrient composition database and under-reporting hindered inter-country comparisons. Average population trans fatty acid intakes below WHO recommended limits may hide inequalities in disadvantaged groups; legislative bans may help alleviate this. There were few associations between NDS-derived consumed food portion size (FPS) and BMI. However, consumed FPS was greater than on-pack serving-size in the majority of foods studied. This review illustrates how NDS can generate information on diet, nutrient intakes and the food environment. However, to enable valid inter-country comparisons, countries should be encouraged to conduct and report harmonised NDS, particularly in the age groups sampled, dietary assessment methodology, nutrient range, underpinning food composition database and treatment of under-reporters. This will aid effective, coordinated policy development that can have a real impact on dietary improvement, on a population and subgroup level, throughout Europe