The recent rapid increase in childhood obesity rates suggests that a consideration of the role of the schools in addressing this problem is necessary. ‘Fits me’ program functions to promote eating daily and healthy breakfast among elementary school children.
Separate children groups were sampled each year by clusters from seven regions around Israel. They filled a self-administered questionnaire at the beginning of 2003, before the program started, and in 2003–2005, after the program. A separate sample was collected in 2006 in a case–control structure. The answer to the question: ‘what do you eat for breakfast?’ considered as a healthy breakfast if it included one of the following food items: A sandwich (not including chocolate, jam or butter), cereals, vegetable, fruit, egg and dairy product.
As compared with 2003 before the program, more children reported eating daily breakfast over the years (51–65% before and until 2005, respectively, P for trend<0.01). Odds ratio (OR) and 95% confidence interval (95% CI) for eating a healthy breakfast, in 2006 in the intervention (n=417) vs controls (n=572), adjusted for sex and age were OR=1.53 (95% CI: 1.15–2.04). However, only a third of 75% of the children who ate a healthy breakfast in the intervention group estimated that they were eating a healthy breakfast.
After implementation an educational program to promote daily and healthy breakfast eating, the goal of a healthier breakfast was achieved. However, one should strive to define an exact definition of a healthy breakfast.
Dietary transitions in the developing world are strongly linked to social and economical changes. Many of these changes relate to globalization; new food items, new marketing methods and new dietary habits have emerged. The recent and rapid increase in childhood obesity suggests that a consideration of the role of the schools in addressing this problem is necessary (Gonzalez-Suarez et al., 2009).
In a cross-sectional study in Israel (Huerta et al., 2006), a three-fold difference in prevalence of overweight was reported in second and fifth graders between 1990 and 2000. Among fifth grade children, the overweight prevalence, according to the Center of Disease Control definition, in 1990 and 2000 was: 2.5 and 7.2%, respectively, in boys, 2.1 and 6.6%, respectively, in girls. Among second graders, prevalence of overweight in 1990 and 2000 was: 2.9 and 8.6%, respectively, in boys and 1.8 and 5.5% in girls, respectively. These higher rates of overweight in the younger age group may reflect the emergence of the obesity epidemic in Israel.
Breakfast is touted as the most important meal of the day (Affenito, 2007). In both adolescents (Summerbell et al., 1996) and adults (Song et al., 2005; Kant et al., 2008), eating breakfast is related to better nutrition (Nicklas et al., 1998; Williams, 2007), lower body mass index (BMI), improved overall quality of life (Chen et al., 2005). In an analysis from a sample of 3652 participants in the Third National Health and Nutrition Examination Survey, there was an association between eating ready-to-eat cereals, cooked cereal or quick breads for breakfast and lower BMI compared with those who skipped breakfast and those who ate meat and eggs. That report concluded that skipping breakfast is not an effective way to manage weight (Cho et al., 2003). A survey in a population sample of 16-year-old girls and boys (n=5448) and their parents (n=4660) found that parental breakfast eating was the most significant factor associated with adolescent breakfast eating. High BMI was significantly associated with adolescent breakfast skipping (Keski-Rahkonen et al., 2003). Daily breakfast habits are highly associated high socioeconomic status (Siega-Riz et al., 2000; O’Dea and Caputi, 2007). Greater stress was associated with reduced likelihood of daily breakfast consumption (Cartwright et al., 2003). These data are mainly from prospective and cross sectional studies. Most intervention studies have found benefits of breakfast for school performance (Pollitt et al., 1998; Grantham-McGregor, 2005; Widenhorn-Müller et al., 2008), but many of these were short-term and had methodological limitations (Rampersaud et al., 2005).
‘Fits me’ program is a non-branding program in schools, targeted at children of a wide range of ages and functions to promote eating healthy breakfast and lead a healthy lifestyle. It is a program for primary school children and kindergartens, designed according to an educational system language that emphasizes the importance of eating breakfast on a daily basis and learning proper nutrition and health habits. The program is organized in lessons and includes various activities. Each school team decides how to implement the program's various features.
‘Fits me’ started in Israel in 2002 as collaboration between the ministry of health, the state parents’ representatives and food companies. In 2007, it was the main program in educating healthy lifestyle in schools through the ministry of education, and included 800 schools in the country. At that time, no information was collected and analyzed in order to evaluate the program and its effects and to improve it.
Eliakim et al. compared 54 preschool children who completed a 14-week ‘Fits me’ program to 47 age-matched controls (age 5–6 years). Favorable changes were observed in BMI percentile (−3.8 vs 2.9, P<0.001) and fitness (endurance time −3.55 vs 3.16%, P<0.017) in the intervention vs control groups (Eliakim et al., 2007). The current analysis summarizes and integrates annual surveys in school children, applied by ‘Fits me’ research team into evaluate the program's effects over time and as a whole, in order to improve its impact.
About the program: the program ‘fits me’ is for children in elementary school. It is built according to the ministry of education vision: to integrate the lifestyle and behavior changing throughout the year. In children in first to third grade, the topics studied are: why breakfast, what is happening at night? What should I eat at breakfast? How to buy breakfast: smart consumer, and who to eat breakfast with. In fourth to sixth grade the program topics are: eating during the day, regular physical activity and self confidence. The program is built of units. Each unit is for 1–2 class hours. The recommended time to spend is at least four units each year. In each school, there was an integrator who was in charge of transmitting the program to the relevant teachers (science, gymnastics and so on). Each teacher could choose the time dedicated to this program.
Both the program and data collections were approved by the Israeli Ministry of Education, the Health Promotion Department.
Between 2003 and 2005 a self-administered questionnaire was administered at the end of the year by teachers in schools in which the program was implemented. A similar questionnaire was sent to the parents by their children. The information about the program was conveyed to the parents by program letters and by schools’ websites. Before the program started children and parents were sampled and served as a reference group. The questionnaire used resembles the breakfast attitudes questionnaire used in other studies (Tapper et al., 2008). Both questionnaires are relatively quick to administer and simple to score. These qualities make it ideal for use in which validity at the individual level is important or in which more time-consuming dietary measures are not feasible (Tapper et al., 2008).
From schools that implemented the program during the previous year, 1000 children were randomly sampled by clusters from seven regions around Israel, each year. The schools in which the program was implemented were randomly selected from the list of schools in each region. From the schools in which the program was implemented, schools which participated in both studies (cross-sectional as well as case–control) were randomly sampled. However, not all the children in the same school underwent the intervention and each sample contained participants and non-participants in the program. Whether a class participated in the program was randomly selected by the teachers. Significant differences were observed between years in gender—fewer boys in increasing years, the percent of younger children and religion. Arabs were sampled only in the year in which the program was translated and tailored to that population.
Because there was a concern that these variables may function as confounders, we collected data in 2006 from two samples in a case–control study structure: 1000 children who participated in the program and 1000 children who did not participate. The 2006 control schools were chosen from the list of closest schools in the same area of the cases school in order to try and eliminate the potential confounding effect of socioeconomic status (the disadvantage of this decision is the lack of Arab sample in this part of the study). The results were compared with the cluster samples in 2003–2005.
We considered the answer to the question ‘what do you eat for breakfast?’ as representing a healthy breakfast if it included one of the following food items: a sandwich (not including ones with chocolate, jam or butter), cereals (cereal types could not be differentiated), vegetable, fruit, cereal bar, egg or dairy product. This is referred to as ‘expert-dichotomous index’, in the text.
A non-healthy breakfast included not eating any of the healthy food items or reporting skipping breakfast. Breakfast eating daily was compared with those who reported skipping on breakfast or eating less than daily.
Baseline demographic characteristics are presented as means and standard deviations for continuous variables or as numbers and percentages for categorical variables. In order to compare the answers over the years, we used a Linear by Linear test (Armitage, 1995) to check for trends in the program's influence over time. Differences between dichotomous variables were assessed using a χ2-test. Multivariate Logistic regression was conducted to predict the probability of children to eat healthy or daily breakfast in schools, with or without intervention, adjusted for class (age), sex, religion and rural or urban residence (Hosmer and Lemeshow, 2000).
In the Surveys from 2003 before, and at the end of each year between 2003 and 2005, there was a significant difference in interviewed childrens’ ages, and more boys answered the questionnaires (Table 1).
Response rate was in 2003 before the program, 2003 after the program, 2004 and 2005: 27, 38, 38 and 26%, respectively, in children and 28, 21, 20 and 15%, respectively, in parents. Response rate in 2006 was 42% in the cases group and 57% in controls.
No difference in age and sex was observed in parents who returned the questionnaire (Table 2). As compared with 2003 before the program, more children reported eating breakfast daily over the years (51–65%, Table 1). This trend was also reported by the parents, although it did not reach statistical significance (53–66%) (Table 2).
Using an expert-dichotomous index for healthy/non-healthy breakfast, there was a significantly higher percent of children eating a healthy breakfast over the years (60–67%), and a significantly higher percentage of children who felt they ate a healthy breakfast, almost 30% higher over the years (Table 1). This observation was consistent with the significantly higher percent of parents reporting that their children ate a healthy breakfast (a difference of 16% over the years, Table 2).
According to the children's reports, the most frequent healthy breakfast was cereals (50, 54 and 47% in 2003, 2004 and 2005, respectively). The most frequent unhealthy breakfast was a cake (including any sweet baked food). This was reported consumed by 10, 15 and 23% of children in 2003, 2004 and 2005, respectively.
These results demonstrate significant increase in the parents’ attitude towards the importance of eating breakfast every day (11% difference). Satisfaction from the program was higher in both children (difference of 14%, Table 1) and parents (19%) over the years (Table 2).
As there was significantly higher percentage of children who ate a healthy breakfast after the program, we analyzed the characteristics of these children as compared with their counterparts who did not eat a healthy breakfast or skipped it (Table 3). There were no significant differences in age and sex among children who did and did not report eating a healthy breakfast. In the 3 years after the program was initialized, 72% of children reported eating a healthy breakfast.
Children who ate healthy breakfast, were more likely to report that eating a healthy breakfast is very important and were more likely to report that the program is interesting. A higher percentage of children reported that they thought they ate healthier after the program. More children who eat a healthy breakfast learned the program and reported that it was interesting. There was no difference in age and sex in parents who reported that their children ate a healthy breakfast compared with the others.
The percent of parents reporting their children eat breakfast daily is almost twice among the parents who think that their children eat a healthy breakfast as compared with those who do not (61.4 and 31.8%, respectively, Table 4). These results resemble those in children, in which 66.4% of the children who reported eating a healthy breakfast, vs 34.3% of the children who reported not eating a healthy breakfast, ate daily breakfast (Table 3).
Children who according to their parents’ reports ate a healthy breakfast had a higher percent of parents ascribing a very high importance to eating breakfast. Among the parents who reported their children eat a healthy breakfast, a higher percent reported their children changed their eating habits as a result of the program and a higher percent answered that they were very content from the program (Table 4).
Separate analyses in children and parents before the program showed similar results. A higher percent of children who reported that they eat a healthy breakfast, and parents who reported that their children eat a healthy breakfast attributed a very high importance to eating breakfast (data not shown).
Results of the case–control sample (participants vs non-participants in the program) in 2006, support the trends observed in 2003–2005 (Table 5). There was no significant difference in cases vs controls in the percent of children who reported eating daily breakfast. However, a higher percent of children reported eating a healthy breakfast. In contrast to 2003–2005 results, there was a lower percent of children who reported skipping breakfast in the 2006 intervention group.
The percent of children who believed they were eating a healthy breakfast was low in both the case and control groups. Only a third of the children in the intervention group reported that they were eating a healthy breakfast, whereas 75% ate a healthy breakfast while 17% of those who did not eat a healthy breakfast thought they ate healthy. These results are supported by the 2003–2005 sample (Table 1). Those in the intervention group thought that eating breakfast is of a very high importance.
The characteristics of children who eat breakfast as compared with those who do not eat breakfast in the intervention group (cases group) are described in Table 6. More children reported that they ate a healthy breakfast among those who actually ate a healthy breakfast (according to the expert-dichotomous index), as compared with their counterparts. A higher percent of children who eat a healthy breakfast think that eating a healthy breakfast is ‘highly important’.
When comparing cases vs controls in 2006, in a multivariate logistic regression analysis, the odds ratio (OR) and 95% confidence interval 95% (CI) for eating a healthy breakfast, adjusted for sex and age (the groups included only Jewish schools), were 1.53 (95% CI: 1.15–2.04). No association was found with sex and age (n=937). The OR for eating a healthy breakfast, comparing children who participated in the program in 2003–2005 to those who did not in 2003, was: OR=2.05 (95% CI: 1.41–2.98) P<0.001 (adjusted for sex, age (fourth vs third grade), ethnicity (Jews vs Arabs) and geography (Urban vs Rural).
The current analysis shows that between 2003 and 2005 following implementation an educational program to promote a healthy breakfast eating, in elementary schools, there occured an increasing trend toward children eating a healthy breakfast. Thus, the goal of improvement in breakfast foods was achieved. A higher percent of children reported eating daily breakfast over the intervention period, and this trend was similar in the parents’ reports.
The contribution of the program is reflected by a higher percent, which reports that eating breakfast is very important, as well as a higher percent of satisfaction among both children and parents. A survey conducted in 2495 fifth and sixth grade children also found that those who did not skip breakfast displayed more positive attitudes than children who skipped breakfast. In addition, more positive attitudes toward breakfast were significantly correlated with consumption of a greater number of ‘healthy’ foods for breakfast (that is, fruit, bread, cereal and milk products), consumption of fewer ‘unhealthy’ foods for breakfast (that is, sweet items and crisps) and parental perceptions that their child usually ate a healthy breakfast (Tapper et al., 2008). A study that investigated associations of daily breakfast consumption with demographic and lifestyle factors in 41 countries, including 4610 children from Israel, found that daily breakfast among 11-, 13- and 15-year olds was consumed by 35% of the girls and 43% of the boys, results as low as the percents reported in the United States (Vereecken et al., 2009). In the current analysis almost half of the children aged 9–10 years ate daily breakfast in both groups before and after the program. In the above ecological study, one of the explanations offered for the disparities in breakfast consumption across countries was the availability of school-breakfast programs (Vereecken et al., 2009). Consumption of school meals was positively related to children's intakes of key food groups, such as milk and fruit (mainly 100% juice), at breakfast (Condon et al., 2009).
According to the current analysis, children who eat a healthy breakfast are children whose parents believe that eating breakfast is very important. This observation is consistent with other studies (Pearson et al., 2009; Vereecken et al., 2009). Moreover, this association was present in 2003 before the program started. As during the years of the program a higher percent of parents think that eating a healthy breakfast is very important, it is possible that eating a healthy breakfast is mediated by parents. These results are consistent with those in a review, which concluded that parents should be encouraged to be positive role models to their children by targeting their own dietary behaviors and that family structure should be considered when designing programs to promote healthy breakfast behaviors (Pearson et al., 2009).
The results of the case–control analysis in 2006 are similar to those in 2003–2005 although the total number of children with healthier habits is lower compared with 2005. This difference can be explained by the change in the program leaders. After 2006 only teachers lead the program, without physicians and dietitians. The assumption was that teachers have the skills and knowledge to teach the program after they learn and watch dietitians practicing it. This assumption needs further evaluation.
A higher percent of children felt that they had eaten a healthy breakfast in 2003–2005 as compared with 2006. However, 68% of those not eating a healthy breakfast think that eating breakfast is important, but only 34% do so. It is noted in other studies that knowledge is not a sign of ability to apply it in lifestyle changes (Bellisle and Rolland-Cachera, 2007). It is possible that the abundant selection of convenient high fat high sugar foods induces the gap between knowledge and practice.
There is also a gap between eating a healthy breakfast and the children's belief that they ate a healthy breakfast.
The percent of children who think they eat a healthy breakfast, although they do not, require a change in the program in order to clarify the healthy breakfast items to the children. A clear definition of what is considered a healthy breakfast is required.
The adjusted OR for eating a healthy breakfast after the program was high in both 2003–2005 and 2006 analyses, showing a strong association between being in school which participated in the program and eating a healthy breakfast. Being older and/or Jewish was associated with a higher OR for eating a healthy breakfast. A cross-sectional study estimated the association between participation in the School Breakfast Program and National School Lunch Program and children's BMI and risk of overweight or obesity; participants included 2228 students in grades 1 through 12. School breakfast participation, but not school lunch, was associated with significantly lower BMI, particularly among non-Hispanic, white students (Gleason and Dodd, 2009).
Our analysis has several shortcomings and limitations: other variables included in the program were not evaluated (such as promoting physical activity and hygiene). There are no objective measures, such as percent of overweight, or hard endpoints, such as disease or death. This is a cross-sectional analysis of different schools each year. It is possible that informative differences existed over the years 2003–2005 because of the sampling. We attempted to overcome this limitation using the 2006 data using a case–control study structure. The low response rate each year may represent a response bias. We assume that in the case–control sample, this bias is non-differential and, therefore, the true differences found may be larger than those found.
Practical recommendation based on the program:
Both parents and children were satisfied with the program and it may be prudent to recommend its continuity.
The goal of a balanced menu was achieved for breakfast.
A parent who believes that eating daily breakfast is important indicated higher chance to eat daily breakfast. Parents’ involvement in the program is crucial.
A child who eats daily breakfast tends to eat it healthy. As there is no change in the percent of children who ate daily breakfast, it may be important to emphasize this goal as a step toward eating a healthy breakfast.
It may be prudent to clarify the information of what is considered a healthy food.
‘Fits me’ (Tafur Alay) is a joint project the Ministry of Health, Israel Association of Family Physicians, Israel Pediatrics Association, Israel Heart Society, Israel Pediatric Dentistry Association, the Association for Advancement of Nursing in Israel's Public Health, Atid – Association for Advancing Nutrition and Diet in Israel, Elective Parents Associations and approved by the Ministry of Education. This study was supported by Unilever Israel – Telma. We thank Prolog Entrepreneurship and Marketing for concept and management. We also thank Orna Levy, chief dietitian, Unilever, Israel for initiating and Israela Herbelin, CEO prolog initiation and marketing CSM for developing and implementing the program.