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Food choice and secondary school meals: the nutritional implications of choices based on preference rather than perceived healthiness
Hospitality Management 22 (2003) 197–215
Food choice and secondary school meals: the nutritional implications of choices based on preference rather than perceived healthiness Carol Noblea,*, Michael Corneyb, Anita Evesc, Michael Kippsc, Margaret Lumbersc a
School of Life Sciences, Whitelands College, University of Surrey Roehampton, West Hill, London SW15 3SN, UK b School of Pharmacy, University of London, London WC1, UK c School of Management Studies for the Service Sector, University of Surrey, Guildford, Surrey GU2 5XH, UK
Abstract Children from secondary schools in the UK selected from photographs, dishes for the meal they would be most likely to choose and the meal they perceived to be the most healthy. They gave reasons for their choices. The nutritional value of the two sets of meals was compared and the reasons for choice were analysed qualitatively. There was an inverse relationship between the foods most likely to be chosen, and those that were perceived to be the most healthy. Although the children’s nutritional knowledge was sound, choices were made more on the basis of convenience and taste than on the ‘healthiness’ of the food. The ‘preferred’ meals were in most respects less healthy than the ‘healthy’ meals. r 2003 Elsevier Science Ltd. All rights reserved. Keywords: Food choice; School meals; Nutritional value
1. Introduction The nutritional quality of the diets of school children in the UK, particularly those of secondary school age, has been a matter of concern for some time. A number of studies carried out in the UK (DoH, 1989; McNeil et al., 1991; Adamson et al., 1992; *Corresponding author. Tel.: +44-20-8392-3228; fax: +44-20-8392-3527. E-mail address: [email protected] (C. Noble). 0278-4319/03/$ - see front matter r 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S0278-4319(03)00018-5
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Crawley, 1993; Strain et al., 1994; Wreiden and Moore, 1995; Hackett et al., 1997) have found some children of this age consuming diets high in fat (particularly saturated fat), and sugar, and low in micronutrients such as calcium, iron and possibly anti-oxidant vitamins. In a more recent study (Gregory et al., 2000) it was found that while the percentage of energy provided by total fats and total carbohydrates was close to the dietary reference values (DRVs) (DoH 1991), the energy coming from saturated fatty acids (SFA) and non-milk extrinsic sugars were higher than these values. It was also found in this study that some children, mainly the older ones and particularly girls, had low intakes of some micronutrients, and there was some evidence of low-micronutrient status. The contribution of school meals to the nutrition of school children has also been much debated. After the 1980 Education Act, when cash cafeterias became almost universal in secondary schools in the UK, concern was expressed that the nutritional value of the school meal depended to a great extent on the choices made by the individual child. It has been recognised (Kipps et al., 1986; Ruxton et al., 1993) that those involved in nutrition education and school caterers would need to work together to help children to make nutritionally sound choices from the cash cafeteria. Despite this, studies in secondary schools in the UK have shown that the meals chosen and consumed by children were often high in fat and sugar and low in calcium and iron, also zinc, riboflavin, folate and vitamin A (DoH, 1989; Noble and Kipps, 1994). In the latest national study of school children’s diets (Gregory et al., 2000), school meals consumed by some children were low in calcium, iron and folate. The 1980 Education Act also effectively abolished the previous nutritional standards for school meals (DES, 1975). Since then, there have been a number of calls for standards or guidelines which more closely reflect current nutritional concerns (British Dietetic Association, 1986; Kipps et al., 1986; Coronary Prevention Group, 1987; White et al., 1992; Noble and Kipps, 1995). There have also been suggestions (Sharp, 1992; Noble and Kipps, 1995) as to the nutrients and levels which might be specified. However, the recent British government consultation paper on nutritional standards for school lunches (DfEE, 1998) proposed that any standards should be food based rather than nutrient based. These standards (DfEE, 2000) based on the ‘Balance of Good Health’ or ‘tilted plate’ came into force in April 2001 and have been welcomed by school caterers. The problem of helping children to choose foods which make up a nutritionally sound meal remains. A number of studies in the UK have identified the food habits and preferences of children of secondary school age. Anderson et al. (1994), Adamson et al. (1996), Currie et al. (1997), Roberts et al. (1997) and Johnson and Hackett (1997) all found high consumption of snacks amongst school children. Other studies (Gardner Merchant, 1994; Passmore, 1997; Douglas, 1998; Sodexho, 2000) have examined the food choices of school children of this age, at school meals. Here again there was a strong preference for snack foods such as cakes and biscuits, crisps, and fizzy drinks. It was found in a number of these studies (Douglas, 1998; Anderson et al., 1994; Johnson and Hackett, 1997) also in those by Lund et al. (1990a, b) and Seaman et al. (1997) that in most cases, the children’s nutritional
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knowledge is fairly sound. All these authors, however, comment on the failure of children to apply their awareness of ‘healthy eating’ in practice. Some explanation is provided by studies on the factors which influence children’s food choice. Chapman and Maclean (1993) and Watt and Sheiham (1997) found that adolescents conceptualise and classify foods into ‘healthy’ foods, associated with weight loss, parents and being at home, and ‘fast’ or ‘junk’ foods, linked with pleasure, friends and independence. Tilston et al. (1992), Gummeson et al. (1996), and Noble et al. (2000) found that the ‘healthiness’ of the meal was not a very important factor in children’s food choice; personal preferences for the taste, texture and appearance of the food had a much greater influence. While a number of authors (Ruxton et al., 1993; Hackett et al., 1997) have pointed out the need for school-based initiatives to improve children’s eating habits, Watt and Sheiham (1997) stress that such efforts should be based on an understanding of their beliefs concerning food. While Lynd-Evans (1993) suggested that the task facing caterers was to make the ‘healthy choices’ also the ‘favourite choices’, Tilston et al. (1992) and Noble et al. (2000) found an inverse relationship between the perceived healthiness of food and children’s liking for it. Despite this, the difference in nutritional value between the ‘healthy choices’ and the ‘favourite choices’ was not as great as many nutritionists feared (Noble et al., 2000). The meals chosen on the basis of preference were, in many respects, no less healthy than those chosen on the basis of the children’s perceptions of the healthiness of the meal, and in some respects the ‘preferred’ meals were ‘healthier’. However, this study was carried out in primary schools, where, while there is some element of choice, the foods are usually arranged so that children have to choose one item from each category, main items such as fish fingers or pizza, starchy items such as potatoes or rice, a vegetable and a pudding. The current paper describes a similar study carried out in secondary schools where children have a free choice of items from the cash cafeteria. While the studies reviewed above have all explored children’s food preferences in general and at school, the factors that influence the children’s choice, their nutritional knowledge, perceptions of healthiness and attitudes to food and health, few of these have looked at their preferences for and perceptions of the healthiness for the same set of foods. This paper reports on which of the foods and dishes commonly served at lunchtime in secondary school cafeterias are most frequently chosen for the meal most likely to be consumed (the ‘preferred’ meals), and which are chosen for perceived healthiness (the ‘healthy’ meals). The reasons for these meal choices are explored. The paper also identifies the foods and dishes that are perceived to be the most and the least healthy, and those that are the most and the least likely to be chosen, in both cases based on a scoring system. The reasons or explanations for these perceptions and preferences are explored. A comparison of the nutritional value of meals chosen on the basis of preference and those chosen on the basis of perceived healthiness will provide an indication of the size of the nutritional gap between the ‘healthy’ and the ‘favourite’ choices, and will provide a measure of the accuracy of children’s perceptions of a ‘healthy’ meal.
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2. Methodology 2.1. Sample selection and description Interviews took place with 181 school children (87 boys and 94 girls) aged 14 and 15 from 10 secondary schools in the South East of England. All the children made regular use of their school cafeteria. Each interview lasted 30 min and was conducted on a one-to-one basis. 2.2. Materials and methods A set of 19 high-quality colour photographs of foods and dishes that would typically be offered in the school cafeteria were used in the interview. The photographs, usually showing one item each, included foods, such as crisps and a can of drink, that would be classified as ‘snacks’ and those, such as chicken fricasse and apple crumble, that would form part of a conventional meal. The interview involved several tasks. The children, who were not aware of the purpose of the study, were first presented with all the photographs and asked to select the foods or dishes that would make up the meal that they would be most likely to choose if they were offered that range of foods (the ‘preferred’ meal). They had a completely free choice of all the items, which is consistent with the cafeteria style of service usually offered in secondary school cafeterias. Having selected the meal, the children were asked to explain why they had chosen this meal. In the second task, the children were asked to rate each of the 19 foods or dishes food on a nine-point scale, marking the point that best reflected their likelihood to choose the item. The scales ranged from ‘very likely to choose’, scored at +4, to ‘very unlikely to choose’, scored at 4. The meal selection and the rating tasks were repeated, this time, with the children being asked, first of all, to select the meal that they thought would be the most healthy (the ‘healthy’ meal), and to explain the reasons for their choice, and, secondly, to rate all the foods or dishes according to how healthy they perceived each one to be. In this case, the scales ranged from ‘very healthy’ (scored at + 4) to ‘not so healthy’ (scored at 4). The methods for this study had been piloted with a small group where the children had been asked to give reasons for their ratings on the ‘likelihood to choose’ and the ‘healthiness’ scales for all 19 foods. This had been found to be very time consuming and earlier studies had indicated that, while children were able to give reasons for liking or disliking those foods that they had placed at either end of the ‘likelhood to choose’ rating scale, and were able to explain particularly high or low ratings for ‘healthiness’, most were less able to give reasons for intermediate ratings. It was therefore decided that since less valuable information was expected from comments on foods rated in the middle of the scale, reasons for ratings would be asked only for those foods or dishes given the three highest and the three lowest ratings for ‘likelihood to choose’ and for ‘healthiness’ by each individual. In this way, the interviews
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could be finished within 30 min, thus minimising the disruption to lessons. Thus, following each of the rating tasks, the foods or dishes given the three highest and the three lowest ratings, by each child, on both the ‘likelihood to choose’ scale and on the ‘healthiness’ scale were identified. The children were then asked to explain why they had given high or low ratings to these foods or dishes on each of the scales. Where more than three items were given particularly high or low ratings (e.g. if four items were rated as ‘very healthy’), the child was asked to identify the three items considered to be the most healthy. All responses were recorded on a questionnaire. The questionnaire was completed by the interviewer except in the case of the rating of items, where the interviewee was asked to cross the appropriate boxes. 2.3. Data analysis For the meal selection task, the frequency with which items were selected for the ‘preferred meal’ and the ‘healthy meal’ was determined and comparisons made between males and females. Mean values for rating scores (from +4 to 4) on both the ‘likelihood to choose’ and the ‘healthiness’ scales were calculated, and linear regression was used to determine whether there was a relationship between the likelihood to choose an item and its perceived healthiness. In all cases, statistical significance is quoted at the 5% level (po0:05). The qualitative data on reasons given for the choice of foods or dishes for the ‘healthy’ meals and for high and low ratings on the ‘healthiness’ scale were analysed by assigning the reasons to categories. A number of subjects gave vague, unqualified reasons such as ‘good for you’, ‘healthy’, ‘nutritious’ ‘bad for you’, ‘unhealthy’. These were all grouped as a single category. Other reasons given were based on the influence of others, ‘they say’, ‘common knowledge’; these also were grouped together. Where more definite reasons were given, these were categorised according to the different levels of nutritional knowledge or understanding that was apparent. Responses included the presence of specific foods or ingredients perceived to be healthy or otherwise, the presence or absence of particular nutrients, or foods or nutrients which made specific contributions to health. Reasons were, in many cases, related to the perceived healthiness or otherwise of food production or cooking methods used. Similarly, the qualitative data on reasons given for the choice of foods or dishes for the ‘preferred’ meals and for high and low ratings on the ‘likely to choose’ scale were analysed by assigning the reasons to categories. The energy and nutrient content of the ‘preferred’ and the ‘healthy’ meals (using portion sizes supplied by the caterers) were determined using Comp-Eat 4, a nutritional analysis package based on McCance and Widdowson’s ‘The Composition of Foods’. The nutritional value of the two sets of meals was compared using Student’s t-test. A chi-squared test was used to determine the significance of any differences in the meal choices of the boys and girls.
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3. Results and discussion 3.1. Foods perceived to be healthy, and foods most likely to be chosen The items most frequently chosen for the ‘healthy’ meal were fresh fruit, salad, mixed vegetables, and milk or water (Table 1). For the ‘preferred’ meals, the most popular choices were snack items such as cans of drink and chips. These items were not chosen at all or by only a small percentage of children for the ‘healthy’ meals. The least popular choices for the ‘preferred’ meals, chicken fricassee, mixed vegetables, mashed potatoes, ham and quiche, were all those foods or dishes which would be part of a main meal. For the ‘preferred’ meals, boys were significantly more likely than girls to choose a beefburger, and girls were more likely to choose salad or a sandwich. There were no significant differences in the items chosen for the ‘healthy’ meals. As in previous studies carried out in primary schools (Tilston et al., 1992; Noble et al., 2000), this study of children of secondary school age found that most of the items perceived to be more healthy were those that were much less likely to be chosen, and the foods most likely to be chosen were mainly those perceived to be less healthy. Moreover, in this study, a regression analysis between the mean ‘healthiness’ and mean ‘likelihood to choose’ scores (Table 1) for the different foods showed a negative relationship between the two variables (R2 ¼ 0:30). Two items, the sandwich, which contained salad, and the fresh fruit, received high ratings for both ‘likelihood to choose’ and ‘healthiness’. If these two items are removed from the regression analysis, the R2 value increased to 0.62, indicating a greater negative relationship. Ratings for ‘healthiness’ were much more polarised (from +3.86 (0.39) to 2.63 (1.51)) than those for ‘likelihood to choose’ (from +2.97 (1.79) to 1.12 (2.45)), and standard deviations were smaller, indicating a strong consensus between pupils as to the ‘healthiness’ or otherwise of foods. Given this inverse relationship between those foods perceived to be healthy and those foods most likely to be eaten, the following section examines the nutritional effects of these choices.
3.2. Nutritional effects of food choices In order to determine the size of the nutritional gap between the ‘favourite’ and the ‘healthy’ choices (Lynd-Evans, 1993), the nutritional value of the ‘preferred’ meals and the ‘healthy’ meals will be compared (Table 2). While there are no quantified nutritional guidelines for school meals, those produced by the Caroline Walker Trust (Sharp, 1992) are often used as a measure of the nutritional adequacy of the meals consumed. While these guidelines, based on the DRVs (DoH 1991), recognise that the school meal accounts for only one of the day’s meals and that the rest of the day’s food intake would contribute further nutrients, they assume that for some children, the school meal is the main meal of the day. The nutritional value of both sets of meals will be compared with these guidelines (Table 2).
Fresh fruit Salad Mixed vegetables Milk/water Jacket potato and tuna Sandwich Chicken fricassee Ham Apple crumble Mashed potatoes Quiche Can of drink Pizza Iced bun Mini cookie Sausages Chips Crisps Beefburger
73.48 67.40 56.35 30.94 24.86 21.55 12.71 10.50 7.18 6.08 2.21 1.66 1.10 1.10 1.10 0.55 0.55 0.00 0.00
79.31 74.71 62.07 32.18 31.03 21.84 16.09 8.05 5.75 6.90 1.15 1.15 1.15 2.30 0.00 0.00 1.15 0.00 0.00
68.09 60.64 51.06 29.79 19.15 21.28 9.57 12.77 8.51 5.32 3.19 2.13 1.06 0.00 2.13 1.06 0.00 0.00 0.00
13.81 9.39 2.76 16.57 8.29 28.18 3.87 1.10 6.63 1.66 0.55 50.83 25.41 14.92 14.36 8.84 46.41 25.97 20.44
10.34 2.30 5.75 14.94 3.45 14.94 6.90 2.30 8.05 3.45 1.15 64.37 34.48 14.94 17.24 11.49 58.62 27.59 29.89
Boys (n ¼ 87) 17.02 15.96 0.00 18.90 12.77 40.43 1.06 0.00 5.32 0.00 0.00 38.30 17.02 14.89 11.70 6.38 35.11 24.47 11.70
Girls (n ¼ 94) 3.86 (0.39) 3.78 (0.61) 3.40 (0.98) 3.34 (1.03) 2.61 (1.42) 2.76 (1.17) 1.82 (1.63) 2.05 (1.46) 0.73 (1.86) 1.56 (1.53) 1.89 (1.45) 1.60 (1.96) 1.48 (1.93) 2.28 (1.61) 1.45 (1.67) 1.08 (1.90) 2.63 (1.51) 2.11 (1.50) 2.02 (1.76)
Total (n ¼ 181)
Girls (n ¼ 94)
Total (n ¼ 181)
Boys (n ¼ 87)
Healthiness
Preferred meals
Healthy meals
1.72 (2.15) 0.96 (2.50) 1.12 (2.45) 0.20 (3.05) 0.17 (3.05) 2.06 (2.28) 0.86 (2.77) 0.41 (2.64) 0.28 (2.89) 0.56 (2.48) 0.71 (2.76) 2.97 (1.79) 1.66 (2.62) 1.62 (2.42) 1.20 (2.24) 0.78 (2.65) 2.19 (2.04) 1.97 (2.10) 0.96 (2.72)
Preference
Mean rating scores (SDs)
Percentage of pupils choosing each item
Table 1 The percentage of pupils choosing each of the food items for their ‘healthy’ meal and their ‘preferred’ meal, and the mean rating scores (SDs) for the perceived healthiness of, and the ‘likelihood to choose’ each item C. Noble et al. / Hospitality Management 22 (2003) 197–215 203
Energy Protein NSP Thiamin Riboflavin Niacin Folate Vitamin C Vitamin A Calcium Sodium Iron Zinc Fat SFA Carbohydrate Sugar Starch
kJ g/MJ g/MJ mg/MJ mg/MJ mg/MJ mg/MJ mg/MJ mg/MJ mg/MJ mg/MJ mg/MJ mg/MJ % energy % energy % energy % energy % energy
Unit
1702 (1928) 7.70 (4.01) 2.16 (0.07) 0.19 0.03) 0.18 (0.04) 3.40 (2.38) 31.02 (0.89) 15.73 (3.77) 140.61 (51.59) 111.37 (37.86) 232.12 (23.42) 0.82 (0.15) 0.80 (0.21) 47.85 (11.50) 14.37 (2.21) 39.46 (4.77) 17.44 (8.51) 21.97 (13.30)
Mean (SD)
Mean (SD)
2563 (53.74) 5.44 (1.19) 1.46 (0.10) 0.13 (0.04) 0.08 (0.04) 2.72 (0.29) 21.08 (11.18) 6.04 (0.90) 47.14 (38.91) 58.99 (19.28) 260.10 (66.31) 0.90 (0.33) 0.61 (0.00) 41.21 (3.49) 11.43 (0.23) 49.66 (1.45) 19.08 (8.47) 30.44 (7.44)
‘Healthy’ meal
‘Preferred’ meal
*
* * * * * * * * * * * * * * * *
Significance
RNI RNI RNI RNI
o35% o11% >50% o11%
>40% RNI
>40% >35% >30% >35%
30% EAR >30% DRV >30% DRV
Guidelines
26.62 29.40 19.30 35.10 18.37 45.65 25.62 34.27 15.10 16.98 40.52 18.18 18.75
(1.04) (14.63) (8.73) (24.85) (11.20) (5.50) (22.27) (7.07) (25.53) (4.88) (16.22) (4.75) (6.48)
‘Preferred’ meal (as % of DRV) Mean (SD)
18.21 29.80 18.66 35.22 27.16 41.12 24.96 60.78 35.55 23.11 24.12 10.68 16.82
(19.74) (71.26) (9.80) (43.70) (14.89) (97.25) (22.63) (37.88) (9.43) (5.00) (21.88) (19.91) (21.99)
‘Healthy’ meal (as % of DRV) Mean (SD)
Table 2 The differences in mean values (SDs) for energy and nutrient content of ‘preferred’ meals (n ¼ 181) and ‘healthy’ meals, expressed as nutrient density (nutrients/MJ) and as a percentage of dietary reference values (DoH, 1991)
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The energy content of the ‘preferred’ meals (Table 2) was significantly higher than that of the ‘healthy’ meals. This is partly due to a higher proportion of the children choosing items such as, chips, pizza, crisps, beefburgers or a can of drink for their ‘preferred’ meal as opposed to fresh fruit, salad or jacket potato with tuna for the ‘healthy’ meal. The children also chose fewer items for the ‘healthy’ meal, indicating that even children of this age are equating ‘healthy’ with ‘low calorie’. The mean value for the energy content of the ‘preferred’ meal was just over 25% of the estimated average requirement (EAR) (DoH, 1991), whereas that of the ‘healthy’ meals was only 18% of the EAR (Table 2). Compared with the 30% of the EAR, suggested in the guidelines, the energy contents are low, particularly for the ‘healthy’ meal. If school children are to be encouraged to choose ‘healthier’ meals, these should have an appropriate energy content. In addition, unless children are provided with foods that they like, energy requirements, which in some cases are high, will not be met. The ‘preferred’ meals contained significantly greater amounts of several nutrients, due in most cases to their higher energy content. Table 2 also shows the nutrient density or nutrient content per megajoule (MJ) of both sets of meals and the percentage of the total energy provided by fats and carbohydrates. This gives a better measure of the nutritional quality or ‘healthiness’ of the meals. In the ‘healthy’ meals a significantly higher percentage of the energy was provided by fat, and due to the frequent selection of a plate of salad which included both potato salad and coleslaw, each providing large amounts of fat in comparison to the energy contents of the other components of the salad. The significantly higher percentage of energy coming from SFA in the ‘healthy’ meal was probably due to the more frequent choice of milk for these meals. The percentage of energy provided by fat in both the ‘preferred’ meals and the ‘healthy’ meals, and that provided by SFA in the ‘healthy’ meals was high compared with the DRV and suggested guidelines (Table 2). Compared with the ‘healthy’ meals, the ‘preferred’ meals provided a significantly higher percentage of the energy as carbohydrate in the form of starch (Table 2). The carbohydrate content of the ‘preferred’ meals compared well with the suggested guidelines, whereas that of the ‘healthy’ meals was considerably lower. This suggests that children are not yet viewing a ‘healthy’ meal as one which contains starchy carbohydrate foods, even though they would choose these foods for preference. There was no significant difference between the two meals in the percentage of energy provided by sugar. In terms of the nutrient density (Table 2), the ‘healthy’ meals provided significantly greater amounts per MJ of the following nutrients NSP, thiamin, riboflavin, niacin, folate, vitamin C, vitamin A, calcium and zinc, whereas the ‘preferred’ meal provided significantly greater amounts per MJ of sodium and of iron. Higher intakes of iron in the ‘preferred’ meals are probably due to the more frequent choice of beefburgers, which provide a good source of easily absorbable iron. There were no significant differences between the two sets of meals in the amounts of protein per MJ. This analysis shows that the meals chosen on the basis of perceived healthiness are indeed of higher nutritional quality, as far as most micronutrients (except iron) are concerned. It also shows that the children’s
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perception of foods such as salad, milk, fresh fruit as ‘healthy’ is also quite sound, even though these are not usually the foods chosen for preference. In both sets of meals, the contents of NSP, folate, vitamin A, calcium and iron were all low compared with the guidelines (Table 2). The content of vitamin A was particularly low in the preferred meal. Compared with DRVs, the contents of riboflavin, particularly in the ‘healthy’ meal, and zinc were low and salt contents high. While this data, refers to only one meal of the day, it does leave quite a high percentage to be provided by the rest of the day’s food intake. If, as would seem to be the case, the foods that children of this age group prefer are sometimes of low nutrient density and if energy intakes are low, intakes of some nutrients could be a cause for concern. These findings support those previous surveys (DoH, 1989; Noble and Kipps, 1994; Gregory et al., 2000) all of which relate to food actually consumed. As the above surveys have all identified the nutrient intakes of teenage girls as being of particular concern, the nutritional value of the ‘preferred’ and ‘healthy’ meals chosen by boys and girls will be compared (Table 3). 3.2.1. ‘Preferred’ meals Most of the significant differences in the nutritional value of the ‘preferred’ meals by the boys and girls in the study are explained by the higher food intakes of the boys. The meals chosen by the boys had significantly higher energy contents, which resulted in significantly higher intakes of several nutrients. However, if the nutrient content of the meals are expressed as a percentage of the total energy provided by fat and carbohydrate, or as nutrients per MJ, some significant differences remain. The meals ‘preferred’ by the girls had significantly higher contents of NSP, thiamin, folate, vitamin C and vitamin A per MJ; whereas the meals ‘preferred’ by the boys provided significantly greater amounts per MJ of riboflavin and zinc. Some of these differences can be explained by the greater popularity of salads, salad sandwiches or jacket potato with tuna among the girls and of chips, pizza or beefburgers among the boys. There were no significant differences in the percentage of energy coming from fats and carbohydrates. While the meals most likely to be chosen by the girls are of rather higher nutritional quality, the low energy contents of these meals could result in intakes of some important nutrients lower than is desirable. Nutrients of particular concern are riboflavin, iron and zinc (Table 2). This supports the findings of previous studies (DoH, 1989; Noble and Kipps, 1994; Gregory et al, 2000). 3.2.2. ‘Healthy’ meals Just as there were few differences between the boys and the girls in the items chosen for the ‘healthy’ meal, there were few differences in the nutritional value of the meals. The ‘healthy’ meals chosen by the boys contained significantly greater amounts per MJ of calcium and riboflavin. This could be explained by their greater liking for pizza or their more frequent choice of milk as a food perceived to be healthy. These findings perhaps indicate that there is little difference in the nutritional knowledge of boys and girls. This is not surprising, given that, despite the greater interest in slimming likely to be shown by the girls, it is probable that at this
Units
kJ g/MJ g/MJ % energy % energy % energy % energy % energy mg/MJ mg/MJ mg/MJ mg/MJ mg/MJ ug/MJ mg/MJ mg/MJ mg/MJ mg/MJ
Nutrient
Energy Protein NSP Fat SFA Carbohydrate Sugar Starch Thiamin Riboflavin Niacin Folate Vitamin C Vitamin A Calcium Sodium Iron Zinc
2958 (972) 5.71 (2.12) 1.26 (0.40) 40.99 (9.42) 11.73 (4.25) 49.39 (9.49) 18.70 (11.42) 30.56 (6.96) 0.11 (0.05) 0.09 (0.04) 2.69 (0.92) 18.90 (6.81) 4.05 (2.44) 38.58 (43.31) 62.35 (30.32) 276.13 (117.95) 0.92 (0.30) 0.68 (0.30)
2189 (1006) 5.18 (3.12) 1.64 (1.01) 41.30 (15.64) 11.14 (4.69) 49.94 (14.14) 19.24 (17.46) 30.56 (13.03) 0.14 (0.10) 0.07 (0.05) 2.74 (2.05) 23.14 (11.43) 7.92 (6.84) 55.23 (52.41) 55.81 (36.53) 244.93 (113.31) 0.89 (0.33) 0.55 (0.31) *
* * *
* *
*
*
1835 (842) 7.84 (3.48) 2.03 (0.85) 48.27 (17.88) 14.86 (5.27) 38.82 (13.46) 17.67 (7.65) 21.11 (14.00) 0.18 (0.10) 0.20 (0.10) 3.37 (2.23) 30.53 (12.65) 15.33 (7.14) 145.90 (67.86) 122.46 (63.08) 224.50 (82.88) 0.79 (0.22) 0.82 (0.30)
Boys Mean (SD)
Significance
Boys Mean (SD)
Girls Mean (SD)
‘Healthy’ meals
‘Preferred’ meals
1576 (757) 7.56 (4.50) 2.27 (1.40) 47.46 (20.96) 13.90 (6.44) 40.06 (17.11) 17.22 (14.40) 22.80 (15.46) 0.20 (0.14) 0.16 (0.10) 3.43 (2.60) 31.49 (16.31) 16.11 (8.51) 135.60 (97.59) 100.87 (68.34) 239.33 (192.76) 0.85 (0.35) 0.77 (0.44)
Girls Mean (SD)
*
*
*
Significance
Table 3 The differences in energy and nutrient content and nutrient density (nutrients/MJ) of ‘preferred’ meals (n ¼ 181) and the ‘healthy’ meals chosen by males and females C. Noble et al. / Hospitality Management 22 (2003) 197–215 207
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stage, they will all have been exposed to similar teaching about food and health and to similar outside sources of information. It has been shown that the ‘preferred’ meal is, in a number of important respects, less healthy than the one that the children perceive to be a ‘healthy’ meal. The following section therefore examines the reasons given by the children for their choices for each set of meals. 3.3. Reasons given for choices for ‘preferred’ meals and ‘healthy’ meals It can be seen from Table 4 that the most common reason given for the choice of foods or dishes for the ‘preferred’ meal was that the food was liked or a ‘favourite’ food. Liking the taste or flavour, or the appearance (‘looks appealing’) were also frequently mentioned. Foods or dishes were also chosen for the ‘preferred’ meal because they were ‘healthy’ or ‘good for you’, and quite frequently because they were ‘convenient’, ‘quick’ or ‘easy to eat’, or could be ‘taken outside’. Some children chose items because they were ‘light’, ‘cold’ or ‘snack’ foods, often because they had a ‘main’ or ‘cooked meal’ at home in the evening. Other reasons for choice included being ‘filling’, combining well to form a meal, or habit, ‘have at home’. Liking the taste or flavour, and the dish being filling were more important reasons for boys than for girls, and girls were more likely than boys to choose a food or dish if they thought that it was ‘healthy’ or ‘good for you’. Healthy foods were, in some cases, encouraged by parents, in others health was ‘not an issue’. One of the most commonly given reasons for choice for the ‘healthy’ meal was that it was ‘healthy’ or ‘good for you’, without any further explanation. In some cases it was because it ‘looked healthy’ or they had been told it was healthy, by ‘teachers’ or ‘TV’. However, where more detailed reasons were given, only a few of the children recognised the ‘healthiness’ or nutritional value of the meal as a whole. This was described in terms of ‘balance’, ‘variety’, ‘covers different food groups’ or ‘got all the things that you need’. Mostly, the children saw the ‘healthiness’ of the meal as due to the presence of individual foods seen to be healthy, or specific nutrients. The presence of vegetables, fruit or salad, (‘have been told to eat vegetables’, ‘five portions of fruit and vegetables’) was frequently given as the reason for choice, more often by girls than boys. Milk or ‘dairy foods’, water, and potatoes were often mentioned as ‘healthy’ foods. The absence of fat, (‘low fat’, ‘not fatty’) and less commonly sugar, were also given as reasons for the choice of items. Some children saw the meal as healthy because it provided energy, and others because it was ‘low calorie’ or ‘not fattening’. The ‘nutritional value’ of the meal, or the presence of ‘nutrients’, particularly ‘vitamins’, but also protein, and minerals, particularly calcium (for ‘teeth’ and ‘bones’), were often given as reasons for choice. Despite seeing potatoes as ‘healthy’, only a small number of children mentioned the presence of carbohydrate as either the main reason or a subsidiary reason for the meal being healthy. Lack of additives, or being fresh or natural were also given as reasons for choice. Since the children most usually saw the ‘healthiness’ of the meal in terms of its individual components, the following section (Table 5) lists the foods with the
25 1 8
3
18
8
9
11 7
8 1
37 1 18
5
31
34
19
17 11
12 9
2
3
3 3
Variety Hot
1 1
2
6
Not fattening/on a diet Balance 2 2
1
4
4 8
6 4
10
26
13
2
12 0 10
quiche Water/drink Bread Cheese
sandwiches
rice
Chicken Potatoes
Vegetables ‘greens’ Mixed Vegetables Milk/‘dairy foods’ Tuna/fish meat
Salad
9 35 1 1
16
12
7 27
11 8
46
2
37
55
2 15 1 1
10
7
6 10
6 5
24
2
21
24
4 3 35
25
Total Boys (n ¼ 181) (n ¼ 87)
Healthy/good for 46 you Like taste/colour 13 Been told/healthy 6 Fruit 74
Taste/flavour Texture Appearance/ looks nice Goes together/ combination Convenient/ quick Healthy/good for you Cheap/good value Filling Have at home/ usual/habit Light/snack/cold Vegetarian
40
78
Likes/favourite
38
Reason
Total Boys (n ¼ 181) (n ¼ 87)
Reason
Girls (n ¼ 94)
‘Healthy’ meals
‘Preferred’ meals
7 20 0 0
6
5
1 17
5 3
22
0
16
31
9 3 39
21
Girls (n ¼ 94)
Not fattening/ low calorie Natural/fresh
Low sugar Balanced/ mixture Energy
Carbohydrate/ starch Fibre Low fat
Protein
Iron
Calcium
Nutrients/nut value Vitamins Vitamin C Minerals
Reason
Table 4 Numbers of pupils giving each different reason for their choice of items for the ‘preferred’ meals and the ‘healthy’ meals
8
13
19
20 14
9 52
12
28
4
24
61 7 15
11
4
2
10
16 8
4 30
5
18
4
11
25 6 8
5
Total Boys (n ¼ 181) (n ¼ 87)
4
11
9
4 6
5 22
7
10
0
13
36 1 7
6
Girls (n ¼ 94) C. Noble et al. / Hospitality Management 22 (2003) 197–215 209
2
0 2
Total
Boys Girls
Chicken fricasse
4 2 2
Total Boys Girls
0 0
Boys Girls
Sandwich
0
Total
Baked potato with tuna
5 66 3 2
3 6
Boys Girls
Total Total Boys Girls
9
Total
Mixed vegetables
Milk or water Beefburger
16 7 9
Total Boys Girls
Salad
20 10 10
Total Boys Girls
Fresh fruit
0 0
0
3 1 2
0 4
4
2 0 1 1
13 4
17
40 22 18
31 11 20
0 2
2
2 1 1
0 3
3
2 1 2 0
8 3
11
5 4 1
15 7 8
0 2
2
0 0 0
3 4
7
6 7 3 3
4 6
10
5 3 2
3 2 1
Healthy Low fat Nutrients Protein
Reasons for high ‘healthiness’ scores
0 1
1
0 0 0
0 1
1
4 7 2 2
8 14
22
34 17 17
52 22 30
0 0
0
0 0 0
0 0
0 0
0
0 0 0
0 0
0
18 22
2 2 0
40
0 0
0
0 0 0
0 0 0
4
4 2
6
19 7 12
16 6 10
0 0
0
0 0 0
0 0
0
9 6
15
0 0
0
0 0 0
0 0 0
Vitamins Natural Calcium Bones/ teeth Total Boys Girls
27 17 10
Sausages Total Boys Girls
8
35 18 17
0 0
0
41 25
22 25
47
2 6
Total
Total Boys Girls
Boys Girls
Total
Boys Girls
Boys Girls
Total
6 4 2
113 53 60
Boys Girls
Minicookie
Pizza
Can of drink
Crisps
Iced bun Total Boys Girls
Chips
Fat
0 0 0
9 9
18
0 0 0
24 30
54
0 0
0 0
0
63 32 31
0 0 0
Sugar
Reasons for low ‘healthiness’ scores
0 0 0
0 0
0
0 0 0
0 0
0
0 1
9 6
15
0 0 0
16 7 9
Salt
0 0 0
1 0
1
5 4 1
1 1
2
4 3
5 4
9
4 0 4
1 1 0
‘No goodness’
Table 5 Numbers of children (n ¼ 181) giving different reasons for high and low ‘healthiness’ scores for foods commonly served at school cafeterias
2 1 1
3 3
6
2 0 2
1 2
3
2 5
1 0
1
6 2 4
6 3 3
High calorie
210 C. Noble et al. / Hospitality Management 22 (2003) 197–215
15 11 4
Total 22 Boys 11 Girls 11
Total 16 Boys 7 Girls 9
Total 14 Boys 1 Girls 13
Total 12 Boys 4 Girls 8
Total 12 Boys 5 Girls 7
Total 11 Boys 8 Girls 3
Total 10 Boys 4 Girls 6
Chips
Pizza
Sandwich
Fresh fruit
Iced bun
Beefburger
Crisps
6 5 1
11 7 4
6 5 1
5 2 3
3 3 0
13 10 3
14 11 3
Can of drink Total 28 Boys 13 Girls 15
7 4 3
0 0 0
0 0 0
1 0 1
3 0 3
3 2 1
1 0 1
4 2 2
12 7 5
8 7 1
2 0 2
0 0 0
17 4 13
5 3 2
10 5 5
7 3 4
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
37 28 9
0 0 0
1 1 0
0 0 0
13 3 10
15 4 11
2 1 1
0 0 0
0 0 0
0 0 0
0 0 0
10 5 5
0 0 0
0 0 0
0 0 0
0 0 0
2 1 1
2 0 2
1 1 0
0 0 0
5 1 4
3 3 0
1 1 0
2 2 0
8 4 4
Like Taste Cheap Easy Refreshing Healthy Sweet Habit to Eat
Reasons for high ‘likelihood to choose’ scores
Ham
Chicken fricasse
Mashed potato
Milk or water
Apple crumble
Mixed vegetables
Quiche
Total 11 Boys 5 Girls 6
Total 17 Boys 3 Girls 14
Total 19 Boys 6 Girls 13
Total 22 Boys 10 Girls 12
Total 27 Boys 13 Girls 14
Total 34 Boys 19 Girls 15
Total 40 Boys 24 Girls 16
Baked potato with tuna Total 44 Boys 28 Girls 16
2 0 2
1 0 1
12 7 5
0 0 0
1 0 1
3 1 2
4 0 4
0 0 0
7 3 4
2 0 2
4 2 2
7 2 5
2 1 1
6 3 3
5 3 2
1 1 0
1 1 0
7 2 5
1 0 1
0 0 0
0 0 0
7 3 4
3 1 2
3 1 2
1 1 0
6 5 1
1 1 0
0 0 0
4 2 2
5 3 2
2 2 0
2 2 0
Dislike Texture Taste Appearance Not easy to eat
Reasons for low ‘likelihood to choose’ scores
Table 6 Numbers of children (n ¼ 181) giving different reasons for high and low ‘preference’ scores for foods commonly served at school cafeterias
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highest and lowest scores for ‘healthiness’. An examination of the reasons given for these high and low scores will provide an idea of the accuracy of children’s perceptions of ‘healthy eating’. 3.4. Reasons for high and low ‘healthiness’ scores Fresh fruit, and mixed vegetables were accurately seen as low fat, salad was also perceived to be low in fat and therefore ‘healthy’ (Table 5). However, the plate of salad used for the photograph contained both coleslaw and potato salad, both of which are high in fat, relative to their energy content. Thus the common perception that salad is invariably a low fat dish can be misleading, and certainly was in this case. The most commonly given reason for the healthiness of these foods was the presence of vitamins. Salad and fresh fruit were also perceived to be healthy because they were ‘fresh’ or ‘natural’. Milk was perceived to be healthy because of the presence of calcium, which was recognised to be ‘good for bones and teeth’. Chips, crisps, beefburgers, sausages and pizza were all accurately seen to be high in fat, and thus perceived to be unhealthy. Iced buns, the can of drink, and mini-cookies seen to be high in sugar, again accurately, and thus perceived to be unhealthy. It is therefore clear that apart from seeing salad as a low fat food (in this case incorrectly) the children’s perceptions of the ‘healthiness’ of the different foods and dishes or otherwise are accurate. The following section therefore examines the reasons why children have in many cases, given those foods which they accurately perceive to be healthy, low ‘likelihood to choose’ scores and why they are more likely to choose those foods which they equally accurately perceive to be ‘unhealthy’. 3.5. Reasons for high and low ‘likelihood to choose’ scores Table 6 shows the foods given the highest and lowest scores for ‘likelihood to choose’ and the reasons given for these high and low scores. Liking the food or liking the taste was in almost all cases the reason most frequently given for high scores. Other reasons include ‘easy to eat’, particularly in the case of sandwiches, and the can of drink was most frequently chosen because it was ‘thirst quenching’ or ‘refreshing’. Sandwiches and fresh fruit were chosen because they were ‘healthy’ or ‘good for you’. ‘Habit’, ‘have at home’ or ‘what I usually have’ were also reasons given. Iced buns were chosen because they were sweet. The most frequently given reason for low ‘likelihood to choose’ scores were dislike of the food, or of the texture, in the case of mashed potato, or the taste, in the case of ham. The appearance of mixed vegetables and chicken fricassee were disliked. Other reasons included ‘not easy’ or ‘not convenient’ to eat.
4. Conclusions This study was carried out in secondary schools where children have a completely free choice of items from the cafeteria. It was found that the most important factors
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influencing their choice were taste and convenience. As a result of this, the gap between the nutritional value of the ‘healthy’ choices and the ‘favourite’ choices is as large as nutritionists have often feared. This is in contrast to children of primary school age (Noble et al., 2000). These findings have implications for caterers, who will need to take heed of the reasons why children like and choose particular foods. If the ‘favourite’ foods are those which are quick and easy to eat, and ‘fast’ foods are associated with pleasure, friends and independence, this is an opportunity for caterers to use their skills to present ‘healthy’ foods in a ‘fast’ form and ‘favourite’ foods in a ‘healthy’ form. For example, bread and potatoes contain starchy carbohydrates and other important nutrients and can be accompanied by foods of high nutrient density, to form a ‘healthy’ meal in a ‘fast’ form. Similarly, ‘favourite’ foods, such as beefburgers can also be served in a ‘healthy’ form by balancing the fat with sufficient carbohydrate, and adding salad ingredients to provide other important nutrients. This study also found that children’s awareness of ‘healthy eating’ and their nutritional knowledge of individual foods and dishes is mainly good. This knowledge is not being applied in practice, however. Those involved in nutrition education will also need to take heed of the reasons why children like and choose particular foods, and the beliefs that the children hold about the foods which they perceive to be healthy. This study revealed a number of misconceptions, e.g. the view that ‘healthy’ equates with ‘low calorie’. Also, the children did not seem to be aware that fatty foods in the diet need to be replaced by those containing starchy carbohydrates. Nutrition education should perhaps address these misconceptions and help children to get away from the idea of ‘healthy’ and ‘unhealthy’ foods. Instead, the aim should be to show children how to combine foods that they like and which are compatible with their lifestyles, in the right proportions to make up a healthy diet. The new guidelines for school meals, based on the ‘Balance of Good Health’ or ‘tilted plate’ model, could provide the initiative for the coming together in schools, of those involved in feeding the children and those responsible for their nutrition education. Although this model has been used for some time now, little of the existing data on either school meals or school children’s diets have been analysed in such a way that it can be compared with the model. Existing or new data on the various combinations of foods frequently served at school meals, and those foods which children commonly eat, need to be analysed to determine whether this model is applicable to the eating habits of children of this age.
Acknowledgements This study was funded by the Ministry of Agriculture, Fisheries, and Food as part of project A72, Nutritional Implications of Food Choices in Catering Outlets. The authors extend thanks to the Ministry for their support.
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References Adamson, A., Rugg-Gunn, A., Butler, T., Appleton, D., Hackett, A., 1992. Nutritional intake, height and weight of 11–12 year-old Northumberland children in 1990 compared with information obtained in 1980. British Journal of Nutrition 68, 543–563. Adamson, A.J., Rugg-Gunn, A.J., Butler, T.J., Appleton, D.R., 1996. The contribution of foods from outside the home to the nutrient intake of young adolescents. Journal of Human Nutrition and Dietetics 9, 55–68. Anderson, A.S., Macintyre, S., West, P., 1994. Dietary patterns among adolescents in the west of Scotland. British Journal of Nutrition 71, 111–122. British Dietetic Association, Community Nutrition Group, 1986. Nutritional guidelines for school meals. British Dietetic Association. Chapman, G., Maclean, H., 1993. ‘Junk food’ and ‘healthy food’: meanings of food in adolescent women’s culture. Journal of Nutrition Education 25 (3), 108–113. Coronary Prevention Group, 1987. Diet or disease: the case for school meals guidelines. The Coronary Prevention Group. Crawley, H., 1993. The energy, nutrient and food intakes of teenagers aged 16–17 years in britain. British Journal of Nutrition 70, 15–26. Currie, C., Todd, J., Young, I., 1997. Health behaviours of Scottish schoolchildren: Report 5: comparisons of national patterns in 1990 and 1994. Health Education Board for Scotland and Research Unit in Health and Behavioural Change, University of Edinburgh, Edinburgh. Department for Education and Employment, 1998. Ingredients for success: a consultation paper on nutritional standards for school lunches. Department for Education and Employment, 2000. The education (Nutritional Standards for School Lunches) (England) regulations 2000. Statutory Instrument 2000, No. 1777, HMSO, London. Department of Education and Science, 1975. Nutrition in schools: report of the Working Party on the Nutritional Aspects of School Meals. London, HMSO. Department of Health, 1989. Diets of British schoolchildren. Report on Health and Social Subjects, No. 36, HMSO, London. Department of Health, 1991. Dietary reference values for food energy and nutrients for the United Kingdom. London, HMSO. Douglas, L., 1998. Children’s food choice. Nutrition and Food Science 1, 14–18. Gardner Merchant Educational Services, 1994. The gardner merchant school meals survey ‘what are our children eating’. Gardner Merchant Ltd., Kenley, Surrey. Gregory, J., Lowe, S., Bates, C.J., Prentice, A., Jackson, L.V., Smithers, G., Wenlock, R., Farron, M., 2000. National diet and nutrition survey: young people aged 4–18 years, Vol. 1. Report of the Diet and Nutrition Survey, TSO, London. Gummeson, L., Jonsson, I., Conner, M.T., Svensson, E., 1996. Assessing factors influencing food choice among 10–16 year-old schoolboys. A pilot study with a stacking box method. Journal of Human Nutrition and Dietetics 9, 219–229. Hackett, A.F., Kirby, S., Howie, M., 1997. A national survey of the diet of children living in urban areas of the United Kingdom. Journal of Human Nutrition and Dietetics 10, 37–51. Johnson, B., Hackett, A.F., 1997. Eating habits of 11–14 year-old schoolchildren living in less affluent areas of Liverpool, UK. Journal of Human Nutrition and Dietetics 10, 135–144. Kipps, M., Noble, C., Thomson, J., 1986. What did they eat at school? Nutrition and Food Science, July/ August 1986. Lund, B.K., Gregson, K., Neale, R.J., Tilston, C.H., 1990a. Dietary awareness of children: specific food components. British Food Journal 2 (8), 23–27. Lund, B.K., Gregson, K., Neale, R.J., Tilston, C.H., 1990b. Dietary awareness of children: specific food items. British Food Journal 2 (8), 28–31. Lynd-Evans, A., 1993. Children’s eating patterns and habits. In: Cawdron, G., Sharp, I. (Eds.), Food for Children—influencing choice and investing in health. National Forum for Coronary Heart Disease Prevention, London.
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McNeil, G., Davidson, L., Morrison, D.C., Crombie, I.K., Keighran, J., Todman, J., 1991. Nutrient intake in schoolchilden: some practical considerations. Proceedings of the Nutrition Society 50, 37–43. Noble, C., Kipps, M., 1994. School meals and the 1980 education act: was the professional concern justified? Hygiene and Nutrition in Food Service and Catering 1 (1), 21–32. Noble, C., Kipps, M., 1995. Implementing quantified guidelines for school meals. International Journal of Hospitality Management 13 (4), 361–374. Noble, C., Corney, M., Eves, A., Kipps, M., Lumbers, M., 2000. Food choice and school meals: primary schoolchildren’s perceptions of the healthiness of foods and the nutritional implications of food choices. International Journal of Hospitality Management 19, 413–432. Passmore, S., 1997. Dietary patterns in school meals in secondary schools: a case study using data from cafeteria sales in Birmingham. Health Education Journal 56, 241–250. Roberts, C., Kingdon, A., Frith, C., Tudor-Smith, C., 1997. Young people in Wales: lifestyle changes 1986–1996. Health Promotion Wales, Technical Report No. 24, Health Promotion Wales, Cardiff. Ruxton, C.H.S., Kirk, T.R., Belton, N.R., Holmes, M.A.M., 1993. School meals: should nutritional guidelines be introduced? British Food Journal 95 (8), 9–12. Seaman, C., Woods, M., Grosset, E., 1997. Attitudes to healthy eating among Scottish schoolchildren. Health Education 1, 19–22. Sharp, I., 1992. Nutritional guidelines for school meals. Report of an Expert Working Group, Caroline Walker Trust. Sodexho, 2000. The Sodexho school meals survey 2000. Sodexho Ltd. Strain, J.J., Robson, P.J., Livingstone, M.B.E., Primrose, E.D., Savage, J.M., Cran, G.W., Boreham, C.A.G., 1994. Estimates of food and macronutrient intake in a random sample on Northern Ireland adolescents. British Journal of Nutrition 72, 343–352. Tilston, C.H., Gregson, K., Neale, R.J., Douglas, C.J., 1992. Dietary awareness of primary schoolchildren. British Food Journal 93 (6), 25–29. Watt, R.G., Sheiham, A., 1997. Towards an understanding of young people’s conceptualisation of food and eating. Health Education Journal 56, 340–349. White, J., Cole-Hamilton, I., Dibb, S., 1992. The nutritional case for school meals. School Meals Campaign. Wreiden, W.L., Moore, E.J.H., 1995. The dietary habits of 11–12 year-old children in two tayside secondary schools—comparison with the targets set by the Scottish diet report. Health Bulletin 53 (5), 299–306.
Food choice and secondary school meals: the nutritional implications of choices based on preference rather than perceived healthiness Carol Noblea,*, Michael Corneyb, Anita Evesc, Michael Kippsc, Margaret Lumbersc a
School of Life Sciences, Whitelands College, University of Surrey Roehampton, West Hill, London SW15 3SN, UK b School of Pharmacy, University of London, London WC1, UK c School of Management Studies for the Service Sector, University of Surrey, Guildford, Surrey GU2 5XH, UK
Abstract Children from secondary schools in the UK selected from photographs, dishes for the meal they would be most likely to choose and the meal they perceived to be the most healthy. They gave reasons for their choices. The nutritional value of the two sets of meals was compared and the reasons for choice were analysed qualitatively. There was an inverse relationship between the foods most likely to be chosen, and those that were perceived to be the most healthy. Although the children’s nutritional knowledge was sound, choices were made more on the basis of convenience and taste than on the ‘healthiness’ of the food. The ‘preferred’ meals were in most respects less healthy than the ‘healthy’ meals. r 2003 Elsevier Science Ltd. All rights reserved. Keywords: Food choice; School meals; Nutritional value
1. Introduction The nutritional quality of the diets of school children in the UK, particularly those of secondary school age, has been a matter of concern for some time. A number of studies carried out in the UK (DoH, 1989; McNeil et al., 1991; Adamson et al., 1992; *Corresponding author. Tel.: +44-20-8392-3228; fax: +44-20-8392-3527. E-mail address: [email protected] (C. Noble). 0278-4319/03/$ - see front matter r 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S0278-4319(03)00018-5
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Crawley, 1993; Strain et al., 1994; Wreiden and Moore, 1995; Hackett et al., 1997) have found some children of this age consuming diets high in fat (particularly saturated fat), and sugar, and low in micronutrients such as calcium, iron and possibly anti-oxidant vitamins. In a more recent study (Gregory et al., 2000) it was found that while the percentage of energy provided by total fats and total carbohydrates was close to the dietary reference values (DRVs) (DoH 1991), the energy coming from saturated fatty acids (SFA) and non-milk extrinsic sugars were higher than these values. It was also found in this study that some children, mainly the older ones and particularly girls, had low intakes of some micronutrients, and there was some evidence of low-micronutrient status. The contribution of school meals to the nutrition of school children has also been much debated. After the 1980 Education Act, when cash cafeterias became almost universal in secondary schools in the UK, concern was expressed that the nutritional value of the school meal depended to a great extent on the choices made by the individual child. It has been recognised (Kipps et al., 1986; Ruxton et al., 1993) that those involved in nutrition education and school caterers would need to work together to help children to make nutritionally sound choices from the cash cafeteria. Despite this, studies in secondary schools in the UK have shown that the meals chosen and consumed by children were often high in fat and sugar and low in calcium and iron, also zinc, riboflavin, folate and vitamin A (DoH, 1989; Noble and Kipps, 1994). In the latest national study of school children’s diets (Gregory et al., 2000), school meals consumed by some children were low in calcium, iron and folate. The 1980 Education Act also effectively abolished the previous nutritional standards for school meals (DES, 1975). Since then, there have been a number of calls for standards or guidelines which more closely reflect current nutritional concerns (British Dietetic Association, 1986; Kipps et al., 1986; Coronary Prevention Group, 1987; White et al., 1992; Noble and Kipps, 1995). There have also been suggestions (Sharp, 1992; Noble and Kipps, 1995) as to the nutrients and levels which might be specified. However, the recent British government consultation paper on nutritional standards for school lunches (DfEE, 1998) proposed that any standards should be food based rather than nutrient based. These standards (DfEE, 2000) based on the ‘Balance of Good Health’ or ‘tilted plate’ came into force in April 2001 and have been welcomed by school caterers. The problem of helping children to choose foods which make up a nutritionally sound meal remains. A number of studies in the UK have identified the food habits and preferences of children of secondary school age. Anderson et al. (1994), Adamson et al. (1996), Currie et al. (1997), Roberts et al. (1997) and Johnson and Hackett (1997) all found high consumption of snacks amongst school children. Other studies (Gardner Merchant, 1994; Passmore, 1997; Douglas, 1998; Sodexho, 2000) have examined the food choices of school children of this age, at school meals. Here again there was a strong preference for snack foods such as cakes and biscuits, crisps, and fizzy drinks. It was found in a number of these studies (Douglas, 1998; Anderson et al., 1994; Johnson and Hackett, 1997) also in those by Lund et al. (1990a, b) and Seaman et al. (1997) that in most cases, the children’s nutritional
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knowledge is fairly sound. All these authors, however, comment on the failure of children to apply their awareness of ‘healthy eating’ in practice. Some explanation is provided by studies on the factors which influence children’s food choice. Chapman and Maclean (1993) and Watt and Sheiham (1997) found that adolescents conceptualise and classify foods into ‘healthy’ foods, associated with weight loss, parents and being at home, and ‘fast’ or ‘junk’ foods, linked with pleasure, friends and independence. Tilston et al. (1992), Gummeson et al. (1996), and Noble et al. (2000) found that the ‘healthiness’ of the meal was not a very important factor in children’s food choice; personal preferences for the taste, texture and appearance of the food had a much greater influence. While a number of authors (Ruxton et al., 1993; Hackett et al., 1997) have pointed out the need for school-based initiatives to improve children’s eating habits, Watt and Sheiham (1997) stress that such efforts should be based on an understanding of their beliefs concerning food. While Lynd-Evans (1993) suggested that the task facing caterers was to make the ‘healthy choices’ also the ‘favourite choices’, Tilston et al. (1992) and Noble et al. (2000) found an inverse relationship between the perceived healthiness of food and children’s liking for it. Despite this, the difference in nutritional value between the ‘healthy choices’ and the ‘favourite choices’ was not as great as many nutritionists feared (Noble et al., 2000). The meals chosen on the basis of preference were, in many respects, no less healthy than those chosen on the basis of the children’s perceptions of the healthiness of the meal, and in some respects the ‘preferred’ meals were ‘healthier’. However, this study was carried out in primary schools, where, while there is some element of choice, the foods are usually arranged so that children have to choose one item from each category, main items such as fish fingers or pizza, starchy items such as potatoes or rice, a vegetable and a pudding. The current paper describes a similar study carried out in secondary schools where children have a free choice of items from the cash cafeteria. While the studies reviewed above have all explored children’s food preferences in general and at school, the factors that influence the children’s choice, their nutritional knowledge, perceptions of healthiness and attitudes to food and health, few of these have looked at their preferences for and perceptions of the healthiness for the same set of foods. This paper reports on which of the foods and dishes commonly served at lunchtime in secondary school cafeterias are most frequently chosen for the meal most likely to be consumed (the ‘preferred’ meals), and which are chosen for perceived healthiness (the ‘healthy’ meals). The reasons for these meal choices are explored. The paper also identifies the foods and dishes that are perceived to be the most and the least healthy, and those that are the most and the least likely to be chosen, in both cases based on a scoring system. The reasons or explanations for these perceptions and preferences are explored. A comparison of the nutritional value of meals chosen on the basis of preference and those chosen on the basis of perceived healthiness will provide an indication of the size of the nutritional gap between the ‘healthy’ and the ‘favourite’ choices, and will provide a measure of the accuracy of children’s perceptions of a ‘healthy’ meal.
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2. Methodology 2.1. Sample selection and description Interviews took place with 181 school children (87 boys and 94 girls) aged 14 and 15 from 10 secondary schools in the South East of England. All the children made regular use of their school cafeteria. Each interview lasted 30 min and was conducted on a one-to-one basis. 2.2. Materials and methods A set of 19 high-quality colour photographs of foods and dishes that would typically be offered in the school cafeteria were used in the interview. The photographs, usually showing one item each, included foods, such as crisps and a can of drink, that would be classified as ‘snacks’ and those, such as chicken fricasse and apple crumble, that would form part of a conventional meal. The interview involved several tasks. The children, who were not aware of the purpose of the study, were first presented with all the photographs and asked to select the foods or dishes that would make up the meal that they would be most likely to choose if they were offered that range of foods (the ‘preferred’ meal). They had a completely free choice of all the items, which is consistent with the cafeteria style of service usually offered in secondary school cafeterias. Having selected the meal, the children were asked to explain why they had chosen this meal. In the second task, the children were asked to rate each of the 19 foods or dishes food on a nine-point scale, marking the point that best reflected their likelihood to choose the item. The scales ranged from ‘very likely to choose’, scored at +4, to ‘very unlikely to choose’, scored at 4. The meal selection and the rating tasks were repeated, this time, with the children being asked, first of all, to select the meal that they thought would be the most healthy (the ‘healthy’ meal), and to explain the reasons for their choice, and, secondly, to rate all the foods or dishes according to how healthy they perceived each one to be. In this case, the scales ranged from ‘very healthy’ (scored at + 4) to ‘not so healthy’ (scored at 4). The methods for this study had been piloted with a small group where the children had been asked to give reasons for their ratings on the ‘likelihood to choose’ and the ‘healthiness’ scales for all 19 foods. This had been found to be very time consuming and earlier studies had indicated that, while children were able to give reasons for liking or disliking those foods that they had placed at either end of the ‘likelhood to choose’ rating scale, and were able to explain particularly high or low ratings for ‘healthiness’, most were less able to give reasons for intermediate ratings. It was therefore decided that since less valuable information was expected from comments on foods rated in the middle of the scale, reasons for ratings would be asked only for those foods or dishes given the three highest and the three lowest ratings for ‘likelihood to choose’ and for ‘healthiness’ by each individual. In this way, the interviews
C. Noble et al. / Hospitality Management 22 (2003) 197–215
201
could be finished within 30 min, thus minimising the disruption to lessons. Thus, following each of the rating tasks, the foods or dishes given the three highest and the three lowest ratings, by each child, on both the ‘likelihood to choose’ scale and on the ‘healthiness’ scale were identified. The children were then asked to explain why they had given high or low ratings to these foods or dishes on each of the scales. Where more than three items were given particularly high or low ratings (e.g. if four items were rated as ‘very healthy’), the child was asked to identify the three items considered to be the most healthy. All responses were recorded on a questionnaire. The questionnaire was completed by the interviewer except in the case of the rating of items, where the interviewee was asked to cross the appropriate boxes. 2.3. Data analysis For the meal selection task, the frequency with which items were selected for the ‘preferred meal’ and the ‘healthy meal’ was determined and comparisons made between males and females. Mean values for rating scores (from +4 to 4) on both the ‘likelihood to choose’ and the ‘healthiness’ scales were calculated, and linear regression was used to determine whether there was a relationship between the likelihood to choose an item and its perceived healthiness. In all cases, statistical significance is quoted at the 5% level (po0:05). The qualitative data on reasons given for the choice of foods or dishes for the ‘healthy’ meals and for high and low ratings on the ‘healthiness’ scale were analysed by assigning the reasons to categories. A number of subjects gave vague, unqualified reasons such as ‘good for you’, ‘healthy’, ‘nutritious’ ‘bad for you’, ‘unhealthy’. These were all grouped as a single category. Other reasons given were based on the influence of others, ‘they say’, ‘common knowledge’; these also were grouped together. Where more definite reasons were given, these were categorised according to the different levels of nutritional knowledge or understanding that was apparent. Responses included the presence of specific foods or ingredients perceived to be healthy or otherwise, the presence or absence of particular nutrients, or foods or nutrients which made specific contributions to health. Reasons were, in many cases, related to the perceived healthiness or otherwise of food production or cooking methods used. Similarly, the qualitative data on reasons given for the choice of foods or dishes for the ‘preferred’ meals and for high and low ratings on the ‘likely to choose’ scale were analysed by assigning the reasons to categories. The energy and nutrient content of the ‘preferred’ and the ‘healthy’ meals (using portion sizes supplied by the caterers) were determined using Comp-Eat 4, a nutritional analysis package based on McCance and Widdowson’s ‘The Composition of Foods’. The nutritional value of the two sets of meals was compared using Student’s t-test. A chi-squared test was used to determine the significance of any differences in the meal choices of the boys and girls.
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3. Results and discussion 3.1. Foods perceived to be healthy, and foods most likely to be chosen The items most frequently chosen for the ‘healthy’ meal were fresh fruit, salad, mixed vegetables, and milk or water (Table 1). For the ‘preferred’ meals, the most popular choices were snack items such as cans of drink and chips. These items were not chosen at all or by only a small percentage of children for the ‘healthy’ meals. The least popular choices for the ‘preferred’ meals, chicken fricassee, mixed vegetables, mashed potatoes, ham and quiche, were all those foods or dishes which would be part of a main meal. For the ‘preferred’ meals, boys were significantly more likely than girls to choose a beefburger, and girls were more likely to choose salad or a sandwich. There were no significant differences in the items chosen for the ‘healthy’ meals. As in previous studies carried out in primary schools (Tilston et al., 1992; Noble et al., 2000), this study of children of secondary school age found that most of the items perceived to be more healthy were those that were much less likely to be chosen, and the foods most likely to be chosen were mainly those perceived to be less healthy. Moreover, in this study, a regression analysis between the mean ‘healthiness’ and mean ‘likelihood to choose’ scores (Table 1) for the different foods showed a negative relationship between the two variables (R2 ¼ 0:30). Two items, the sandwich, which contained salad, and the fresh fruit, received high ratings for both ‘likelihood to choose’ and ‘healthiness’. If these two items are removed from the regression analysis, the R2 value increased to 0.62, indicating a greater negative relationship. Ratings for ‘healthiness’ were much more polarised (from +3.86 (0.39) to 2.63 (1.51)) than those for ‘likelihood to choose’ (from +2.97 (1.79) to 1.12 (2.45)), and standard deviations were smaller, indicating a strong consensus between pupils as to the ‘healthiness’ or otherwise of foods. Given this inverse relationship between those foods perceived to be healthy and those foods most likely to be eaten, the following section examines the nutritional effects of these choices.
3.2. Nutritional effects of food choices In order to determine the size of the nutritional gap between the ‘favourite’ and the ‘healthy’ choices (Lynd-Evans, 1993), the nutritional value of the ‘preferred’ meals and the ‘healthy’ meals will be compared (Table 2). While there are no quantified nutritional guidelines for school meals, those produced by the Caroline Walker Trust (Sharp, 1992) are often used as a measure of the nutritional adequacy of the meals consumed. While these guidelines, based on the DRVs (DoH 1991), recognise that the school meal accounts for only one of the day’s meals and that the rest of the day’s food intake would contribute further nutrients, they assume that for some children, the school meal is the main meal of the day. The nutritional value of both sets of meals will be compared with these guidelines (Table 2).
Fresh fruit Salad Mixed vegetables Milk/water Jacket potato and tuna Sandwich Chicken fricassee Ham Apple crumble Mashed potatoes Quiche Can of drink Pizza Iced bun Mini cookie Sausages Chips Crisps Beefburger
73.48 67.40 56.35 30.94 24.86 21.55 12.71 10.50 7.18 6.08 2.21 1.66 1.10 1.10 1.10 0.55 0.55 0.00 0.00
79.31 74.71 62.07 32.18 31.03 21.84 16.09 8.05 5.75 6.90 1.15 1.15 1.15 2.30 0.00 0.00 1.15 0.00 0.00
68.09 60.64 51.06 29.79 19.15 21.28 9.57 12.77 8.51 5.32 3.19 2.13 1.06 0.00 2.13 1.06 0.00 0.00 0.00
13.81 9.39 2.76 16.57 8.29 28.18 3.87 1.10 6.63 1.66 0.55 50.83 25.41 14.92 14.36 8.84 46.41 25.97 20.44
10.34 2.30 5.75 14.94 3.45 14.94 6.90 2.30 8.05 3.45 1.15 64.37 34.48 14.94 17.24 11.49 58.62 27.59 29.89
Boys (n ¼ 87) 17.02 15.96 0.00 18.90 12.77 40.43 1.06 0.00 5.32 0.00 0.00 38.30 17.02 14.89 11.70 6.38 35.11 24.47 11.70
Girls (n ¼ 94) 3.86 (0.39) 3.78 (0.61) 3.40 (0.98) 3.34 (1.03) 2.61 (1.42) 2.76 (1.17) 1.82 (1.63) 2.05 (1.46) 0.73 (1.86) 1.56 (1.53) 1.89 (1.45) 1.60 (1.96) 1.48 (1.93) 2.28 (1.61) 1.45 (1.67) 1.08 (1.90) 2.63 (1.51) 2.11 (1.50) 2.02 (1.76)
Total (n ¼ 181)
Girls (n ¼ 94)
Total (n ¼ 181)
Boys (n ¼ 87)
Healthiness
Preferred meals
Healthy meals
1.72 (2.15) 0.96 (2.50) 1.12 (2.45) 0.20 (3.05) 0.17 (3.05) 2.06 (2.28) 0.86 (2.77) 0.41 (2.64) 0.28 (2.89) 0.56 (2.48) 0.71 (2.76) 2.97 (1.79) 1.66 (2.62) 1.62 (2.42) 1.20 (2.24) 0.78 (2.65) 2.19 (2.04) 1.97 (2.10) 0.96 (2.72)
Preference
Mean rating scores (SDs)
Percentage of pupils choosing each item
Table 1 The percentage of pupils choosing each of the food items for their ‘healthy’ meal and their ‘preferred’ meal, and the mean rating scores (SDs) for the perceived healthiness of, and the ‘likelihood to choose’ each item C. Noble et al. / Hospitality Management 22 (2003) 197–215 203
Energy Protein NSP Thiamin Riboflavin Niacin Folate Vitamin C Vitamin A Calcium Sodium Iron Zinc Fat SFA Carbohydrate Sugar Starch
kJ g/MJ g/MJ mg/MJ mg/MJ mg/MJ mg/MJ mg/MJ mg/MJ mg/MJ mg/MJ mg/MJ mg/MJ % energy % energy % energy % energy % energy
Unit
1702 (1928) 7.70 (4.01) 2.16 (0.07) 0.19 0.03) 0.18 (0.04) 3.40 (2.38) 31.02 (0.89) 15.73 (3.77) 140.61 (51.59) 111.37 (37.86) 232.12 (23.42) 0.82 (0.15) 0.80 (0.21) 47.85 (11.50) 14.37 (2.21) 39.46 (4.77) 17.44 (8.51) 21.97 (13.30)
Mean (SD)
Mean (SD)
2563 (53.74) 5.44 (1.19) 1.46 (0.10) 0.13 (0.04) 0.08 (0.04) 2.72 (0.29) 21.08 (11.18) 6.04 (0.90) 47.14 (38.91) 58.99 (19.28) 260.10 (66.31) 0.90 (0.33) 0.61 (0.00) 41.21 (3.49) 11.43 (0.23) 49.66 (1.45) 19.08 (8.47) 30.44 (7.44)
‘Healthy’ meal
‘Preferred’ meal
*
* * * * * * * * * * * * * * * *
Significance
RNI RNI RNI RNI
o35% o11% >50% o11%
>40% RNI
>40% >35% >30% >35%
30% EAR >30% DRV >30% DRV
Guidelines
26.62 29.40 19.30 35.10 18.37 45.65 25.62 34.27 15.10 16.98 40.52 18.18 18.75
(1.04) (14.63) (8.73) (24.85) (11.20) (5.50) (22.27) (7.07) (25.53) (4.88) (16.22) (4.75) (6.48)
‘Preferred’ meal (as % of DRV) Mean (SD)
18.21 29.80 18.66 35.22 27.16 41.12 24.96 60.78 35.55 23.11 24.12 10.68 16.82
(19.74) (71.26) (9.80) (43.70) (14.89) (97.25) (22.63) (37.88) (9.43) (5.00) (21.88) (19.91) (21.99)
‘Healthy’ meal (as % of DRV) Mean (SD)
Table 2 The differences in mean values (SDs) for energy and nutrient content of ‘preferred’ meals (n ¼ 181) and ‘healthy’ meals, expressed as nutrient density (nutrients/MJ) and as a percentage of dietary reference values (DoH, 1991)
204 C. Noble et al. / Hospitality Management 22 (2003) 197–215
C. Noble et al. / Hospitality Management 22 (2003) 197–215
205
The energy content of the ‘preferred’ meals (Table 2) was significantly higher than that of the ‘healthy’ meals. This is partly due to a higher proportion of the children choosing items such as, chips, pizza, crisps, beefburgers or a can of drink for their ‘preferred’ meal as opposed to fresh fruit, salad or jacket potato with tuna for the ‘healthy’ meal. The children also chose fewer items for the ‘healthy’ meal, indicating that even children of this age are equating ‘healthy’ with ‘low calorie’. The mean value for the energy content of the ‘preferred’ meal was just over 25% of the estimated average requirement (EAR) (DoH, 1991), whereas that of the ‘healthy’ meals was only 18% of the EAR (Table 2). Compared with the 30% of the EAR, suggested in the guidelines, the energy contents are low, particularly for the ‘healthy’ meal. If school children are to be encouraged to choose ‘healthier’ meals, these should have an appropriate energy content. In addition, unless children are provided with foods that they like, energy requirements, which in some cases are high, will not be met. The ‘preferred’ meals contained significantly greater amounts of several nutrients, due in most cases to their higher energy content. Table 2 also shows the nutrient density or nutrient content per megajoule (MJ) of both sets of meals and the percentage of the total energy provided by fats and carbohydrates. This gives a better measure of the nutritional quality or ‘healthiness’ of the meals. In the ‘healthy’ meals a significantly higher percentage of the energy was provided by fat, and due to the frequent selection of a plate of salad which included both potato salad and coleslaw, each providing large amounts of fat in comparison to the energy contents of the other components of the salad. The significantly higher percentage of energy coming from SFA in the ‘healthy’ meal was probably due to the more frequent choice of milk for these meals. The percentage of energy provided by fat in both the ‘preferred’ meals and the ‘healthy’ meals, and that provided by SFA in the ‘healthy’ meals was high compared with the DRV and suggested guidelines (Table 2). Compared with the ‘healthy’ meals, the ‘preferred’ meals provided a significantly higher percentage of the energy as carbohydrate in the form of starch (Table 2). The carbohydrate content of the ‘preferred’ meals compared well with the suggested guidelines, whereas that of the ‘healthy’ meals was considerably lower. This suggests that children are not yet viewing a ‘healthy’ meal as one which contains starchy carbohydrate foods, even though they would choose these foods for preference. There was no significant difference between the two meals in the percentage of energy provided by sugar. In terms of the nutrient density (Table 2), the ‘healthy’ meals provided significantly greater amounts per MJ of the following nutrients NSP, thiamin, riboflavin, niacin, folate, vitamin C, vitamin A, calcium and zinc, whereas the ‘preferred’ meal provided significantly greater amounts per MJ of sodium and of iron. Higher intakes of iron in the ‘preferred’ meals are probably due to the more frequent choice of beefburgers, which provide a good source of easily absorbable iron. There were no significant differences between the two sets of meals in the amounts of protein per MJ. This analysis shows that the meals chosen on the basis of perceived healthiness are indeed of higher nutritional quality, as far as most micronutrients (except iron) are concerned. It also shows that the children’s
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perception of foods such as salad, milk, fresh fruit as ‘healthy’ is also quite sound, even though these are not usually the foods chosen for preference. In both sets of meals, the contents of NSP, folate, vitamin A, calcium and iron were all low compared with the guidelines (Table 2). The content of vitamin A was particularly low in the preferred meal. Compared with DRVs, the contents of riboflavin, particularly in the ‘healthy’ meal, and zinc were low and salt contents high. While this data, refers to only one meal of the day, it does leave quite a high percentage to be provided by the rest of the day’s food intake. If, as would seem to be the case, the foods that children of this age group prefer are sometimes of low nutrient density and if energy intakes are low, intakes of some nutrients could be a cause for concern. These findings support those previous surveys (DoH, 1989; Noble and Kipps, 1994; Gregory et al., 2000) all of which relate to food actually consumed. As the above surveys have all identified the nutrient intakes of teenage girls as being of particular concern, the nutritional value of the ‘preferred’ and ‘healthy’ meals chosen by boys and girls will be compared (Table 3). 3.2.1. ‘Preferred’ meals Most of the significant differences in the nutritional value of the ‘preferred’ meals by the boys and girls in the study are explained by the higher food intakes of the boys. The meals chosen by the boys had significantly higher energy contents, which resulted in significantly higher intakes of several nutrients. However, if the nutrient content of the meals are expressed as a percentage of the total energy provided by fat and carbohydrate, or as nutrients per MJ, some significant differences remain. The meals ‘preferred’ by the girls had significantly higher contents of NSP, thiamin, folate, vitamin C and vitamin A per MJ; whereas the meals ‘preferred’ by the boys provided significantly greater amounts per MJ of riboflavin and zinc. Some of these differences can be explained by the greater popularity of salads, salad sandwiches or jacket potato with tuna among the girls and of chips, pizza or beefburgers among the boys. There were no significant differences in the percentage of energy coming from fats and carbohydrates. While the meals most likely to be chosen by the girls are of rather higher nutritional quality, the low energy contents of these meals could result in intakes of some important nutrients lower than is desirable. Nutrients of particular concern are riboflavin, iron and zinc (Table 2). This supports the findings of previous studies (DoH, 1989; Noble and Kipps, 1994; Gregory et al, 2000). 3.2.2. ‘Healthy’ meals Just as there were few differences between the boys and the girls in the items chosen for the ‘healthy’ meal, there were few differences in the nutritional value of the meals. The ‘healthy’ meals chosen by the boys contained significantly greater amounts per MJ of calcium and riboflavin. This could be explained by their greater liking for pizza or their more frequent choice of milk as a food perceived to be healthy. These findings perhaps indicate that there is little difference in the nutritional knowledge of boys and girls. This is not surprising, given that, despite the greater interest in slimming likely to be shown by the girls, it is probable that at this
Units
kJ g/MJ g/MJ % energy % energy % energy % energy % energy mg/MJ mg/MJ mg/MJ mg/MJ mg/MJ ug/MJ mg/MJ mg/MJ mg/MJ mg/MJ
Nutrient
Energy Protein NSP Fat SFA Carbohydrate Sugar Starch Thiamin Riboflavin Niacin Folate Vitamin C Vitamin A Calcium Sodium Iron Zinc
2958 (972) 5.71 (2.12) 1.26 (0.40) 40.99 (9.42) 11.73 (4.25) 49.39 (9.49) 18.70 (11.42) 30.56 (6.96) 0.11 (0.05) 0.09 (0.04) 2.69 (0.92) 18.90 (6.81) 4.05 (2.44) 38.58 (43.31) 62.35 (30.32) 276.13 (117.95) 0.92 (0.30) 0.68 (0.30)
2189 (1006) 5.18 (3.12) 1.64 (1.01) 41.30 (15.64) 11.14 (4.69) 49.94 (14.14) 19.24 (17.46) 30.56 (13.03) 0.14 (0.10) 0.07 (0.05) 2.74 (2.05) 23.14 (11.43) 7.92 (6.84) 55.23 (52.41) 55.81 (36.53) 244.93 (113.31) 0.89 (0.33) 0.55 (0.31) *
* * *
* *
*
*
1835 (842) 7.84 (3.48) 2.03 (0.85) 48.27 (17.88) 14.86 (5.27) 38.82 (13.46) 17.67 (7.65) 21.11 (14.00) 0.18 (0.10) 0.20 (0.10) 3.37 (2.23) 30.53 (12.65) 15.33 (7.14) 145.90 (67.86) 122.46 (63.08) 224.50 (82.88) 0.79 (0.22) 0.82 (0.30)
Boys Mean (SD)
Significance
Boys Mean (SD)
Girls Mean (SD)
‘Healthy’ meals
‘Preferred’ meals
1576 (757) 7.56 (4.50) 2.27 (1.40) 47.46 (20.96) 13.90 (6.44) 40.06 (17.11) 17.22 (14.40) 22.80 (15.46) 0.20 (0.14) 0.16 (0.10) 3.43 (2.60) 31.49 (16.31) 16.11 (8.51) 135.60 (97.59) 100.87 (68.34) 239.33 (192.76) 0.85 (0.35) 0.77 (0.44)
Girls Mean (SD)
*
*
*
Significance
Table 3 The differences in energy and nutrient content and nutrient density (nutrients/MJ) of ‘preferred’ meals (n ¼ 181) and the ‘healthy’ meals chosen by males and females C. Noble et al. / Hospitality Management 22 (2003) 197–215 207
208
C. Noble et al. / Hospitality Management 22 (2003) 197–215
stage, they will all have been exposed to similar teaching about food and health and to similar outside sources of information. It has been shown that the ‘preferred’ meal is, in a number of important respects, less healthy than the one that the children perceive to be a ‘healthy’ meal. The following section therefore examines the reasons given by the children for their choices for each set of meals. 3.3. Reasons given for choices for ‘preferred’ meals and ‘healthy’ meals It can be seen from Table 4 that the most common reason given for the choice of foods or dishes for the ‘preferred’ meal was that the food was liked or a ‘favourite’ food. Liking the taste or flavour, or the appearance (‘looks appealing’) were also frequently mentioned. Foods or dishes were also chosen for the ‘preferred’ meal because they were ‘healthy’ or ‘good for you’, and quite frequently because they were ‘convenient’, ‘quick’ or ‘easy to eat’, or could be ‘taken outside’. Some children chose items because they were ‘light’, ‘cold’ or ‘snack’ foods, often because they had a ‘main’ or ‘cooked meal’ at home in the evening. Other reasons for choice included being ‘filling’, combining well to form a meal, or habit, ‘have at home’. Liking the taste or flavour, and the dish being filling were more important reasons for boys than for girls, and girls were more likely than boys to choose a food or dish if they thought that it was ‘healthy’ or ‘good for you’. Healthy foods were, in some cases, encouraged by parents, in others health was ‘not an issue’. One of the most commonly given reasons for choice for the ‘healthy’ meal was that it was ‘healthy’ or ‘good for you’, without any further explanation. In some cases it was because it ‘looked healthy’ or they had been told it was healthy, by ‘teachers’ or ‘TV’. However, where more detailed reasons were given, only a few of the children recognised the ‘healthiness’ or nutritional value of the meal as a whole. This was described in terms of ‘balance’, ‘variety’, ‘covers different food groups’ or ‘got all the things that you need’. Mostly, the children saw the ‘healthiness’ of the meal as due to the presence of individual foods seen to be healthy, or specific nutrients. The presence of vegetables, fruit or salad, (‘have been told to eat vegetables’, ‘five portions of fruit and vegetables’) was frequently given as the reason for choice, more often by girls than boys. Milk or ‘dairy foods’, water, and potatoes were often mentioned as ‘healthy’ foods. The absence of fat, (‘low fat’, ‘not fatty’) and less commonly sugar, were also given as reasons for the choice of items. Some children saw the meal as healthy because it provided energy, and others because it was ‘low calorie’ or ‘not fattening’. The ‘nutritional value’ of the meal, or the presence of ‘nutrients’, particularly ‘vitamins’, but also protein, and minerals, particularly calcium (for ‘teeth’ and ‘bones’), were often given as reasons for choice. Despite seeing potatoes as ‘healthy’, only a small number of children mentioned the presence of carbohydrate as either the main reason or a subsidiary reason for the meal being healthy. Lack of additives, or being fresh or natural were also given as reasons for choice. Since the children most usually saw the ‘healthiness’ of the meal in terms of its individual components, the following section (Table 5) lists the foods with the
25 1 8
3
18
8
9
11 7
8 1
37 1 18
5
31
34
19
17 11
12 9
2
3
3 3
Variety Hot
1 1
2
6
Not fattening/on a diet Balance 2 2
1
4
4 8
6 4
10
26
13
2
12 0 10
quiche Water/drink Bread Cheese
sandwiches
rice
Chicken Potatoes
Vegetables ‘greens’ Mixed Vegetables Milk/‘dairy foods’ Tuna/fish meat
Salad
9 35 1 1
16
12
7 27
11 8
46
2
37
55
2 15 1 1
10
7
6 10
6 5
24
2
21
24
4 3 35
25
Total Boys (n ¼ 181) (n ¼ 87)
Healthy/good for 46 you Like taste/colour 13 Been told/healthy 6 Fruit 74
Taste/flavour Texture Appearance/ looks nice Goes together/ combination Convenient/ quick Healthy/good for you Cheap/good value Filling Have at home/ usual/habit Light/snack/cold Vegetarian
40
78
Likes/favourite
38
Reason
Total Boys (n ¼ 181) (n ¼ 87)
Reason
Girls (n ¼ 94)
‘Healthy’ meals
‘Preferred’ meals
7 20 0 0
6
5
1 17
5 3
22
0
16
31
9 3 39
21
Girls (n ¼ 94)
Not fattening/ low calorie Natural/fresh
Low sugar Balanced/ mixture Energy
Carbohydrate/ starch Fibre Low fat
Protein
Iron
Calcium
Nutrients/nut value Vitamins Vitamin C Minerals
Reason
Table 4 Numbers of pupils giving each different reason for their choice of items for the ‘preferred’ meals and the ‘healthy’ meals
8
13
19
20 14
9 52
12
28
4
24
61 7 15
11
4
2
10
16 8
4 30
5
18
4
11
25 6 8
5
Total Boys (n ¼ 181) (n ¼ 87)
4
11
9
4 6
5 22
7
10
0
13
36 1 7
6
Girls (n ¼ 94) C. Noble et al. / Hospitality Management 22 (2003) 197–215 209
2
0 2
Total
Boys Girls
Chicken fricasse
4 2 2
Total Boys Girls
0 0
Boys Girls
Sandwich
0
Total
Baked potato with tuna
5 66 3 2
3 6
Boys Girls
Total Total Boys Girls
9
Total
Mixed vegetables
Milk or water Beefburger
16 7 9
Total Boys Girls
Salad
20 10 10
Total Boys Girls
Fresh fruit
0 0
0
3 1 2
0 4
4
2 0 1 1
13 4
17
40 22 18
31 11 20
0 2
2
2 1 1
0 3
3
2 1 2 0
8 3
11
5 4 1
15 7 8
0 2
2
0 0 0
3 4
7
6 7 3 3
4 6
10
5 3 2
3 2 1
Healthy Low fat Nutrients Protein
Reasons for high ‘healthiness’ scores
0 1
1
0 0 0
0 1
1
4 7 2 2
8 14
22
34 17 17
52 22 30
0 0
0
0 0 0
0 0
0 0
0
0 0 0
0 0
0
18 22
2 2 0
40
0 0
0
0 0 0
0 0 0
4
4 2
6
19 7 12
16 6 10
0 0
0
0 0 0
0 0
0
9 6
15
0 0
0
0 0 0
0 0 0
Vitamins Natural Calcium Bones/ teeth Total Boys Girls
27 17 10
Sausages Total Boys Girls
8
35 18 17
0 0
0
41 25
22 25
47
2 6
Total
Total Boys Girls
Boys Girls
Total
Boys Girls
Boys Girls
Total
6 4 2
113 53 60
Boys Girls
Minicookie
Pizza
Can of drink
Crisps
Iced bun Total Boys Girls
Chips
Fat
0 0 0
9 9
18
0 0 0
24 30
54
0 0
0 0
0
63 32 31
0 0 0
Sugar
Reasons for low ‘healthiness’ scores
0 0 0
0 0
0
0 0 0
0 0
0
0 1
9 6
15
0 0 0
16 7 9
Salt
0 0 0
1 0
1
5 4 1
1 1
2
4 3
5 4
9
4 0 4
1 1 0
‘No goodness’
Table 5 Numbers of children (n ¼ 181) giving different reasons for high and low ‘healthiness’ scores for foods commonly served at school cafeterias
2 1 1
3 3
6
2 0 2
1 2
3
2 5
1 0
1
6 2 4
6 3 3
High calorie
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15 11 4
Total 22 Boys 11 Girls 11
Total 16 Boys 7 Girls 9
Total 14 Boys 1 Girls 13
Total 12 Boys 4 Girls 8
Total 12 Boys 5 Girls 7
Total 11 Boys 8 Girls 3
Total 10 Boys 4 Girls 6
Chips
Pizza
Sandwich
Fresh fruit
Iced bun
Beefburger
Crisps
6 5 1
11 7 4
6 5 1
5 2 3
3 3 0
13 10 3
14 11 3
Can of drink Total 28 Boys 13 Girls 15
7 4 3
0 0 0
0 0 0
1 0 1
3 0 3
3 2 1
1 0 1
4 2 2
12 7 5
8 7 1
2 0 2
0 0 0
17 4 13
5 3 2
10 5 5
7 3 4
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
37 28 9
0 0 0
1 1 0
0 0 0
13 3 10
15 4 11
2 1 1
0 0 0
0 0 0
0 0 0
0 0 0
10 5 5
0 0 0
0 0 0
0 0 0
0 0 0
2 1 1
2 0 2
1 1 0
0 0 0
5 1 4
3 3 0
1 1 0
2 2 0
8 4 4
Like Taste Cheap Easy Refreshing Healthy Sweet Habit to Eat
Reasons for high ‘likelihood to choose’ scores
Ham
Chicken fricasse
Mashed potato
Milk or water
Apple crumble
Mixed vegetables
Quiche
Total 11 Boys 5 Girls 6
Total 17 Boys 3 Girls 14
Total 19 Boys 6 Girls 13
Total 22 Boys 10 Girls 12
Total 27 Boys 13 Girls 14
Total 34 Boys 19 Girls 15
Total 40 Boys 24 Girls 16
Baked potato with tuna Total 44 Boys 28 Girls 16
2 0 2
1 0 1
12 7 5
0 0 0
1 0 1
3 1 2
4 0 4
0 0 0
7 3 4
2 0 2
4 2 2
7 2 5
2 1 1
6 3 3
5 3 2
1 1 0
1 1 0
7 2 5
1 0 1
0 0 0
0 0 0
7 3 4
3 1 2
3 1 2
1 1 0
6 5 1
1 1 0
0 0 0
4 2 2
5 3 2
2 2 0
2 2 0
Dislike Texture Taste Appearance Not easy to eat
Reasons for low ‘likelihood to choose’ scores
Table 6 Numbers of children (n ¼ 181) giving different reasons for high and low ‘preference’ scores for foods commonly served at school cafeterias
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highest and lowest scores for ‘healthiness’. An examination of the reasons given for these high and low scores will provide an idea of the accuracy of children’s perceptions of ‘healthy eating’. 3.4. Reasons for high and low ‘healthiness’ scores Fresh fruit, and mixed vegetables were accurately seen as low fat, salad was also perceived to be low in fat and therefore ‘healthy’ (Table 5). However, the plate of salad used for the photograph contained both coleslaw and potato salad, both of which are high in fat, relative to their energy content. Thus the common perception that salad is invariably a low fat dish can be misleading, and certainly was in this case. The most commonly given reason for the healthiness of these foods was the presence of vitamins. Salad and fresh fruit were also perceived to be healthy because they were ‘fresh’ or ‘natural’. Milk was perceived to be healthy because of the presence of calcium, which was recognised to be ‘good for bones and teeth’. Chips, crisps, beefburgers, sausages and pizza were all accurately seen to be high in fat, and thus perceived to be unhealthy. Iced buns, the can of drink, and mini-cookies seen to be high in sugar, again accurately, and thus perceived to be unhealthy. It is therefore clear that apart from seeing salad as a low fat food (in this case incorrectly) the children’s perceptions of the ‘healthiness’ of the different foods and dishes or otherwise are accurate. The following section therefore examines the reasons why children have in many cases, given those foods which they accurately perceive to be healthy, low ‘likelihood to choose’ scores and why they are more likely to choose those foods which they equally accurately perceive to be ‘unhealthy’. 3.5. Reasons for high and low ‘likelihood to choose’ scores Table 6 shows the foods given the highest and lowest scores for ‘likelihood to choose’ and the reasons given for these high and low scores. Liking the food or liking the taste was in almost all cases the reason most frequently given for high scores. Other reasons include ‘easy to eat’, particularly in the case of sandwiches, and the can of drink was most frequently chosen because it was ‘thirst quenching’ or ‘refreshing’. Sandwiches and fresh fruit were chosen because they were ‘healthy’ or ‘good for you’. ‘Habit’, ‘have at home’ or ‘what I usually have’ were also reasons given. Iced buns were chosen because they were sweet. The most frequently given reason for low ‘likelihood to choose’ scores were dislike of the food, or of the texture, in the case of mashed potato, or the taste, in the case of ham. The appearance of mixed vegetables and chicken fricassee were disliked. Other reasons included ‘not easy’ or ‘not convenient’ to eat.
4. Conclusions This study was carried out in secondary schools where children have a completely free choice of items from the cafeteria. It was found that the most important factors
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influencing their choice were taste and convenience. As a result of this, the gap between the nutritional value of the ‘healthy’ choices and the ‘favourite’ choices is as large as nutritionists have often feared. This is in contrast to children of primary school age (Noble et al., 2000). These findings have implications for caterers, who will need to take heed of the reasons why children like and choose particular foods. If the ‘favourite’ foods are those which are quick and easy to eat, and ‘fast’ foods are associated with pleasure, friends and independence, this is an opportunity for caterers to use their skills to present ‘healthy’ foods in a ‘fast’ form and ‘favourite’ foods in a ‘healthy’ form. For example, bread and potatoes contain starchy carbohydrates and other important nutrients and can be accompanied by foods of high nutrient density, to form a ‘healthy’ meal in a ‘fast’ form. Similarly, ‘favourite’ foods, such as beefburgers can also be served in a ‘healthy’ form by balancing the fat with sufficient carbohydrate, and adding salad ingredients to provide other important nutrients. This study also found that children’s awareness of ‘healthy eating’ and their nutritional knowledge of individual foods and dishes is mainly good. This knowledge is not being applied in practice, however. Those involved in nutrition education will also need to take heed of the reasons why children like and choose particular foods, and the beliefs that the children hold about the foods which they perceive to be healthy. This study revealed a number of misconceptions, e.g. the view that ‘healthy’ equates with ‘low calorie’. Also, the children did not seem to be aware that fatty foods in the diet need to be replaced by those containing starchy carbohydrates. Nutrition education should perhaps address these misconceptions and help children to get away from the idea of ‘healthy’ and ‘unhealthy’ foods. Instead, the aim should be to show children how to combine foods that they like and which are compatible with their lifestyles, in the right proportions to make up a healthy diet. The new guidelines for school meals, based on the ‘Balance of Good Health’ or ‘tilted plate’ model, could provide the initiative for the coming together in schools, of those involved in feeding the children and those responsible for their nutrition education. Although this model has been used for some time now, little of the existing data on either school meals or school children’s diets have been analysed in such a way that it can be compared with the model. Existing or new data on the various combinations of foods frequently served at school meals, and those foods which children commonly eat, need to be analysed to determine whether this model is applicable to the eating habits of children of this age.
Acknowledgements This study was funded by the Ministry of Agriculture, Fisheries, and Food as part of project A72, Nutritional Implications of Food Choices in Catering Outlets. The authors extend thanks to the Ministry for their support.
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