Dietary habits and nutrient intake of South Asian children (1-3 years) living in the UK Wafaa A G M Husain Submitted in accordance with the requirements for the degree of Doctor of Philosophy The University of Leeds School of Food Science & Nutrition September 2013 I Intellectual property and Publication Statements The candidate confirms that the work submitted is her own and that appropriate credit has been given where reference has been made to the work of others. This copy has been supplied on the understanding that it is copyright material and that no quotation from the thesis may be published without proper acknowledgement © 2013 The University of Leeds and Wafaa A G M Husain. The right of Wafaa Husain to be identified as Author of this work has been asserted by her in accordance with the Copyright, Designs and Patents Act 1988. II Acknowledgments Thanks to Allah for all blessing and opportunities for me to achieve my dream. When I reached this part of my work I could not hold back my tears. What can I say? I am forever grateful to a number of people who have each contributed in a special way, without whom this thesis might not have been written. First and foremost, I would like to express my deep gratitude to my son, Bader, who is the light of my life, who endured all the difficulties with me, who held my hand through hard times, encouraged me and supported me, especially through the months of writing. My very special thanks to the person whom I owe everything for who I am today, my dear husband, Naser. Your love, faith and confidence in my abilities, and your understanding that I had a dream to achieve, were all things that got me to where I am today. To my Mum and Dad who brought me up to be the person I am today, and to my family who are the most important people in my life, thank you for your unconditional love and support. Thank you to all my friends, who are many, in particular Fatemah, Maryam and Khulood who were my family when I was so far away from home, who supported me and who were there for me in times of need. Fatemah, we have shared many moments together during this journey. Both the hard and beautiful times will be kept in our memories and will last forever. Maryam, I will miss those moments when we both sat and drank coffee, planning our future. Khulood, believing in my ability and reminding me that it would not last forever was a huge help. Thank you, I hope our friendships will last forever. This acknowledgement would be incomplete if I did not mention the very special people who help me to traverse my path and reach the light at the end of the tunnel; School Administrator and Head of Administration Mrs Catherine Roberts and Postgraduate (research) Student Support Officer Ms Angela Morrison. I have learned from you that ‘it is never too late’. You have left a mark on my life, so thank you for your care and kind attention, and for trying to keep a smile on my face. III I am thankful to the Head of School, Prof. Mike Morgan, who always makes an effort to create a healthy environment for all students, making it possible for all to work hard and persevere. I would like to express my deepest appreciation to Dr. Caroline Orfila and Dr Melvin Holmes, who generously agreed to be my supervisors during the writing stage of the thesis, despite their busy schedule and responsibilities. Thank you for your useful comments. Thanks to all my colleagues in the PhD group at the University of Leeds, including Dr. Tanefa Apekey, Dr. Sara Garduno, Ebun-Oluwa Oladele and Dr. Stefania Chillo. Special thanks to you, Stefani, for your help during the final stage of this thesis; without your help and support this would not have been achieved. I would like to extend my thanks to my previous supervisor, Dr. Santosh Khokar, who gave me the opportunity to start this research and gain skills and expertise during my PhD journey. I gratefully acknowledge all participants who contributed to this study and made it possible. Last but by no means least, I would like to express gratitude to my country and the Public Authority for Applied Education and Training. This PhD study would not have been possible without your financial support IV Abstract This cross-sectional study is the first study to be carried out in the UK that explored and assessed the dietary habits and nutrient intakes of pre-school South Asian (SA) children (1 to 3 years old) living in the UK. A cohort of SA mothers completed a questionnaire with questions about their children dietary habits, sleeping habits and mothers’ nutritional knowledge (n=160). Food intake information was gathered by three 24-hour multiple pass recalls (MPRs). Household measurements and a newly developed food photograph booklet for SA food were used to estimate food portion sizes. All foods were analysed for nutrient composition using the WinDiets software and the latest available data on SA foods generated by the FSA and EuroFIR. A questionnaires regarding factors influencing SA mothers’ weaning practices was administered through in-depth interviews (n=30). The results suggest that there were various dietary habits and practices to be found amongst SA children. These habits were found to be influenced by the mother’s religion, culture and beliefs. In addition, the study has shown that milk and milk products was the largest food group that contributed towards the daily diet. SA children have energy intakes significantly lower than the EAR when compared to the UK recommendations, both amongst boys (1126.4 kcal/d ±197.75) and girls (1106.2 ± 225.86). They are most likely to have adequate intakes of most nutrients except for vitamin A, vitamin D, Fe and Zn; mean intakes were found to be below the RNI (96%, 18.7%, 89.5% and 95.5% of the RNI, respectively). Furthermore, it was found that a 24-hour MPR was an appropriate tool to be used with SAs and that participants can enhance their estimation of portion sizes using food photographs. These findings enhance our understanding of SA dietary habits and can serve as a basis for future studies. V Contribution to PhD thesis The candidate confirms that the work submitted is her own, except where work which has formed part of jointly-authored publications has been included. The contribution of the candidate and the other authors to this work has been explicitly indicated below. The candidate confirms that appropriate credit has been given within the thesis where reference has been made to the work of others. Ethical Approval Applications for Ethics for the study were prepared by the researcher Wafaa Husain. Recruitment and data analysis All the data collection, coding and data entry and statistical analysis were carried out by the researcher Wafaa Husain. Development and validation of portion sizes Validation process of the food photographs booklet was jointly carried out by the researcher, Mrs. Fatemah Ashkanani and Dr. Sara Garduño Diaz. Food consumption and average food portion sizes Data entry for the food portion sizes by meal times was carried out by the MSc student Ms. Huimin Huo under the supervision of the researcher Wafaa Husain VI Table Of Contents Chapter 1: Literature review ................................................................................... 1 1.1 Introduction .................................................................................................. 1 1.1.1 Ethnic group in the UK ......................................................................... 1 1.1.2 Demographics of South Asian population in the UK............................ 2 1.1.3 Food Consumption and Lifestyle of the South Asian Community ....... 6 1.1.4 Inter-generational differences ............................................................... 9 1.1.5 Lifestyle factors affecting South Asians’ food consumption .............. 10 1.1.6 Effect of migration on meal patterns ................................................... 16 1.1.7 Effect of custom on maternal and pre-school age children’s food intake 18 1.1.8 Pre-school age children’s nutrient intake ............................................ 24 1.1.9 The implications of non-communicable diseases and their cost ......... 36 1.1.10 Health and dietary habits, lifestyle and genetic predisposition ........... 39 1.1.11 Overview of research methods that can be used in dietary assessment of pre-school children ....................................................................................... 40 1.1.12 Sources of errors and difficulties in dietary studies with children and minority ethnic groups ...................................................................................... 47 1.2 Key findings ............................................................................................... 51 1.3 Aim and objectives of the study ................................................................. 52 Chapter 2: Methodology ....................................................................................... 54 2.1 Introduction ................................................................................................ 54 2.2 Part I (quantitative approach) ..................................................................... 55 2.2.1. Dietary habits, sleeping habits and mothers’ nutritional knowledge questionnaire ..................................................................................................... 55 2.2.2. Development and validation of food photograph booklet................... 61 2.2.3. The 24 hour Multiple Pass Recall (24 hour MPRs) ............................ 69 2.2.4. Statistical analysis ............................................................................... 79 VII 2.3 Part II (qualitative approach) ...................................................................... 82 2.3.1 Individual in-depth interview .............................................................. 82 2.3.2 Statistical analysis ............................................................................... 86 2.4 Key finding ................................................................................................. 87 Chapter 3: Dietary habits, sleeping habits and mothers’ nutritional knowledge among children from different ethnic groups............................................................ 88 3.1 Introduction ................................................................................................ 88 3.2 Aim ............................................................................................................. 88 3.3 Results ........................................................................................................ 88 3.3.1 Response level ..................................................................................... 88 3.3.2 The study participants: demographic and socio-economic characteristics .................................................................................................... 88 3.3.3 Dietary habits ...................................................................................... 92 3.3.4 Lifestyle............................................................................................... 99 3.3.5 Mothers’ nutritional knowledge ........................................................ 101 3.4 Discussion ................................................................................................ 103 3.4.1 Demographic and socioeconomic characteristics ............................. 103 3.4.2 Dietary habits .................................................................................... 105 3.4.3 Sleeping habits .................................................................................. 109 3.4.4 Nutritional knowledge ....................................................................... 109 3.5 Key finding ............................................................................................... 111 Chapter 4: Validation of food photographs booklet ........................................... 112 4.1 Introduction .............................................................................................. 112 4.2 Aims ......................................................................................................... 112 4.3 Results ...................................................................................................... 113 4.3.1 Phase 1 validation ............................................................................. 113 4.3.2 Phase 2 validation ............................................................................. 118 4.4 Discussion ................................................................................................ 121 VIII 4.5 Key findings ............................................................................................. 125 Chapter 5: Food consumption and average food portion sizes ........................... 126 5.1 Introduction .............................................................................................. 126 5.2 Aims ......................................................................................................... 126 5.3 Results ...................................................................................................... 127 5.3.1 Household level response .................................................................. 127 5.3.2 The study participants: demographic and socio-economic characteristics .................................................................................................. 127 5.3.3 Commonly consumed foods in terms of food groups ....................... 129 5.3.4 Energy, macronutrients and micronutrients in average portions of most commonly traditional consumed foods by food group ................................... 132 5.3.5 Comparison with the NDNS food portion sizes ................................ 133 5.3.6 Meal and snack patterns .................................................................... 141 5.4 Discussion ................................................................................................ 145 5.4.1 Selection of dietary assessment method ............................................ 145 5.4.2 Food consumption and average portion sizes in term of food group and meal time ......................................................................................................... 145 5.5 Key findings: ............................................................................................ 152 Chapter 6: Assessment of dietary intake ............................................................. 153 6.1 Introduction .............................................................................................. 153 6.2 Aims ......................................................................................................... 153 6.3 Results ...................................................................................................... 153 6.3.1 The study participants’ demographic and socio-economic characteristics .................................................................................................. 153 6.3.2 Anthropometric characteristics ......................................................... 153 6.3.3 Over- and under-reporting of energy intake...................................... 156 6.3.4 Comparison with different recommendations ................................... 157 IX 6.3.5 Comparison between South Asian children in the present study and children from the National Diet and Nutrition Survey (NDNS) (the new rolling programme for 2008/2009) ............................................................................. 166 6.3.6 Effect of socio-demographic factors on the dietary intake of South Asians 169 6.4 Discussion ................................................................................................ 171 6.4.1 Weight status ..................................................................................... 171 6.4.2 Over- and under-reporting of energy intake...................................... 173 6.4.3 Nutrient intake ................................................................................... 174 6.4.4 Factors affecting nutrient intakes ...................................................... 177 6.5 Key findings ............................................................................................. 179 Chapter 7: Weaning habits and factors influencing food choice among South Asian mothers ......................................................................................................... 180 7.1 Introduction .............................................................................................. 180 7.2 Aim ........................................................................................................... 180 7.3 Results ...................................................................................................... 180 7.3.1 The study participants: demographic and socio-economic characteristics .................................................................................................. 180 7.3.2 Main findings .................................................................................... 181 7.4 Discussion ................................................................................................ 191 7.4.1 Selection of in-depth interview method ............................................ 191 7.4.2 Main findings .................................................................................... 192 7.5 Key findings ............................................................................................. 196 Chapter 8: General discussion and future research ............................................. 198 8.1 Introduction .............................................................................................. 198 8.2 Recruitment .............................................................................................. 199 8.3 Dietary assessment tools .......................................................................... 200 8.3.1 Development of food photographs .................................................... 201 8.3.2 Food composition database ............................................................... 202