Validation of a self-completion measure of breakfast foods, snacks and fruits and vegetables consumed by 9- to 11-year-old schoolchildren

Comparison of School vs Home Breakfast Consumption with Cardiometabolic and Dietary Parameters in Low-Income, Multiracial/Ethnic Elementary School-Aged Children

BACKGROUND

Breakfast consumption is often associated with improving cardiometabolic parameters and diet quality. However, literature evaluating breakfast consumption with these outcomes between the school and home environments is limited.

OBJECTIVE

This study examined relationships between breakfast consumption locations (school vs home) and cardiometabolic parameters, breakfast dietary intake, and daily dietary intake.

DESIGN

This cross-sectional study used baseline data from TX Sprouts, a 1-year school-based gardening, nutrition, and cooking cluster-randomized trial, implemented in 16 elementary schools in Austin, TX, during 2016 to 2019.

PARTICIPANTS/SETTING

Analyses included 383 low-income, multiracial/ethnic elementary school-aged children (mean age = 9.2 years; 60.6% Hispanic; 70.5% free/reduced lunch; 58.5% home breakfast consumers).

MAIN OUTCOME MEASURES

Cardiometabolic parameters were obtained via fasting blood draws, and dietary intake was assessed using one 24-hour dietary recall conducted on a random, unannounced weekday. Cardiometabolic and dietary parameters (ie, energy intake, macronutrients, and food group servings) for breakfast and for the day were evaluated.

STATISTICAL ANALYSES PERFORMED

Multivariate analysis of covariance was performed to examine cardiometabolic parameters and dietary intake between school and home breakfasts.

RESULTS

School breakfast consumers (SBC) had lower fasting triglyceride levels than home breakfast consumers (HBC) (89.0 mg/dL vs 95.7 mg/dL; P = 0.03) (to convert to mmol/L, multiply by 0.0113). SBC had lower total fat for the day (P = 0.02) and lower total and saturated fat, sodium, and refined grains at breakfast (P ≤ 0.01) than HBC. However, SBC had lower protein at breakfast (P = 0.01) and higher carbohydrates, total sugar, and added sugar for the day and at breakfast (P ≤ 0.03) than HBC.

CONCLUSIONS

SBC compared with HBC had lower fat intake, which may have contributed to the lower triglyceride level observed in SBC, but also had lower protein intake at breakfast and higher added sugar intake for the day and at breakfast. These results suggest dietary intake differed between HBC and SBC; that is, the home and school environments, but more research is needed to evaluate if such differences are due to School Breakfast Program guidelines.

Measuring energy, macro and micronutrient intake in UK children and adolescents: a comparison of validated dietary assessment tools

Background

Measuring dietary intake in children and adolescents can be challenging due to misreporting, difficulties in establishing portion size and reliance on recording dietary data via proxy reporters. The aim of this review was to present results from a recent systematic review of reviews reporting and comparing validated dietary assessment tools used in younger populations in the UK.

Methods

Validation data for dietary assessment tools used in younger populations (≤18 years) were extracted and summarised using results from a systematic review of reviews of validated dietary assessment tools. Mean differences and Bland-Altman limits of agreement (LOA) between the test and reference tool were extracted or calculated and compared for energy, macronutrients and micronutrients.

Results

Seventeen studies which reported validation of 14 dietary assessment tools (DATs) were identified with relevant nutrition information. The most commonly validated nutrients were energy, carbohydrate, protein, fat, calcium, iron, folate and vitamin C. There were no validated DATs reporting assessment of zinc, iodine or selenium intake. The most frequently used reference method was the weighed food diary, followed by doubly labelled water and 24 h recall. Summary plots were created to facilitate comparison between tools. On average, the test tools reported higher mean intakes than the reference methods with some studies consistently reporting wide LOA. Out of the 14 DATs, absolute values for LOA and mean difference were obtained for 11 DATs for EI. From the 24 validation results assessing EI, 16 (67%) reported higher mean intakes than the reference. Of the seven (29%) validation studies using doubly labelled water (DLW) as the reference, results for the test DATs were not substantially better or worse than those using other reference measures. Further information on the studies from this review is available on the www.nutritools.org website.

Conclusions

Validated dietary assessment tools for use with children and adolescents in the UK have been identified and compared. Whilst tools are generally validated for macronutrient intakes, micronutrients are poorly evaluated. Validation studies that include estimates of zinc, selenium, dietary fibre, sugars and sodium are needed.

A systematic review of reviews identifying UK validated dietary assessment tools for inclusion on an interactive guided website for researchers: www.nutritools.org

Background: Health researchers may struggle to choose suitable validated dietary assessment tools (DATs) for their target population. The aim of this review was to identify and collate information on validated UK DATs and validation studies for inclusion on a website to support researchers to choose appropriate DATs.Design: A systematic review of reviews of DATs was undertaken. DATs validated in UK populations were extracted from the studies identified. A searchable website was designed to display these data. Additionally, mean differences and limits of agreement between test and comparison methods were summarized by a method, weighting by sample size.Results: Over 900 validation results covering 5 life stages, 18 nutrients, 6 dietary assessment methods, and 9 validation method types were extracted from 63 validated DATs which were identified from 68 reviews. These were incorporated into www.nutritools.org. Limits of agreement were determined for about half of validations. Thirty four DATs were FFQs. Only 17 DATs were validated against biomarkers, and only 19 DATs were validated in infant/children/adolescents.Conclusions: The interactive www.nutritools.org website holds extensive validation data identified from this review and can be used to guide researchers to critically compare and choose a suitable DAT for their research question, leading to improvement of nutritional epidemiology research.

A cluster randomised controlled trial of an intervention based on the Health Action Process Approach for increasing fruit and vegetable consumption in Iranian adolescents

OBJECTIVE

To evaluate an intervention programme based on the Health Action Process Approach and designed to increase the intake of fruit and vegetables (F&V) among Iranian adolescents aged 13 to 18.

DESIGN

A randomised controlled trial with three arms examined the short- (1 month) and long-term (6 months) effects of the intervention. There were two intervention groups (one included adolescents only [A group; n = 510]; the second included mothers and adolescents [M + A group; n = 462]) and a control group (n = 483). All participants were recruited from schools.

MAIN OUTCOME MEASURES

Social cognitions, self-regulatory processes and F&V intake.

RESULTS

The intervention led to an increase in F&V intake for adolescents in the short and long terms. Adolescents in the M + A group increased their F& V intake more than adolescents in the A group. Outcome expectancies, self-monitoring, intentions, action and coping planning, perceived social support and behavioural automaticity mediated the effect of the intervention on F&V intake.

CONCLUSION

The theory-based intervention led to an increase in F&V intake and promoted more positive social cognitions and self-regulatory processes among Iranian adolescents. The findings also provide evidence that involving mothers in an intervention can confer additional benefit.

Active for Life Year 5: a cluster randomised controlled trial of a primary school-based intervention to increase levels of physical activity, decrease sedentary behaviour and improve diet

Background

Previous studies of the effect of school-based interventions to improve healthy behaviours have had important limitations.

Objective

To investigate the effectiveness of a school-based intervention to increase physical activity, reduce sedentary behaviour and increase fruit and vegetable consumption.

Design

Cluster randomised controlled trial.

Setting

Sixty English primary schools.

Participants

Children in year 4 (aged 8–9 years) at recruitment, year 5 (aged 9–10 years) during the intervention and immediate follow-up and year 6 (aged 10–11 years) during 1 year of follow-up.

Intervention

Active for Life Year 5 (AFLY5) included teacher training, lesson plans, materials for 16 lessons, parent-interactive homework and written materials for school newsletters and parents.

Main outcome measures

Primary outcome measures included accelerometer-assessed levels of physical activity and sedentary behaviour, and child-reported consumption of fruit and vegetables. Secondary outcome measures included child-reported screen viewing; consumption of snacks, high-fat food and high-energy drinks; body mass index; and waist circumference.

Results

We recruited 60 schools (2221 children). At the immediate follow-up, no difference was found between children in intervention and control schools for any of the three primary outcomes. The intervention was effective on three of the nine secondary outcomes; children in intervention schools reported spending less time screen viewing at weekends [–21 minutes per day, 95% confidence interval (CI) –37 to –4 minutes per day], eating fewer servings of snacks per day (–0.22, 95% CI –0.38 to –0.05 servings of snacks per day) and drinking fewer servings of high-energy drinks per day (–0.26, 95% CI –0.43 to –0.10 servings of high-energy drinks per day) than the children in control schools. The results remained consistent 1 year later. The intervention increased children’s perception of maternal efforts to limit the time they spent screen viewing and children’s knowledge about healthy physical activity and fruit and vegetable consumption, with these two mediators explaining approximately one-quarter of the effect of the intervention on screen viewing. The intervention did not affect other mediators. The cost of implementing the intervention from a provider perspective was approximately £18 per child. Process evaluation showed that AFLY5 was implemented with a high degree of fidelity. Teachers supported the aims of AFLY5, but their views of the programme itself were mixed.

Limitations

Responses to parental questionnaires for the economic evaluation were low and we struggled to engage all teachers for the process evaluation. Although the participating schools included a range of levels of socioeconomic deprivation, class sizes and rural and urban settings, we cannot assume that results generalise to all primary schools.

Conclusions

AFLY5 is not effective at increasing levels of physical activity, reducing sedentary behaviour and increasing fruit and vegetable consumption in primary school children, but may be effective in reducing time spent screen viewing at weekends and the consumption of snacks and high-energy drinks.

Future work

Our findings suggest that school-based interventions are unlikely to have a major impact on promoting healthy levels of physical activity and healthy diets in primary school children. We would recommend trials of the effect and cost-effectiveness of more intensive family and community interventions.

Trial registration

Current Controlled Trials ISRCTN50133740.

Funding

This project was funded by the National Institute for Health Research Public Health Research programme and will be published in full inPublic Health Research; Vol. 4, No. 7. See the NIHR Journals Library website for further project information.

Children's school-breakfast reports and school-lunch reports (in 24-h dietary recalls): conventional and reporting-error-sensitive measures show inconsistent accuracy results for retention interval and breakfast location

Validation-study data were analysed to investigate retention interval (RI) and prompt effects on the accuracy of fourth-grade children's reports of school-breakfast and school-lunch (in 24-h recalls), and the accuracy of school-breakfast reports by breakfast location (classroom; cafeteria). Randomly selected fourth-grade children at ten schools in four districts were observed eating school-provided breakfast and lunch, and were interviewed under one of eight conditions created by crossing two RIs ('short'--prior-24-hour recall obtained in the afternoon and 'long'--previous-day recall obtained in the morning) with four prompts ('forward'--distant to recent, 'meal name'--breakfast, etc., 'open'--no instructions, and 'reverse'--recent to distant). Each condition had sixty children (half were girls). Of 480 children, 355 and 409 reported meals satisfying criteria for reports of school-breakfast and school-lunch, respectively. For breakfast and lunch separately, a conventional measure--report rate--and reporting-error-sensitive measures--correspondence rate and inflation ratio--were calculated for energy per meal-reporting child. Correspondence rate and inflation ratio--but not report rate--showed better accuracy for school-breakfast and school-lunch reports with the short RI than with the long RI; this pattern was not found for some prompts for each sex. Correspondence rate and inflation ratio showed better school-breakfast report accuracy for the classroom than for cafeteria location for each prompt, but report rate showed the opposite. For each RI, correspondence rate and inflation ratio showed better accuracy for lunch than for breakfast, but report rate showed the opposite. When choosing RI and prompts for recalls, researchers and practitioners should select a short RI to maximise accuracy. Recommendations for prompt selections are less clear. As report rates distort validation-study accuracy conclusions, reporting-error-sensitive measures are recommended.

Association between breakfast consumption and educational outcomes in 9-11-year-old children

Objective

Breakfast consumption has been consistently associated with health outcomes and cognitive functioning in schoolchildren. Evidence of direct links with educational outcomes remains equivocal. We aimed to examine the link between breakfast consumption in 9–11-year-old children and educational outcomes obtained 6–18 months later.

Design

Data on individual-level free school meal entitlement and educational outcomes (Statutory Assessment Tests (SATs) at Key Stage 2) were obtained via the SAIL databank and linked to earlier data collected on breakfast consumption. Multilevel modelling assessed associations between breakfast consumption and SATs.

Setting

Trial of the Primary School Free Breakfast Initiative in Wales.

Subjects

Year 5 and 6 students, n 3093 (baseline) and n 3055 (follow-up).

Results

Significant associations were found between all dietary behaviours and better performance in SATs, adjusted for gender and individual- and school-level free school meal entitlement (OR=1·95; CI 1·58, 2·40 for breakfast, OR=1·08; CI 1·04, 1·13 for healthy breakfast items). No association was observed between number of unhealthy breakfast items consumed and educational performance. Association of breakfast consumption with educational performance was stronger where the measure of breakfast consumption was more proximal to SATs tests (OR=2·02 measured 6 months prior to SATs, OR=1·61 measured 18 months prior).

Conclusions

Significant positive associations between self-reported breakfast consumption and educational outcomes were observed. Future research should aim to explore the mechanisms by which breakfast consumption and educational outcomes are linked, and understand how to promote breakfast consumption among schoolchildren. Communicating findings of educational benefits to schools may help to enhance buy-in to efforts to improve health behaviours of pupils.

Effectiveness of Prompts on Fourth-Grade Children's Dietary Recall Accuracy Depends on Retention Interval and Varies by Gender

BACKGROUND

Dietary recall accuracy is related to retention interval (RI) (i.e., time between to-be-reported meals and the interview), and possibly to prompts. To the best of our knowledge, no study has evaluated their combined effect.

OBJECTIVE

The combined influence of RI and prompts on children's recall accuracy was investigated in this study. Two RIs [short (prior-24-h recall obtained in afternoon) and long (previous-day recall obtained in morning)] were crossed with 4 prompts [forward (distant-to-recent), meal-name (breakfast, lunch, etc.), open (no instructions), and reverse (recent-to-distant)], creating 8 conditions.

METHODS

Fourth-grade children (n = 480; 50% girls) were randomly selected from consenting children at 10 schools in 4 districts in a southern state during 3 school years (2011-2012, 2012-2013, and 2013-2014). Each child was observed eating school-provided breakfast and lunch, and interviewed one time under 1 of the 8 conditions. Condition assignment was constrained so that each had 60 children (30 girls). Accuracy measures were food-item omission and intrusion rates, and energy correspondence rate and inflation ratio. For each measure, linear models determined effects of RI, prompt, gender, and interactions (2-way, 3-way); race/ethnicity, school year, and district were control variables.

RESULTS

RI (P values < 0.015) and prompt (P values < 0.005) were significant for all 4 accuracy measures. RI × prompt (P values < 0.001) was significant for 3 accuracy measures (not intrusion rate). Prompt × gender (P = 0.005) was significant for omission rate. RI × prompt × gender was significant for intrusion rate and inflation ratio (P values < 0.001). For the short vs. long RI across prompts and genders, accuracy was better by 33-50% for each accuracy measure.

CONCLUSIONS

To obtain the most accurate recalls possible from children, studies should be designed to use a short rather than long RI. Prompts affect children's recall accuracy, although the effectiveness of different prompts depends on RI and varies by gender: at a short RI, the choice of prompts has little systematic effect on accuracy, whereas at a long RI, reverse prompts may elicit the most accurate recalls.

Validation of 2 Brief Fruit and Vegetable Assessment Instruments Among Third-Grade Students

OBJECTIVE

To evaluate the validity of 2 brief instruments to estimate fruit and vegetable (FV) intake among third-grade children.

METHODS

Children from an elementary school and a community center (n = 107) completed 2 retrospective questions for FV intake (fruit and vegetable questionnaire [FVQ]) and a food record (A Day in the Life Questionnaire [DILQ]) to estimate FV intake. Agreement between intake based on these instruments and 3 24-hour dietary recalls was determined.

RESULTS

Disattenuated Pearson correlation coefficients ranged from 0.40 to 0.69 for FV intake; however, the low reliability of multiple 24-hour recalls may have inflated the strength of the correlations. Altman-Bland difference plots suggested that the FVQ overestimated FV intake whereas the DILQ overestimated fruit and underestimated vegetable intake. Limits of agreement were wide for both tools, indicating poor overall agreement.

CONCLUSIONS AND IMPLICATIONS

The FVQ and DILQ were not valid instruments to evaluate FV consumption under current study conditions. Other assessment methods and instruments should be considered for young children.

More than Just a Meal: Breakfast Club Attendance and Children's Social Relationships

The health benefits of school food have been widely promoted in recent years while the social opportunities that surround eating occasions at school have received little attention. Breakfast clubs (BCs), which take place at the start of the school day, offer a unique opportunity for children to consume a breakfast meal on their school premises in the company of their peers. Alternatively, after-school clubs (ASCs), which take place on school premises at the end of the school day, whilst also providing children with social opportunities tend to focus on sports engagement and skill development. The aim of the current paper is to investigate whether attendance at BCs and ASCs has an impact on children's friendship quality and experiences of peer victimization. BC attendees, ASC attendees, and non-attendees completed the Friendship Qualities Scale and the Multidimensional Peer Victimization Scale (MPVS) at two time points. Time-1 data were collected 2 months after the introduction of school clubs. Time-2 data were then collected on the same measures again 6 months later. Results of the analyses of Time-1 data showed no significant differences between groups on any of the measures at Time-1. However, at Time-2, BC attendees showed improved levels of friendship quality compared to the other two groups. Moreover, analysis of the MPVS data at Time-2 showed that children who attended BC or ASC experienced a decline in victimization across time. The current findings suggest that BC attendance facilitates the quality of children's relationships with their best friend over time. Additionally, attendance at a breakfast or ASC was associated with a reduction in victimization over time. The results have implications for utilization of breakfast and ASCs to aid children's social relationships in school over time.

A validation study concerning the effects of interview content, retention interval, and grade on children's recall accuracy for dietary intake and/or physical activity

BACKGROUND

Practitioners and researchers are interested in assessing children's dietary intake and physical activity together to maximize resources and minimize subject burden.

OBJECTIVE

Our aim was to investigate differences in dietary and/or physical activity recall accuracy by content (diet only; physical activity only; diet and physical activity), retention interval (same-day recalls in the afternoon; previous-day recalls in the morning), and grade (third; fifth).

DESIGN

Children (n=144; 66% African American, 13% white, 12% Hispanic, 9% other; 50% girls) from four schools were randomly selected for interviews about one of three contents. Each content group was equally divided by retention interval, each equally divided by grade, each equally divided by sex. Information concerning diet and physical activity at school was validated with school-provided breakfast and lunch observations, and accelerometry, respectively. Dietary accuracy measures were food-item omission and intrusion rates, and kilocalorie correspondence rate and inflation ratio. Physical activity accuracy measures were absolute and arithmetic differences for moderate to vigorous physical activity minutes.

STATISTICAL ANALYSES PERFORMED

For each accuracy measure, linear models determined effects of content, retention interval, grade, and their two-way and three-way interactions; ethnicity and sex were control variables.

RESULTS

Content was significant within four interactions: intrusion rate (content×retention-interval×grade; P=0.0004), correspondence rate (content×grade; P=0.0004), inflation ratio (content×grade; P=0.0104), and arithmetic difference (content×retention-interval×grade; P=0.0070). Retention interval was significant for correspondence rate (P=0.0004), inflation ratio (P=0.0014), and three interactions: omission rate (retention-interval×grade; P=0.0095), intrusion rate, and arithmetic difference (both already mentioned). Grade was significant for absolute difference (P=0.0233) and five interactions mentioned. Content effects depended on other factors. Grade effects were mixed. Dietary accuracy was better with same-day than previous-day retention interval.

CONCLUSIONS

Results do not support integrating dietary intake and physical activity in children's recalls, but do support using shorter rather than longer retention intervals to yield more accurate dietary recalls. Additional validation studies need to clarify age effects and identify evidence-based practices to improve children's accuracy for recalling dietary intake and/or physical activity.

Effect of intervention aimed at increasing physical activity, reducing sedentary behaviour, and increasing fruit and vegetable consumption in children: active for Life Year 5 (AFLY5) school based cluster randomised controlled trial

OBJECTIVE

To investigate the effectiveness of a school based intervention to increase physical activity, reduce sedentary behaviour, and increase fruit and vegetable consumption in children.

DESIGN

Cluster randomised controlled trial.

SETTING

60 primary schools in the south west of England.

PARTICIPANTS

Primary school children who were in school year 4 (age 8-9 years) at recruitment and baseline assessment, in year 5 during the intervention, and at the end of year 5 (age 9-10) at follow-up assessment.

INTERVENTION

The Active for Life Year 5 (AFLY5) intervention consisted of teacher training, provision of lesson and child-parent interactive homework plans, all materials required for lessons and homework, and written materials for school newsletters and parents. The intervention was delivered when children were in school year 5 (age 9-10 years). Schools allocated to control received standard teaching.

MAIN OUTCOME MEASURES

The pre-specified primary outcomes were accelerometer assessed minutes of moderate to vigorous physical activity per day, accelerometer assessed minutes of sedentary behaviour per day, and reported daily consumption of servings of fruit and vegetables.

RESULTS

60 schools with more than 2221 children were recruited; valid data were available for fruit and vegetable consumption for 2121 children, for accelerometer assessed physical activity and sedentary behaviour for 1252 children, and for secondary outcomes for between 1825 and 2212 children for the main analyses. None of the three primary outcomes differed between children in schools allocated to the AFLY5 intervention and those allocated to the control group. The difference in means comparing the intervention group with the control group was -1.35 (95% confidence interval -5.29 to 2.59) minutes per day for moderate to vigorous physical activity, -0.11 (-9.71 to 9.49) minutes per day for sedentary behaviour, and 0.08 (-0.12 to 0.28) servings per day for fruit and vegetable consumption. The intervention was effective for three out of nine of the secondary outcomes after multiple testing was taken into account: self reported time spent in screen viewing at the weekend (-21 (-37 to -4) minutes per day), self reported servings of snacks per day (-0.22 (-0.38 to -0.05)), and servings of high energy drinks per day (-0.26 (-0.43 to -0.10)) were all reduced. Results from a series of sensitivity analyses testing different assumptions about missing data and from per protocol analyses produced similar results.

CONCLUSION

The findings suggest that the AFLY5 school based intervention is not effective at increasing levels of physical activity, decreasing sedentary behaviour, and increasing fruit and vegetable consumption in primary school children. Change in these activities may require more intensive behavioural interventions with children or upstream interventions at the family and societal level, as well as at the school environment level. These findings have relevance for researchers, policy makers, public health practitioners, and doctors who are involved in health promotion, policy making, and commissioning services. Trial registration Current Controlled Trials ISRCTN50133740.

Impacts of the Primary School Free Breakfast Initiative on socio-economic inequalities in breakfast consumption among 9-11-year-old schoolchildren in Wales

Objectives

Universal interventions may widen or narrow inequalities if disproportionately effective among higher or lower socio-economic groups. The present paper examines impacts of the Primary School Free Breakfast Initiative in Wales on inequalities in children's dietary behaviours and cognitive functioning.

Design

Cluster-randomised controlled trial. Responses were linked to free school meal (FSM) entitlement via the Secure Anonymised Information Linkage databank. Impacts on inequalities were evaluated using weighted school-level regression models with interaction terms for intervention × whole-school percentage FSM entitlement and intervention × aggregated individual FSM entitlement. Individual-level regression models included interaction terms for intervention × individual FSM entitlement.

Setting

Fifty-five intervention and fifty-six wait-list control primary schools.

Subjects

Approximately 4500 children completed measures of dietary behaviours and cognitive tests at baseline and 12-month follow-up.

Results

School-level models indicated that children in intervention schools ate a greater number of healthy items for breakfast than children in control schools (b = 0·25; 95 % CI 0·07, 0·44), with larger increases observed in more deprived schools (interaction term b = 1·76; 95 % CI 0·36, 3·16). An interaction between intervention and household-level deprivation was not significant. Despite no main effects on breakfast skipping, a significant interaction was observed, indicating declines in breakfast skipping in more deprived schools (interaction term b = −0·07; 95 % CI −0·15, −0·00) and households (OR = 0·67; 95 % CI 0·46, 0·98). No significant influence on inequality was observed for the remaining outcomes.

Conclusions

Universal breakfast provision may reduce socio-economic inequalities in consumption of healthy breakfast items and breakfast skipping. There was no evidence of intervention-generated inequalities in any outcomes.

A pilot study of the effects of interview content, retention interval, and grade on accuracy of dietary information from children

OBJECTIVE

Investigate differences in dietary recall accuracy by interview content (diet only or diet and physical activity), retention interval (same day or previous day), and grade (third or fifth).

METHODS

Thirty-two children observed eating school-provided meals and interviewed once each; interview content and retention interval randomly assigned. Multivariate analysis of variance on rates for omissions (foods observed but unreported) and intrusions (foods reported but unobserved); independent variables: interview content, retention interval, grade.

RESULTS

Accuracy differed by retention interval (P = .05; better for same day [omission rate, intrusion rate: 28%, 20%] than previous day [54%, 45%]) but not interview content (P > .48; diet only: 41%, 33%; diet and physical activity: 41%, 33%) or grade (P > .27; third: 48%, 42%; fifth: 34%, 24%).

CONCLUSIONS AND IMPLICATIONS

Although the small sample limits firm conclusions, results provide evidence-based direction to enhance accuracy: specifically, to shorten the retention interval. Larger validation studies need to investigate the combined effect of interview content, retention interval, and grade on accuracy.

Food sustainability education as a route to healthier eating: evaluation of a multi-component school programme in English primary schools

Promising approaches to the promotion of healthier eating among children in primary school settings include the opportunity to practise practical cooking and growing, promoting the take up of healthier school meals and nutritional education. However, less is known about the potential for strategies that integrate approaches through a focus on food sustainability issues--such as the promotion of awareness about local, seasonal, organic, fair trade and higher animal welfare foods. This paper presents an evaluation of the Food for Life Partnership, a multi-component programme that sought to address both the health and sustainability aspects of food. The study consisted of a two-stage cross-sectional survey of Years 5 and 6 students (ages 9-11) in 30 primary schools at enrolment and after 18-24 months, combined with an analysis of programme delivery. Higher self-reported fruit and vegetable consumption in the second stage survey was associated with a range of indicators of school participation in the programme. These included the reform of school meal procurement and preparation; experiential food growing, cooking and farm-based education and improved opportunities for stakeholder engagement. The study therefore develops a case for multilevel programmes that incorporate sustainability issues alongside experiential food education in primary school settings.

Validation of food diaries as measures of dietary behaviour change

This study aimed to validate the ability of a 24-h food diary (the DIET-24) to accurately detect change in children's fruit and vegetable consumption at school snack time following implementation of the Food Dudes healthy eating intervention. Participants were 4- to 9-year-old children from two primary schools in England. There were 148 participants in the intervention school and 43 participants in the no intervention control school. For each child, snack-time fruit and vegetable consumption was measured separately by weight (grammes), and compared with teachers' estimates (to the nearest half portion) using the DIET-24. Both consumption measures were taken at T1 (pre-intervention) and T2 (post-intervention). At each time-point, Spearman rank correlations between the two measures were low to moderate, but significant. However, when compared with weighed measures, the DIET-24 did not always accurately detect significant changes in children's fruit and vegetable consumption following the intervention. To provide sensitive measures of behaviour change, it is important that dietary measures assess as accurately as possible the amount of food consumed, rather than, as is often the case, rely on all-or-none portion estimates. This issue is important for the establishment of a reliable evidence-base for healthy eating interventions.

Relative validation of the KiGGS Food Frequency Questionnaire among adolescents in Germany

BACKGROUND

The aim of this study was to determine the relative validity of the self-administered Food Frequency Questionnaire (FFQ) "What do you eat?", which was used in the German National Health Interview and Examination Survey for Children and Adolescents (KiGGS 2003-2006).

METHODS

The validation was conducted in the EsKiMo Nutrition Module, a subsample of KiGGS. The study population included 1,213 adolescents aged between 12 and 17. A modified diet history interview DISHES (Dietary Interview Software for Health Examination Studies) was used as the reference method. In order to compare the food groups, the data assessed with both instruments were aggregated to 40 similar food groups. The statistical analysis included calculating and comparing Spearman's correlation coefficients, calculating the mean difference between both methods, and ranking participants (quartiles) according to food group consumption, including weighted kappa coefficients. Correlations were also evaluated for relative body weight and socioeconomic status subgroups.

RESULTS

In the total study population the Spearman correlation coefficients ranged from 0.22 for pasta/rice to 0.69 for margarine; most values were 0.50 and higher. The mean difference ranged between 1.4% for milk and 100.3% for pasta/rice. The 2.5 percentiles and 97.5 percentiles indicated a wide range of differences. Classifications in the same and adjacent quartile varied between 70.1% for pasta/rice and 90.8% for coffee. For most groups, Cohen's weighted kappa showed values between 0.21 and 0.60. Only for white bread and pasta/rice were values less than 0.20. Most of the 40 food groups showed acceptable to good correlations in all investigated subgroups concerning age, sex, body weight and socio-economic status.

CONCLUSIONS

The KiGGS FFQ showed fair to moderate ranking validity except for pasta/rice and white bread. However, the ability to assess absolute intakes is limited. The correlation coefficients for most food items were similar for normal weight and overweight as well as for different socio-economic status groups. Overall, the results of the relative validity were comparable to FFQs from the current literature.

The Active for Life Year 5 (AFLY5) school based cluster randomised controlled trial: study protocol for a randomized controlled trial

Background

Low levels of physical activity, high levels of sedentary behaviour and low levels of fruit and vegetable consumption are common in children and are associated with adverse health outcomes. The aim of this paper is to describe the protocol for a cluster randomised controlled trial (RCT) designed to evaluate a school-based intervention that aims to increase levels of physical activity, decrease sedentary behaviour and increase consumption of fruit and vegetables in school children.

Methods/design

The Active for Life Year 5 (AFLY5) study is a school-based, cluster RCT that targets school children in Year 5 (age 9-10 years). All state junior/primary schools in the area covered by Bristol City and North Somerset Council are invited to participate; special schools are excluded. Eligible schools are randomised to one of two arms: intervention arm (receive the intervention 2011-2012) and control arm (receive the intervention after the final follow-up assessment, 2013-2014). The primary outcomes of the trial are levels of accelerometer assessed physical activity and sedentary behaviour and questionnaire assessed fruit and vegetable consumption. A number of secondary outcomes will also be measured, including body mass index, waist circumference and overweight/obesity. Outcomes will be assessed at baseline (prior to intervention when the children are in Year 4), at the end of intervention 'immediate follow-up' and '12 months long-term' follow-up. We will use random effects linear and logistic regression models to compare outcomes by randomised arm. The economic evaluation from a societal perspective will take the form of a cost consequence analysis. Data from focus groups and interviews with pupils, parents and teachers will be used to increase understanding of how the intervention has any effect and is integrated into normal school activity.

Discussion

The results of the trial will provide information about the public health effectiveness of a school-based intervention aimed at improving levels of physical activity, sedentary behaviour and diet in children.

Trial registration

ISRCTN50133740

Validation of a group-administered pictorial dietary recall with 9- to 11-year-old children

OBJECTIVE

Determine validity of Day in the Life Questionnaire-Colorado (DILQ-CO) as a dietary assessment tool for classroom-administered use.

METHODS

Agreement between DILQ-CO responses and weighed plate waste measured in 125 fourth-grade students in 2 low-income schools. Validity assessed by comparing reported school lunch items and portion size estimations on DILQ-CO to plate waste. Agreement calculated using Spearman correlations, κ statistic, percent agreement, exclusions, intrusions, and mismatches.

RESULTS

Substantial-to-almost-perfect agreements for students' reports of food eaten in all but the dessert category (κ coefficients: 0.65-0.97; 81%-99% matches). Significant correlations (P ≤ .05) were found between students' reports of how much was eaten and plate waste measurements for 6 of 10 items; agreement ranged from 47%-82%.

CONCLUSIONS AND IMPLICATIONS

Classroom-administered DILQ-CO provided a valid measure of reported school lunch items, with amounts reported eaten of lower but still acceptable agreement. This tool shows promise as a group-administered dietary recall with children.

The reliability and validity of a short FFQ among Australian Aboriginal and Torres Strait Islander and non-Indigenous rural children

OBJECTIVE

To determine the reproducibility and validity of a short FFQ (SFFQ) for Australian rural children aged 10 to 12 years, particularly Aboriginal and Torres Strait Islander children.

DESIGN

In this cross-sectional study participants completed the SFFQ on two occasions and three 24 h recalls. Concurrent validity was established by comparing results of the first SFFQ against food recalls; reproducibility was established by comparing the two SFFQ.

SETTING

The north coast of New South Wales in the Australian summer of late 2005.

SUBJECTS

Two hundred and forty-one children (ninety-two Aboriginal and Torres Strait Islander children and 100 boys) completed two SFFQ and were included in the reproducibility study; of these, 205 participants with a mean age of 10·8 (sd 0·7) years took part in the validity study.

RESULTS

The SFFQ showed moderate to good reproducibility among all children with kappa coefficients for repeated measures between 0·41 and 0·80. Eighteen of twenty-three questions demonstrated good validity against the mean of the 24 h recalls, with statistically significant increasing trends (P ≤ 0·05) for mean daily weight and/or frequency as survey response categories increased. A similar number of short questions showed good validity for Aboriginal and Torres Strait Islander children as for their non-Indigenous counterparts.

CONCLUSIONS

Many short questions in this SFFQ are able to discriminate between different categories of food intake and provide information on relative intake within the given population. They can be used to monitor and/or evaluate population-wide health programmes, including those with rural Aboriginal and Torres Strait Islander children.

Free healthy breakfasts in primary schools: a cluster randomised controlled trial of a policy intervention in Wales, UK

Objective

The present study evaluated the impact of a national school programme of universal free healthy breakfast provision in Wales, UK.

Design

A cluster randomised controlled trial with repeated cross-sectional design and a 12-month follow-up. Primary outcomes were breakfast skipping, breakfast diet and episodic memory. Secondary outcomes were frequency of eating breakfast at home and at school, breakfast attitudes, rest-of-day diet and class behaviour.

Setting

Primary schools in nine local education authority areas.

Subjects

A total of 4350 students (aged 9–11 years) at baseline and 4472 at follow-up in 111 schools.

Results

Students in intervention schools reported significantly higher numbers of healthy food items consumed at breakfast and more positive attitudes towards breakfast eating at 12 months. Parents in intervention schools reported significantly higher rates of consumption of breakfast at school and correspondingly lower rates of breakfast consumption at home. No other significant differences were found.

Conclusions

The intervention did not reduce breakfast skipping; rather, pupils substituted breakfast at home for breakfast at school. However, there were improvements in children’s nutritional intake at breakfast time, if not the rest of the day, and more positive attitudes to breakfast, which may have implications for life-course dietary behaviours. There was no impact on episodic memory or classroom behaviour, which may require targeting breakfast skippers.

Diet outcomes of a pilot school-based randomised controlled obesity prevention study with 9-10 year olds in England

OBJECTIVES

To assess the effect of a US obesity prevention intervention on dietary outcomes in English 9-10 year old children in 2006.

METHODS

A pilot cluster randomised controlled trial in 19 schools with children aged 9 to 10 with lessons taught by teachers. Diet was assessed at baseline and 5 months later using questionnaires. Full intention-to-treat analysis (n=506) and analyses using only those with complete baseline and follow-up data (n=393).

RESULTS

8.5% of children ate 5 or more portions of fruit and vegetables per day. The odds of eating healthy amounts of fruit and vegetables (OR 1.39 (95%CI: 0.69, 2.80)) and snacks (OR 1.22 (95%CI: 0.68, 2.21)) were greater in children from the intervention compared to control schools. Point estimates were less than one for consumption of no portions of high fat food and one or zero high energy drinks. A full-scale trial would require 2640 children (106 schools) with 80% power to detect an odds ratio of at least 1.30 for healthy levels of consumption for the four dietary outcomes, with an alpha level of 0.01.

CONCLUSIONS

The US intervention can be transferred to England and it might be effective in increasing fruit and vegetable consumption and decreasing snacks.

Total daily water intake in Guatemalan children

BACKGROUND

Water is an essential nutrient, but recommendations for total water requirements only emerged in 2005, in the context of estimated average population targets in the Dietary Reference Intakes (DRIs) for US and Canadian societies.

OBJECTIVE

To assess total daily water acquisition, and the contribution of water acquired from all possible sources, among Guatemalan children.

METHODS

A total of 449 urban Guatemalan schoolchildren, aged 8 to 11 years, evenly divided between two socioeconomic strata, completed a 1-day pictorial registry of all foods and beverages consumed. Estimated energy intake, total water intake, and the contributions of water from drinking water, beverages, intrinsic and extrinsic water in foods, and the oxidation of macronutrients were assessed.

RESULTS

The contribution of water from the examined water sources was 8% for drinking water, 49% for beverages, 29% for all foods, and 14% for metabolism of macronutrients, with only slight variance across sexes and social class. The average total daily water acquisition was 1,841 +/- 572 mL for boys and 1,834 +/- 484 mL for girls, which fall short of the North American DRI recommendations of 2.4 and 2.1 L, respectively There was correspondingly lower average consumption of dietary liquids.

CONCLUSIONS

Foods play an important role in the acquisition of water from their hydration and metabolic oxidation, contributing 43.8% of the daily supply to these children. There is still a calculated shortfall of daily water acquisition, as compared with the DRI recommendations, which could be overcome by greater intake of plain water and low-energy fresh produce.

Dietary intakes and food sources of fat and fatty acids in Guatemalan schoolchildren: a cross-sectional study

BACKGROUND

Consumption of healthy diets that contribute with adequate amounts of fat and fatty acids is needed for children. Among Guatemalan children, there is little information about fat intakes. Therefore, the present study sought to assess intakes of dietary fats and examine food sources of those fats in Guatemalan children.

METHODS

The study subjects consisted of a convenience sample of 449 third- and fourth-grade schoolchildren (8-10 y), attending public or private schools in Quetzaltenango City, Guatemala. Dietary data was obtained by means of a single pictorial 24-h record.

RESULTS

The percentages of total energy (%E) from total fat, saturated fat (SFA) and monounsaturated fat (MUFA) reached 29%E for total fat and 10%E for each SFA and MUFA, without gender differences. %E from fats in high vs. low-socio economic status (SES) children were significantly higher for boys, but not for girls, for total fat (p = 0.002) and SFA (p < 0.001). Large proportions of the children had low levels of intakes of some fatty acids (FA), particularly for n-3 FA, with >97% of all groups consuming less than 1%E from this fats. Fried eggs, sweet rolls, whole milk and cheese were main sources of total fat and, SFA. Whole milk and sweet bread were important sources of n-3 FA for high- and low-SES boys and girls, respectively. Fried plantain was the main source of n-3 FA for girls in the high-SES group. Fried fish, seafood soup, and shrimp, consumed only by boys in low amounts, were sources of eicosapentaenoic (EPA) and docosahexaenoic (DHA) acids, which may explain the low intakes of these nutrients.

CONCLUSIONS

alpha-linolenic acid, EPA and DHA were the most limiting fatty acids in diets of Guatemalan schoolchildren, which could be partially explained by the low consumption of sources of these nutrients, particularly fish and seafood (for EPA and DHA). This population will benefit from a higher consumption of culturally acceptable foods that are rich in these limiting nutrients.

Contribution of beverages to energy, macronutrient and micronutrient intake of third- and fourth-grade schoolchildren in Quetzaltenango, Guatemala

Beverages are selected based on availability, culture, taste preference, health, safety and social context. Beverages may be important to energy and to the macronutrient and micronutrient quality of overall intake. The aim of this study was to determine the contribution of beverages to the dietary energy and estimated macro- and micronutrient intake to the diet of young schoolchildren. We analyzed data from third- and fourth-grade urban Guatemalan school-children aged predominantly 8-10 years old. One-day pictorial registries of all beverages, foods and snacks consumed over a 24-h period were collected from children from private (n = 219) and public (n = 230) schools. Food composition nutrient values were assigned to the items consumed. Eleven main categories of beverages were identified. The contribution of each of the 11 beverage categories to energy, macro- and micronutrients was evaluated. The estimated intake of beverages was 475,300 mL, as reported by the 449 children. As a group, the beverage consumed in the greatest quantity was coffee (126,500 mL), followed by plain water (62,000 mL). Beverages represented a mean energy contribution of 418 +/- 26 kcal (21.5% of total dietary energy). The beverages varied in energy density from 0 (water) to 1.5 kcal mL(-1) (thin gruels). Beverages contributed one-third of the dietary carbohydrate. Through the contribution of fortified drinks, beverages were important sources of vitamin A (55%), vitamin C (38%), zinc (21%) and calcium (19%). Milk was an important source for vitamin D (10%). These results show the importance of drinks to nutrition and the balance of concerns of overweight/obesity with micronutrient quality.

Development and validation of a beverage and snack questionnaire for use in evaluation of school nutrition policies

School nutrition policies limiting access to sweetened beverages, candy, and salty snacks have the potential to improve the health of children. To effectively evaluate policy success, appropriate and validated dietary assessment instruments are needed. The objective of this study was to develop and validate a beverage and snack questionnaire suitable for use among young adolescents. A new 19-item Beverage and Snack Questionnaire (BSQ) was administered to middle school students on two occasions, 2 weeks apart, to measure test-retest reliability. The questionnaire inquired about frequency of consumption, both at school and away from school, of soft drinks, salty snacks, sweets, milk, and fruits and vegetables. Students also completed 4-day food records. To assess validity, food-record data were compared with BSQ data. Forty-six students of diverse backgrounds from metropolitan Seattle, WA, participated in this study. Participants answered the BSQ during class time and completed the food record at home. Pearson correlation coefficients assessed test-retest reliability and validity. Using frequency per week data, the test-retest reliability coefficients were r=0.85 for fruits and vegetables consumed at school and r=0.74 and r=0.72 for beverages and sweets/snacks, respectively, consumed at school. Correlations ranged from r=0.73 to 0.77 for foods consumed outside of school. Compared with the criterion food record, validity coefficients were very good: r=0.69 to 0.71 for foods consumed at school and r=0.63 to 0.70 for foods consumed away from school. The validity coefficients for the 19 individual food items ranged from r=0.56 to 0.87. This easy-to-administer 19-item questionnaire captures data on sugar-sweetened beverages, salty snacks, sweets, milk, and fruit and vegetables as well as a more lengthy and expensive food record does. The BSQ can be used by nutrition researchers and practitioners to accurately evaluate student consumption of foods that are the focus of school nutrition policies.

Relative validity of a self-completion 24 h recall questionnaire to assess beverage consumption among schoolchildren aged 7 to 9 years

OBJECTIVE

Drinking habits in children are associated with diet quality, but validated assessment tools for large-scale studies in young children are lacking. Therefore, we validated a self-completion 24 h recall questionnaire (RQ) focusing on beverage consumption with a 24 h weighed record (WR).

DESIGN

Thirty-five voluntary participants from the DONALD (Dortmund Nutritional and Anthropometric Longitudinally Designed) Study cohort aged 7-9 years completed the RQ. The illustrated RQ required ticking the number of glasses of seven beverage categories consumed in five time intervals in the previous 24 h. As a reference, parents completed weighed records of their child's diet. Agreement between the RQ and WR was tested by classification into consumers and non-consumers (kappa coefficients, kappa), by the children's ability to estimate the exact beverage and total volume consumed (Wilcoxon signed-rank test, Spearman rank correlation), and by ranking children according to reported beverage volumes.

RESULTS

The RQ and WR showed a good level of agreement for classifying participants into consumers and non-consumers of the single beverage categories (kappa values between 0.78 and 0.94). Correlation coefficients for the volume of the single categories ranged between 0.81 and 0.91. The total beverage volume was overestimated in the RQ, on average, by 114 ml (P = 0.015). Agreement in ranking into tertiles by beverage volume was moderate to good for juice/soft drinks (kappa = 0.44), milk (kappa = 0.57) and water (kappa = 0.70), but fair for the total beverage volume (kappa = 0.23).

CONCLUSIONS

Our self-completion 24 h RQ could estimate the consumption of several beverage categories among young children at the group level, but quantification of total beverage volume was flawed.

Validação da terceira versão do Questionário Alimentar do Dia Anterior (QUADA-3) para escolares de 6 a 11 anos

O estudo objetivou conferir validade à terceira versão do Questionário Alimentar do Dia Anterior (QUADA-3) para escolares. O QUADA-3 é um instrumento estruturado com seis refeições e 21 alimentos. Participaram 164 escolares de 6 a 11 anos de idade, de uma escola pública de período integral, em 2007. A validade foi testada pela comparação entre os itens alimentares selecionados no questionário e a observação direta de alimentos consumidos em três refeições escolares do dia anterior (lanche da manhã, almoço, lanche da tarde). Análise de regressão logística multivariada foi conduzida para avaliar a discordância entre as respostas do questionário e o registro das observações. Os resultados indicaram alta sensibilidade e especificidade para a maioria dos itens alimentares. Em média, os valores de sensibilidade e especificidade foram de 70,2% e de 96,2%, respectivamente, para os 12 itens alimentares nas três refeições combinadas. Os escolares de 6 a 8 anos, quando comparados aos de 9 a 11 anos, apresentam maiores taxas de discordância de respostas entre o QUADA-3 e as observações. Os resultados indicaram que o QUADA-3 pode gerar dados válidos para avaliar o consumo alimentar do dia anterior em nível de grupo de escolares.

Reproducibility of the School-Based Nutrition Monitoring Questionnaire among fourth-grade students in Texas

OBJECTIVE

To assess reproducibility of a School-Based Nutrition Monitoring (SBNM) questionnaire for fourth-grade students.

DESIGN

Test-retest.

SETTING

Fourth-grade elementary school classrooms

PARTICIPANTS

Multiethnic fourth-grade students from 2 area school districts (N = 322).

MAIN OUTCOME MEASURES

Reproducibility coefficients with time intervals between questionnaire administrations of 2 hours for the yesterday food choice and physical activity questions or 2 weeks for the nutrition knowledge and attitude questions.

ANALYSIS

Spearman rank order correlation, percent agreement, and Kappa statistic calculated for each individual questionnaire item.

RESULTS

Of 43 questions that were included in the reproducibility analyses, test-retest kappa values were moderate to high (greater than 0.40) for more than 90% of the questions (39 questions). Spearman coefficients were greater than 0.70 for 24 questions, whereas percent agreement exceeded 75% for 28 questions.

CONCLUSIONS AND IMPLICATIONS

The SBNM questionnaire showed good to excellent reproducibility for nutrition behavior questions, physical activity, weight behavior, and food selection skills overall. However, questions that assessed nutrition knowledge and attitudes were not as reproducible, probably resulting from learning effects over time. Results from the study indicate that this questionnaire can be easily administered in an elementary school classroom and can be used to measure nutrition behaviors among 9- to 10-year-old school children.

Free breakfasts in schools: design and conduct of a cluster randomised controlled trial of the Primary School Free Breakfast Initiative in Wales [ISRCTN18336527]

Background

School-based breakfast provision is increasingly being seen as a means of improving educational performance and dietary behaviour amongst children. Furthermore, recognition is growing that breakfast provision offers potential as a means of addressing social inequalities in these outcomes. At present however, the evidence base on the effectiveness of breakfast provision in bringing about these improvements is limited.

Methods/Design

This paper describes the research design of a large scale evaluation of the effectiveness of the Welsh Assembly Government's Primary School Free Breakfast Initiative. A cluster randomised trial, with school as the unit of randomisation was used for the outcome evaluation, with a nested qualitative process evaluation. Quantitative outcome measures included dietary habits, attitudes, cognitive function, classroom behaviour, and school attendance. The study recruited 111 primary schools in Wales, of which 56 were randomly assigned to control condition and 55 to intervention. Participants were Year 5 and 6 students (aged 9–11 years) in these schools. Data were collected for all 111 schools at each of three time points: baseline, 4 month and 12 month follow-up. This was achieved through a repeated cross-sectional survey of approximately 4350 students on each of these occasions. Of those students in Year 5 at baseline, 1975 provided data at one or both of the follow-ups, forming a nested cohort. The evaluation also included a nested process evaluation, using questionnaires, semi-structured interviews and case studies with students, school staff, and local authority scheme coordinators as key informants.

Discussion

An overview of the methods used for the evaluation is presented, providing an example of the feasibility of conducting robust evaluations of policy initiatives using a randomised trial design with nested process evaluation. Details are provided of response rates and the flow of participants. Reflection is offered on methodological issues encountered at various stages through the course of the study, focusing upon issues associated with conducting a randomised trial of a government policy initiative, and with conducting research in school settings.

Trial registration

Current Controlled Trials ISRCTN18336527

Development of a scale to measure 9–11-year-olds' attitudes towards breakfast

OBJECTIVE

Development and validation of a questionnaire to measure children's attitudes towards breakfast.

DESIGN

A pilot study was used to select questionnaire items and assess test-retest reliability. The questionnaire was then administered to a larger sample of children together with a dietary recall questionnaire. Randomly selected subsets of these children also completed a dietary recall interview or their parents were asked to complete a questionnaire relating to their child's breakfast eating habits.

SETTING

Primary schools in south, west and north Wales, UK.

SUBJECTS

A total of 2495 children (199 in pilot testing, 2382 in the main study) in years 5 and 6 (aged 9-11 years).

RESULTS

The 13-item scale showed good construct validity, high internal reliability and acceptable test-retest reliability. Boys displayed more positive attitudes towards breakfast than girls but differences between the two age groups did not reach statistical significance. Children who did not skip breakfast displayed more positive attitudes than children who skipped breakfast. In addition, more positive attitudes towards breakfast were significantly correlated with consumption of a greater number of 'healthy' foods for breakfast (i.e., fruit, bread, cereal, milk products), consumption of fewer 'unhealthy' foods for breakfast (i.e., sweet items, crisps) and parental perceptions that their child usually ate a healthy breakfast.

CONCLUSIONS

The breakfast attitudes questionnaire is a robust measure that is relatively quick to administer and simple to score. These qualities make it ideal for use where validity at the individual level is important or where more time-consuming dietary measures are not feasible.