The Epidemic

Acknowledgements We would like to thank our Supervising Tutor, Ms Beh Stee Zhe, for her invaluable support and encouragement, and Ms Lydia Tan, Coordinator for South Zone (Secondary School / Junior College), Youth Health Promotion Unit, Health Promotion Board, for consenting to our interview, which has been crucial in shaping our report into the best possible.

Advice:
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Use a Table to enter the information in the Contents Page to avoid formatting problems. Blank the lines. You can be creative in your use of heading titles. However, if you wish to do so, the bottom-line is still clarity: the reader must have some idea what the heading refers to before reading the details.

Contents Page 1 Introduction to E1: Unhealthy Eating Habits of Children in US 1.1 Project Background and History 1.2 Rationale for Choice of Topic 1.2.1 Consequences of E1 1.2.2 Why the Need for Intervention to counteract E1 1.2.3 How E1 is escalating/worsening Strategies Employed in dealing with E1 and Lessons Learnt 2.1 Ann Coopers Berkeley School Salad Bars 2.2 Berkeleys School Lunch Initiative 2.3 Partnering CLIF Kids Introduction to E2: Unhealthy Eating Habits of Children in Singapore 3.1 Project Background and History 3.2 Rationale for Choice of E2 3.2.1 Consequences of E2 3.2.2 Why the Need for Intervention to counteract E2 3.2.3 How E2 is escalating/worsening Our Proposals 4.1 Overview 4.2 Proposal 1: U-Pack! Fun Recipes for Uths 4.2.1 Objectives and Application of Lessons Learnt 4.2.2 Details 4.2.3 Evaluation 4.3 Proposal 2: . 4.3.1 Objectives and Application of Lessons Learnt 4.3.2 Details 4.3.3 Evaluation 4.5 Proposal 2: . 4.4.1 Objectives and Application of Lessons Learnt 4.4.2 Details 4.4.3 Evaluation 5

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Conclusion

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Appendices 6.1 Interview Transcript 6.2 Survey Questions And Results 6.3 Survey Analysis

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Annexes (To be incorporated in the WR main body) A: U-Pack Lunchbox Design (We design) B: U-Pack Healthy Recipes for Uths (Competition?) C: Publicity Plan for Outreach D: Pictures of Adverts/Coasters/Cutlery with in-your-face messages E: Screenshot of U-Pack Facebook Page

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1 1.1

Introduction to E1 Unhealthy Eating Habits of Children in US Project Background and History

Unhealthy eating habits amongst children (see Table 1.1) are increasingly becoming an issue of concern for health authorities in developed nations like the United States of America and also in Singapore, resulting in consequences like childhood obesity and other health-related issues.
Percentage of Most Commonly Consumed Foods Among Children, Age 2-5 years old (2004)
100% 80% 60% 40% 20% 0%
M ilk 2-3 year-olds 4-5 year-olds 91% 93% Bread 81% 86% Soft Drinks 72% 79% Cereal 71% 72% Juice 47% 41% Cookies 42% 46%

Percent of consumers

Table 1.1: In 2004, soft drinks were the 3rd most commonly consumed food among American children ages 25, with cookies and french fries ranking 6th and 7th respectively.
French Fries 32% 33% Banana 30% 25% Peanut Butter 28% 28% M acaroni and Cheese 28% 19%

M cConahy, K.L., Smicklas-Wright, H., M itchell, D.C., and M .F. Picciano. (2004). Portion Size of Common Foods Predicts Energy Intake among Preschool-Aged Children. American Dietetic Association 104: 975-979.

For our project, we have thus decided to focus on the topic of unhealthy eating habits among the young, drawing lessons learnt from a variety of strategies used in the US to deal with this emergency, and apply these lessons learnt to Singapore, where the same problem has emerged. The emergency of poor eating habits amongst children has its roots in several factors (Fig. 1.2):

Fast food culture Food advertisements target children Unhealthy food served in schools Families cooking less, eating out more Fig 1.2: Factors leading to Unhealthy Eating Habits Amongst Children in the US

Firstly, parents in modern societies today are cooking less often, either due to the long working hours of both parents, or the convenience of TV dinners in comparison to cooking entire meals.1 Parents are therefore less able to ensure their childrens intake of healthy food. Secondly, unhealthy food being served in schools also plays a part.2 (Table 1.3)
Percentage of NC Students who bought food or drinks from vending machines at school one or more times during the past seven days (2007)
Percentage of Students

100 80 60 40 20 0 6th 7th 8th 9th 10th 11th 12th

49% 36% 38%

53%

46%

49% 37%

Table 1.3: In 2007, the percentage of N.C. students who bought food or drinks from the vending machines at school one or more times during the past seven days had a range between 36% and 53%, for 6th graders and 9th graders respectively.

Source: North Carolina Youth Risk Behavior Surveillance System, North Carolina Department of Public Instruction and North Carolina Department of Health and Human Services. (2007).

Thirdly, children are increasingly becoming easy targets of marketing campaigns promoting fast food and junk food. Such campaigns use popular celebrity or cartoon character endorsement, offer free toys, or have product placements in films or television programmes targeted at the young.3 Lastly, the prevalence of fast food culture in the US is making its effect felt especially on the young. Both children and adolescents are eating less at home than in earlier eras,

Less than a third of Americans are cooking their evening dinners from scratch, according to a new survey by the Institute of Food Technologists. The data shows a seven percent percent reduction over the past two years. Although 75% of Americans are eating their dinners at home, nearly half those meals are fast food, delivery, or takeout from restaurants or grocery delis. In fact, Americans spent more on fast food last year than on education. From: http://www.gather.com/viewArticle.action?articleId=281474976732488&grpId =3659174697238716 2 A study conducted by the University of Michigan found that most middle and high schools in the US have contracts with soft drink companies, making access to sugary drinks easily available to students in schools. Other high-fat, high- sugar and salty foods are also sold in schools through vending machines and snack carts. 3 A survey of American schoolchildren found that ninety-six percent could identify Ronald McDonald. The only fictional character with a higher degree of recognition was Santa Claus.

and more at restaurants and fast-food outlets.4 This is harmful considering that fast food and restaurant foods are typically calorically dense, nutrient-poor, and yet highly palatable.

1.2

Rationale for Choice of Topic

In explaining the rationale for our choice of this topic, we will examine the implications of unhealthy eating habits in the US and how it has become an emergency.

1.2.1 Consequences of unhealthy eating habits amongst children That the trend requires immediate attention is apparent from the consequences observed: Obesity has serious implications on health. Obese people are a lot more likely to suffer from heart diseases, high blood pressure, stroke and certain forms of cancer. Lifestyle diseases and obesity are more acute in US than anywhere else in the world. One report in 20065 estimated the economic cost resulting from lifestyle diseases to total as much as $200 billion annually. In fact, Philips6 cited poor diet as one of the key reasons leading to lif estyle illnesses, and commented on the need for health practitioners to intervene in this area to promote lasting health improvements in their patients. In 1900, communicable diseases account for most of the deaths in the US. By 1990, however, lifestyle diseases account for as much as 60% of all deaths in the US. Since unhealthy eating habits is one of the key factors causing lifestyle

The number of fast food establishments in the US has increased from 70,000 in 1970 to almost 200,000 in 2002. 5 US experts warn about lifestyle diseases. http://www.business-standard.com/india/news/us-expert-warnsth about-lifestyle-diseases/239365/ (accessed: 14 Jul 2009). 6 Edward M Phillips is the director of outpatient medical services in Harvard Medical School (HMS).

diseases, there is clearly an urgent need to address the situation. [Alternative: Lifestyle diseases have clearly been on the rise since the early 20th century. (Refer Fig. 1.4) The consequences of ignoring the link between eating habits and lifestyle diseases cannot be easily ignored.]

Fig. 1.4: Lifestyle diseases accounts for more than 60% of deaths: given rising affluence of the average family in the US and the consequent change in eating habits, these figures are likely higher now.

. Unwittingly, consumption habits (which results in the rearing of more livestock) lead to environmental degradation and global warming. 20% of greenhouse gases currently generated is due to lifestock rearing related activities, more than the pollution attributed to transportation. Devoting land to lifestock rearing has also led to loss of biodiversity as well as land degradation. Lifestock rearing leads to more air and water pollution, and sometimes even resulted in water shortages. Besides the methane produced by animals is 20 times more poisonous than carbon dioxide.

1.2.2 Why the need for intervention to counteract unhealthy eating habits This emergency is made even more apparent due to the need for intervention. Americans do not, in general, think that their present dietary pattern is a problem. Some of these perceptions can be found in Table 1.5:
Common Misconceptions Many Americans are not aware that they consume as much as 7 times as much meat than they actually need. Clearly, the current demand is based not on needs, but wants. People have been led to believe that a healthy diet requires one to consume more varieties of meat and vegetables than is actually needed. Another misconception is that a vegan diet is inadequate, and that generous portions of meat are necessary for a growing teenager.

These misconceptions led to overeating and rising obesity levels.

Table 1.5: Misleading Americans are perceptions very hard to dislodge, and these therefore require active intervention from authorities.

A study by the American Heart Association noted that 50% of obese children go on to become obese in adulthood as well. Contrary to what some people believe, obesity is not something that children will grow out of. Intervention is therefore required to inculcate good eating habits in children from young.

1.2.3 Evidence that obesity levels are on the rise in America. A recent report7 reveals that Americans are getting fatter. Among children 10-17, about 30% are overweight or obese in 30 states. Studies have found that overweight children are more likely to become obese as adults, and obese children are almost certain to remain that way.

This was reported in an article dated July 1 2009, Fat in the USA: Obesity is Rising. http://www.businessweek.com/technology/content/jul2009/tc2009071_442911.htm (accessed 14/07/09).

st

Dr. James S. Marks8 makes it clear how the trend has ominous implications for the future, "There is a huge wave of obese adults coming that will bankrupt us as a nation unless we get this under control now.

Such evidence is corroborated by other independent reports. A medical review9 noted that the situation has been observed for some time, and shows no sign of abating at all in the last 4 or 5 years. Whatever measures have been implemented thus far to combat this trend are clearly inadequate.

2 2.1

Strategies Employed in Dealing with E1 and Lessons Learnt Ann Coopers Berkeley School Salad Bars

Cooper understood the need to develop healthy eating habits from young. In order to achieve this, she convinced 15 of Berkeleys 16 elementary schools to start fresh salad bars (Fig. 2.1). The children are given a choice of a dozen ingredients from which they can make their own salads. The variety offered encouraged children eat more healthily, and made them responsible for their own eating habits.

Fig 2.1: School lunches at Berkeley High School now feature a salad bar

Marks is the senior vice-president of the Robert Wood Johnson Foundation, a not-for-profit foundation that focuses primarily on healthcare. It has over $8.8 billion in assets under management. 9 Conducted by the Harvard School of Medicine, in 2008. Diet and civilization diseases in the USA.

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That the strategy is successful is the result of Coopers determination and con viction. Prior to the strategys implementation, many skeptics believe it unlikely that children would voluntarily eat fresh salads. But such worries turned out to be unfounded it is not true that children do not like vegetables or salads; it is just that they have not been given the opportunities to try out the vegetables that they do like!

2.1.1 Lessons drawn i. By allowing children to choose their own ingredients for their salads, children are empowered and made responsible for their own decision to be healthy. ii. In order for an idea to work, people need to be given a chance to experience it for themselves. In this example, it was because children are given an opportunity to try out salads for themselves that Cooper was able to prove her skeptics wrong.

2.2

Berkeleys School Lunch Initiative

2.2.1 Lessons Drawn 2.3 Partnering CLIF Kids

2.3.1 Lessons Drawn

..

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Introduction to E2 Unhealthy Eating Habits of Children in Singapore

Many other developed countries, and also increasingly developing nations, suffer the same problem of unhealthy eating habits amongst their young, including Singapore.

3.1

Project Background and History

The emergency of unhealthy eating habits of children in Singapore has its roots in several factors:
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Since independence, Singapore has become a more prosperous nation. Singaporeans are also having fewer children. These two factors together contribute to parents being able to afford better nutrition for their children. This however, has led to uncontrolled overeating in children in extreme cases.

Many families in Singapore have two working parents, thus the children in such families do not have anyone to prepare their meals for them and resort to eating their meals out.

With economical hawker centers, coffee shops, airconditioned food courts and higherends restaurants spread all over the island, all types and forms of food are readily available at the doorsteps of its population. Such convenience, coupled with the abundance of variety, and reasonably priced food has prompted a significant proportion of its population to eat out regularly.10 It is important to note that food stalls and restaurants do not generally attempt to provide healthy choices of food, as maintaining low operating costs and tasty food are of higher priority. As such, children who constantly take their meals outside are exposed to food with higher saturated fat content and sodium levels.

10

Ang, K.L., & Foo,S. (2002). An exploratory study of eating patterns of Singapore children and teenagers. Health Management, 102(5), 239-248.

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3.2

Rationale for Choice of Topic

We shall discuss the rationale for our choice of this topic by looking at the consequences of this emergency, the need for intervention and how the emergency is showing signs of worsening.

3.2.1 Consequences Unhealthy eating habits amongst the young in Singapore inevitably lead to a greater problem of childhood obesity. The consequences of childhood obesity are twofold (Fig. 3.1):
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Medical - Obese children are at increased risk of developing diseases like hypertension and liver disease. They also may develop respiratory problems during sleep, namely in obstructive sleep apnoea which can leave them tired in the day, hindering their ability to concentrate in school. Finally the extra weight that obese children carry can put stress on their joints and result in leg pain.11

Psychosocial - Obese children may also suffer emotional and social consequences. Other children and also adults may tease them about their weight and this may cause the child to be self-conscious and embarrassed. This can result in low self-esteem and a change in selfimage, particularly during adolescence. 12
Fig. 3.1: Classification of medical and psychosocial consequences of childhood obesity.

11 12

http://www.nestle.com.sg/Health+And+Nutrition/Specific+Needs/children.htm French SA, Story M, Perry CL. Self-esteem and obesity in children and adolescents: a literature review. Obes Res 1995; 3:479-90.

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3.2.2 Why the need for intervention It is true that the government has been making a concerted effort to reverse the emergency of unhealthy eating habits among children in Singapore. Such efforts include the infamous Trim And Fit program instituted in schools between 1992 2007. However the TAF programme was abolished in 2008 after much criticism about how it caused stigmatization of students in its program, and in some cases, led to eating orders in some children.13 The TAF programme has since been replaced by the Holistic Health Framework which aims to take into account the physical, mental and social well-being of all students. While this is a good effort at taking care of the health of children in Singapore, certainly more can be done specifically about the unhealthy eating habits of Singaporean children, which we seek to address in our project.

3.2.3 How topic is emergent The total proportion of overweight and obese students (that is, overweight plus worse-thanoverweight) in primary and secondary schools and junior colleges did fall from 11.1% in 1994 to 9.5% in 2007. Unfortunately, it is notable that within that encouraging drop, the percentage of obese students increased from 2.8% in 1994 to 3.6% in 2007.14 Furthermore, the main nutrition-related health problem among schoolchildren is still obesity.15 As such the emergency of unhealthy eating habits among Singaporean children still shows signs of emergence.

13 14

Sandra Davie. School link to eating disorders possible:. The Straits Times, 16 May 2005 Ministry of Health. Speech III by Mr Heng Chee How, Minister Of State for Health. 03 Mar 2008. http://www.moh.gov.sg/mohcorp/speeches.aspx?id=18384 15 http://www.singstat.gov.sg/pubn/reference/yos/statsT-health.pdf

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Addressing the Unhealthy Eating Habits of the Young in Singapore

Our proposals target the main 3 key stakeholders in this issue, namely students, parents and schools. (Fig. 4.1) By adopting a range of strategies targeted at different sectors of the community, we hope to comprehensively address the problem of obesity before it worsens and becomes a national emergency.

Fig. 4.1: The 3 main stakeholders in addressing unhealthy eating habits of Singaporean youths

4.1

Proposal 1: U-Pack! Fun Recipes for Uths

4.1.1 Overview Proposal 1 focuses on encouraging and enabling students to prepare their own healthy home-cooked food to pack to school. As children today spend long hours in school and eat at least 1 or even 2 meals in school, encouraging children to have more healthy eating habits should thus begin from the meals taken in school. We propose building on the existing Home Economics lessons of secondary school students to incorporate more healthy and fuss-free recipes for preparation of meals for lunchboxes. Creative lunchboxes that can be custom-designed will also be given to students so as to encourage them to pack their own food.

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This will be a collaborative effort between the Health Promotion Board and the Ministry of Education, as these two agencies have the most resources to reach our target audience, namely children and young people.

4.1.2 Objectives and application of lessons learnt This proposal has 3 objectives (Fig. 4.2):
a.

Empower students with the ability to prepare and pack their own healthy meals to school.

b. c.

Convince students of the ease of preparing their own healthy meals. Educate students on the choice of healthy ingredients to use in their meals.

Fig. 4.2: The 3 objectives of Proposal 1

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The following lessons from E1 can be applied to this strategy: Currently, supposedly while cut tuckshops down on have the

unhealthy (sweet drinks and deepfried foods) food sold in school16, such standards still vary. According to a survey (Table 4.3) we did with 100 student respondents, 69% of them said that their canteen still sold sugary drinks and fried foods.17

Table 4.3: Respondents opinion on whether their canteens sold unhealthy food. (Source: Survey Results)

As such, the proposal of encouraging students to pack their own healthy home-cooked food to school empowers children to prepare their own meals, and allows them to take up the responsibility of maintaining healthy eating habits for themselves.

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The Model School Tuckshop Programme (MSTP) was introduced in 2003 to enhance the availability of healthier food choices in school tuckshops through an integrated programme involving teachers, tuckshop vendors and students. http://www.hpb.gov.sg/hpb/default.asp?pg_id=1709 17 We surveyed students from 18 different schools. 30% of them come from primary schools, 50% from secondary schools and 20% from junior colleges.

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Many young people are also not fully convinced that healthy food can taste good. According to our survey (Table 83% 4.4), of an the

overwhelming

respondents believe that fast food tastes better than healthy food.

Which tastes better?

Fast Food Healthy Food

83% 17%

Table 4.4: Respondents opinion on whether healthy food can taste good. (Source: Survey Results)

Therefore, in order to convince them that healthy food is good, students need to be given a chance to try it out. Our proposal thus allows students to have the opportunity to try preparing healthy food for their own meals.

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4.1.3 Details of Proposal 1 Recipe Internationale!! Students will be taught an easy-to-prepare healthy recipe from a different country every week for 9 weeks (See Table 4.5 for Scheme of Work). They will also be taught how to calculate the calories and fat content of the dish.
Lesson 1 2 3 4 5 6 7 8 9 Recipe Tuna sushi rolls Thai mango salad Healthy fried brown rice Pasta Primavera Mexican bean salad Vietnamese fresh spring roll Chicken tikka wraps Tomato & thyme fish with rice Low-fat Banana Oat Muffins

Tuna Sushi rolls

Table 4.5: Suggested Scheme of Work for Recipe Internationale!

Makes 16 small rolls Ingredients (serves 4) 1 cup sushi rice, rinsed 1 tablespoon seasoned rice vinegar 4 nori sheets (dried, roasted seaweed) 1/2 avocado, sliced lengthways 105g can tuna drained, flaked 1/2 cucumber, cut into thin strips 1 small carrot, grated Soy sauce, to serve Method 1. Place rice and 1 1/2 cups cold water in a saucepan over high heat. Cover and bring to the boil. Reduce heat to low and cook for 15 minutes or until rice is tender and liquid absorbed. Remove from heat. Stand for 5 minutes. 2. Place rice and vinegar in a bowl. Stir to combine. Allow to cool completely, stirring regularly to prevent rice becoming gluggy. 3. Place 1 nori sheet, shiny-side down, on a sushi mat. Using moist hands, spread one-quarter of the rice mixture over the nori sheet, leaving a 3cm-wide border around the edges. Place one-quarter of the avocado along the edge facing you. Top with onequarter each of the salmon, cucumber and carrot. Using the sushi mat, roll up firmly to enclose filling. Repeat with remaining nori, rice mixture, salmon and vegetables. 4. Slice each roll into 4 pieces. Wrap in plastic wrap.

Fig. 4.6: Sample recipe for Recipe Internationale!

There will be a practical assessment at the 10th week (see Table 4.7 for judging criteria), where students will prepare a simple dish that can amalgamate ingredients and cooking styles from the recipes taught over the last 9 weeks.

Table 4.7: Criteria for Practical Assessment - Recipe Internationale!

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Recipe Press!! A blog (Fig. 4.8) will be set up for students to blog on their progress in the module. They may also use this platform to share tips for healthy cooking. food preparation/

Fig. 4.8: Sample Student Blog entries for Recipe Press!!

UPack!! We also propose a collaboration with Ngee Ann Polytechnic students from the School of Design to design a lunchbox for our target audience called the UPack (Fig. 4.9).

The UPack can be customizable through the use of decals to make every single one unique. It will be launched on ACES Day by the Minister of Education Dr Ng Eng Hen.

Fig. 4.9: Artists impression of the UPack!

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4.1.4 Evaluation

The merits of the ideas introduced in Proposal 1 are (Fig. 4.10):

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The use of Home Economics lessons to develop healthy recipes builds on an existing resource to help educate students on healthy eating habits.

The introduction of customizable lunchboxes is also a creative way of resurrecting an old idea to solve a new problem.

Trying out new healthy recipes in Home Economics lessons helps convince students that healthy food is not as bland as thought.

Empowering students with the ability to prepare their own healthy meals allows them to take charge of their own health.

However, there are some possible problems and limitations with the ideas in Proposal 1 (Fig. 4.10):
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Students may not be able to find the time in their busy schedules to prepare food for their own lunchboxes.

Students may also find it inconvenient and unfashionable to carry a lunchbox, thus the design of the lunchbox needs to be more compact and yet stylish to motivate students to bring their lunchboxes to school.

Fig. 4.10: Merits and demerits of Proposal 1

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4.3 Proposal 2: 4.3.1 Objectives and Application of Lessons Learnt 4.3.2 Details 4.3.3 Evaluation 4.5 Proposal 2: . 4.4.1 Objectives and Application of Lessons Learnt 4.4.2 Details 4.4.3 Evaluation

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Conclusion

This report has highlighted the emergence of unhealthy eating habits amongst children as an increasing problem both in the US and in Singapore by looking at the long-term consequences of this problem for both countries. It is clearly evident that intervention is imperative in order to prevent the problem from becoming a full-fledged emergency. We have thus looked at the strategies that have been employed in the US against this problem, and extracted important lessons learnt for transference to help battle this same problem in Singapore through creative yet effective proposals. While this problem is not an easy one to solve and will not go away overnight, we are confident that together with the support and collaboration of the identified stakeholders, the battle can be won.

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