Steps towards reducing Australia s healthcare burden A collaborative approach to adequate dairy food consumption in children

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1 Steps towards reducing Australia s healthcare burden A collaborative approach to adequate dairy food consumption in children

2 Overview Recent studies indicate adequate dairy food consumption is associated with a reduced risk of overweight and obesity and related chronic diseases, yet many Australian children are falling short of the recommended intakes of dairy foods such as milk, cheese and yogurt. Since food behaviours formed in childhood shape lifelong dietary habits, an opportunity exists for health professionals and policymakers to improve the health of Australians by actively supporting and developing measures that improve children s dairy food consumption. This paper outlines the health benefits associated with adequate dairy food consumption in childhood and later in life and the potential healthcare savings in adulthood, making recommendations to improve children s health through a collaborative approach. Introduction The social and financial burden of obesity on Australian society is substantial, costing the healthcare system $58 billion per annum, with associated chronic diseases reaching nearly $12 billion.1 3 Recent studies have demonstrated a link between adequate dairy food consumption and a reduced risk of overweight, obesity and chronic diseases such as osteoporosis, cardiovascular disease and type 2 diabetes. Authorities in both Australia and the United States acknowledge the body of evidence to support the health benefits of dairy foods and have shaped their dietary recommendations accordingly.4, 5 Despite such recommendations, most Australians underconsume dairy foods,6 fruit, vegetables and whole grains, while consuming too many refined cereals7 and extra foods.8,9 Extra foods such as hot chips, cakes, muffins, potato crisps, sweet biscuits, icecream, pies and chocolate may contribute excessively to children s energy intake and increase the risk of weight gain.10 The 2007 Australian National Children s Nutrition and Physical Activity Survey (the Survey) indicated children are consuming up to twice the recommended limits of energy-dense, nutrient-poor extra foods.11 These foods often displace core foods, such as vegetables, fruit and dairy foods, from children s diets.11 The Survey also found the nutrient most lacking from the diet of children over the age of 4 years was calcium.12 A closer look at the Survey shows the inadequate intake of calcium is matched by an underconsumption of dairy foods.13 Nicklas has suggested children with a low intake of calcium and dairy foods were less likely to consume dairy foods in adulthood, noting children with healthier eating habits were less likely to develop chronic diseases in adulthood.14 Dietary interventions promoting the consumption of dairy foods such as milk, cheese and yogurt demonstrate the feasibility of improving children s dairy intake where increases of one serve a day are achievable.15 Encouraging children to consume adequate serves of dairy foods may track into adulthood to deliver considerable healthcare savings associated with reduced risk of chronic disease later in life. Research by Doidge et al. suggests around $2 billion per year could be saved from Australia s health expenditure if Australians aged 12+ years consumed adequate amounts of dairy foods.16 This figure is comparable to the entire public health budget. The results of various studies investigating the health benefits of dairy food consumption are outlined overleaf. The reasons for the underconsumption of dairy foods, and recommendations to address the barriers to childhood dairy food consumption, are also presented to facilitate discussion and action on how to promote adequate dairy food intake in children. A collaborative approach between government, policymakers, key stakeholders and the broader community has the potential to improve the diet of Australian children and influence current and future health outcomes. Key points: Adequate dairy food consumption is linked to a reduced risk of overweight and obesity and associated chronic diseases, as acknowledged in the NHMRC s evidence statements supporting the Australian Dietary Guidelines4 From the age of 4 years, Australian children are not meeting the recommended intakes of dairy food, such as milk, cheese and yogurt, which are being displaced from their diets by energy dense, nutrient-poor extra foods, such as hot chips, cakes and muffins, potato crisps, sweet biscuits, ice cream, pies and chocolate Several barriers have been identified that lead to the inadequate intake of dairy foods in children Addressing these barriers through a collaborative approach offers health benefits throughout childhood and adulthood, and may considerably reduce Australia s healthcare costs.

3 Adequate dairy food consumption why does it matter? Health benefits associated with adequate dairy food consumption The burden of obesity and chronic disease on the Australian healthcare system is considerable, as shown in the table below. Several studies have investigated the effects of dairy food consumption on different measures of health in children and adults, as outlined in the table below. Annual cost to Australian healthcare system Evidence relating dairy food consumption to children s health Obesity $58.2 billion 17 Osteoporosis $1.9 billion (direct) and $7.4 billion (indirect) 18 Type 2 diabetes Up to $6 billion 3 Cardiovascular disease $5.9 billion 2 The latest national figures show more than a quarter of children have an unhealthy body weight, with 23% of children considered overweight or obese. 19 The prevalence of childhood obesity is also increasing. 20 Due to the link between obesity and chronic disease, these increasing rates are a public health concern as chronic disease adversely affects longevity, disability free life years, quality of life and productivity. 21 Australian children aged 2 16 by Body Mass Index (BMI) category, 2007 (per cent) a 17% 6% a Population weights applied. Source: 2007 Australian National Children s Nutrition and Physical Activity Survey 19 5% 72% Normal Overweight Obese Underweight Healthy weight Lowered blood pressure Reduced risk of type 2 diabetes Bone health Prevention of chronic disease in adulthood Dairy food consumption appears to protect against overweight and obesity in children. A birth cohort study of 362 Australian children by Garden et al. found that higher intakes of dairy foods as a percentage of total energy at 18 months of age had a negative relationship with Body Mass Index (BMI) at 8 years. 22 Similarly, Moore et al. reported that higher dairy food consumption at 3 6 years of age was associated with a lower BMI and lower sum of four skin folds at years of age. 23 Louie et al. systematically reviewed ten prospective cohort studies that examined the relationship between dairy food consumption and overweight/ obesity in children aged 2 14 years. 24 Six studies reported no significant association with weight gain, three studies reported a protective association and one reported an increased risk of weight gain with the consumption of more than three serves of milk a day. In a birth cohort study of 335 children, Rangan et al. found that dairy food consumption had a protective effect on blood pressure in children. 25 Children who consumed more than 2.9 serves of dairy foods per day at 18 months had much lower blood pressure at 8 years of age than children who consumed less than 1.4 serves of dairy foods per day. They also reported that children who consumed two or more serves of dairy products both at 18 months and 9 years of age had lower blood pressure than other children who consumed less dairy food. A study by Malik et al. interviewed 37,038 women about their dairy food intake in high school and then followed them for 7 years. 26 The researchers found that women who had higher dairy food intakes in adolescence were 38% less likely to develop type 2 diabetes in adulthood. A meta-analysis of seven cohort studies by Tong et al. also found an inverse relationship between the daily intake of dairy foods and the development of type 2 diabetes. 27 Achieving peak bone mass is critical for reducing the risk of bone fractures and osteoporosis, and is partly dependent on calcium intake in childhood and adolescence. 28 A meta-analysis of 21 randomised controlled trials found that high calcium intakes significantly increased children s total body and lumbar spine bone mineral content. 29 Retrospective studies have also shown that poor childhood dairy food consumption is associated with higher rates of fractures in adulthood Dairy foods are a complex mixture of saturated fats, protein, vitamins and minerals that when consumed may not exert effects predicted by their content of saturated fats. A recent prospective study has examined the effect of specific food sources of saturated fat on cardiovascular disease risk, reporting that a higher intake of saturated fat from dairy foods was associated with lower risk of cardiovascular disease. Each 5 g/d greater intake of saturated fat from dairy foods was associated with a 21% lower risk of cardiovascular disease. 34 The National Health and Medical Research Council has found sufficient evidence to link daily consumption of two to three serves of dairy foods with reduced risks of ischaemic heart disease, myocardial infarction, hypertension, stroke, type 2 diabetes, metabolic syndrome, colorectal cancer and osteoporosis. 4 Since adequate dairy food consumption in childhood is likely to continue into adulthood, 14 encouraging adequate consumption of dairy foods in childhood can have long-term health benefits. Key points Adequate dairy food consumption is linked to a reduced risk of overweight and obesity and associated chronic diseases, as acknowledged in the NHMRC s evidence statements supporting the Australian Dietary Guidelines4 the Fromage of 4 years, Australian children are not meeting the recommended intakes of dairy foods, which are being displaced from their diets by energy dense, nutrient poor extra foods, such as hot chips, cakes and

4 Children s calcium and dairy food consumption is inadequate Only one in five children aged 4 11 years consumes the recommended amount of dairy foods each day. Data from the Survey indicated that many children had an inadequate dietary calcium intake, particularly as they grew into adolescence. 12 An analysis of the data revealed that 45% of children aged 9 11 years failed to meet the Estimated Average Requirement (EAR) for calcium and that this figure increased to 69% in children aged years. The figures were worse for adolescent girls who were less likely to meet their calcium needs than were boys. Percentage of children who do not meet the EAR for calcium* Years of age Boys Girls All children 2 3 1% 1% 1% 4 8 7% 15% 11% % 55% 45% On average, only one in five children aged 4 11 years consumes the recommended amount of dairy foods each day. 35 Adequate consumption of dairy foods, including milk, cheese and yogurt, is important for children to meet their Recommended Dietary Intake (RDI) of calcium. Three serves of dairy foods every day provide most children with their RDI of calcium. A serve is equivalent to a glass of milk (250 ml), two slices of cheese (40 g) or a tub of yogurt (200 g), each providing approximately 300 mg of calcium. In addition to providing a rich source of calcium, dairy foods provide a unique package of nutrients that includes protein, riboflavin, vitamin B12, magnesium, potassium, zinc, vitamin A, phosphorus and carbohydrates. Percentage of children who meet the recommended serves for dairy foods* % 89% 69% % 82% 62% *Percentage of children failing to meet the EAR for calcium according to age, using estimates of usual nutrient intakes from the 2007 Australian National Children s Nutrition and Physical Activity Survey % Age (years) *Percentage of children meeting Australian Guide to Healthy Eating (AGHE) (1998) recommendations for dairy consumption according to age, using estimates of usual nutrient intakes from a reanalysis of the 2007 Australian National Children s Nutrition and Physical Activity Survey

5 Recommendations for addressing barriers to childhood dairy food consumption Collaborative initiatives aligning health communications from governments, key stakeholders including health professionals and non-government organisations, and communities have the potential to overcome barriers to inadequate dairy food 36, 37 consumption and improve children s health. Children s RDI for calcium increases as they grow older, as shown in the table below. The RDI increases during adolescence to meet the demands of a growing skeleton. Data from the Survey indicated that the average calcium intake for adolescents aged years was 989 mg/day, which falls short of the RDI of 1300 mg/day by more than one serve of dairy foods. 12 Recommended intakes of calcium and dairy foods and consumption of dairy foods in Australian children Age (years) RDI for calcium (mg) Number of serves of dairy foods typically consumed (mean)* Recommended number of serves of dairy foods to meet the RDI for calcium *Using estimates of usual intake from a reanalysis of the 2007 Australian National Children s Nutrition and Physical Activity Survey 35 Barriers to adequate dairy food consumption in childhood Parents understanding of dairy serves and dietary recommendations Parents awareness of the recommended dairy food intakes and what constitutes a serve of dairy food increases the chance that their children will meet their daily requirements. 38 Consumer research has suggested that although parents think their children are consuming enough dairy foods, they are unsure of the recommended daily intakes and are unaware of the increased requirements as children grow older. 38 Parental influence Parents dietary habits and behaviours influence their children s intake of dairy foods. 15 Parents, especially mothers, are generally responsible for purchasing and preparing food and providing dairy foods in the home. They are also role models and can shape children s dietary habits by consuming dairy foods themselves. A US study of 182 children aged 5 9 years found that milk-drinking mothers were more likely to have milk-drinking daughters. 40 Perception that dairy foods contribute to weight gain Market research suggests that a significant number of consumers perceive dairy foods as fattening. 38 However, recent studies have indicated that dairy food consumption is not associated with overweight and obesity, and may even 22, 24 have a protective effect against weight gain. Recommendations for addressing barriers Raise awareness of the underconsumption of dairy foods Implement education activities to improve parents understanding of the dietary recommendations for dairy foods and what constitutes a serve of dairy food. Nolan-Clark et al. observed that consumers attitudes towards dairy products could be improved through nutrition education 39 Raise parents awareness of the importance of dairy food consumption for themselves and their children, and of their influence as dietary role models for their children Encourage mothers to increase their children s dairy intake by providing them with practical advice on how to incorporate dairy foods in their children s daily diets Highlight to parents that dairy food consumption is not linked to excess weight gain Highlight that the consumption of extra foods by children might contribute to excessive energy intakes and weight gain 10

6 Parents are role models that shape children s dietary habits, influencing their intake of dairy foods. Conclusions Barriers to adequate dairy food consumption in childhood Added sugars in flavoured milk Fifty-two per cent of parents with children aged 5 12 years believe flavoured milk contains too much added sugar. 41 However, Johnson et al. found no relationship between flavoured milk intake and the consumption of added sugars. 42 Similarly, Murphy et al. reported no difference between intakes of added sugars in flavoured milk drinkers compared to nonmilk drinkers, although increased intakes of added sugars were observed in younger children aged 2 5 years who consumed flavoured milk compared to children consuming plain milk. 43 Both studies reported higher intakes of calcium among children who consumed flavoured milk compared to those who exclusively consumed plain milk. 42, 43 Studies have also shown that the consumption of flavoured milk does not adversely affect 43, 44 children s BMI. Availability of competitive foods Australian children consume up to twice the recommended limits of energy-dense, nutrient- poor extra foods. 11 These foods displace nutrient-dense core foods, such as dairy foods, from children s diets. Extra foods and beverages available at schools through vending machines or canteens can compete with dairy foods in children s diets. 14 Recommendations for addressing barriers Raise awareness of the benefits of plain and flavoured milk. Flavoured milk contains the same nutrients as plain milk and provides a nutrient-rich choice for children and adolescents compared to soft drinks and fruit juice Flavoured milk may be useful in encouraging children and adolescents to meet their recommendations for calcium 43 Raise awareness of the contribution of extra foods to the energy, sugar and fat intakes of Australian children Encourage the replacement of extra foods with core foods, such as fruit, vegetables and dairy foods Improve the availability and accessibility of dairy foods at home and at school 15 Use taste exposure to promote childhood dairy food intake 15 and encourage children to consume plain or flavoured milk in preference to soft drinks, fruit juice and sugar-sweetened fruit drinks The burden of chronic disease may be reduced by at least $2 billion if Australians consumed the recommended intakes of dairy foods. 16 Adequate consumption of dairy foods, such as milk, cheese and yogurt, throughout life is associated with several health benefits, including a reduced risk of overweight and obesity. Increasing the consumption of dairy foods by children increases the likelihood that they will consume adequate amounts of dairy foods as adults. 14 Improving the diet of Australian children requires collaborative interventions, encompassing nutrition education alongside supporting programs and policies, to encourage adequate consumption of dairy 14, 36 foods. Building on the evidence presented, more research is needed to highlight the benefits of dairy foods for children s health and to improve understanding of barriers to consumption. A collaborative approach between Dairy Australia, health professional bodies, policymakers and other key stakeholders is required to deliver dietary advice and interventions that will ensure adequate consumption of dairy foods by Australian children and thus improve health now and in the future. Key recommendations for increasing children s dairy food intake include: Raising public awareness of children s underconsumption of dairy foods Educating parents and children about the importance of dairy foods in a healthy diet and the recommended serves of dairy each day for children at every age Encouraging the replacement of extra foods in the diet with core foods, such as fruit, vegetables and dairy foods Improving the availability and accessibility of dairy foods to children both inside and outside the home Promoting the consumption of wholegrain cereal-based breakfasts. Eating meals outside the home Meals, snacks and beverages eaten outside the home are more likely to be higher in fat and lower in fibre and calcium than those eaten at home. 14 In addition, adolescents rarely order milk at fast-food establishments because it is either unavailable or not as visible as other options such as soft drinks. 14 Support measures to improve the availability and accessibility of dairy foods in establishments outside the home 14 Encourage children and parents to eat more meals at home 14 Skipping breakfast The NSW Schools Physical Activity and Nutrition Survey found that 15.4% of primary school children did not consume breakfast. 45 This figure increased in high school children, among whom 26.8% of boys and 42.4% of girls did not consume breakfast. Children are more likely to consume dairy foods during breakfast, particularly if they have a cereal-based breakfast. 14 Girls who consumed cereal at breakfast had significantly higher daily calcium intakes than girls who ate a non-cereal breakfast. 46 Promote the consumption of breakfast, in particular wholegrain cereal-based breakfasts, among parents, children and adolescents Provide milk to schoolchildren as part of breakfast programs 15

7 For further information or to discuss, contact: Dr Roxanne Portolesi Nutrition Science Manager References 1. National Health Priority Action Council. National Chronic Disease Strategy. Canberra: Department of Health and Ageing, Australian Institute of Health and Welfare. Cardiovascular disease: Australian facts. Canberra: AIHW, Shaw J et al. Diabetes: the silent pandemic and its impact on Australia National Health and Medical Research Council. A review of the evidence to address targeted questions to inform the revision of the Australian Dietary Guidelines. Canberra: NHMRC, US Department of Agriculture and US Department of Health and Human Services. Dietary Guidelines for Americans. 7th edition, Washington, DC: US Government Printing Office, Doidge JC et al. ANZJPH 2012 [in press]. 7. National Health and Medical Research Council. Australian Dietary Guidelines incorporating the Australian Guide to Healthy Eating. Draft for public consultation. Canberra: Rangan AM, et al. Eur J Clin Nutr 2009 Jul;63(7): Rangan AM et al. Eu J Clin Nutr 2008;62: Swinburn BA et al. Public Health Nutr 2004;7(1A): Rangan AM et al. Obes Res Clin Pract 2011;5:e Commonwealth Scientific Industrial Research Organisation Preventative Health Nutrition Research Flagship and University of South Australia Australian National Children s Nutrition and Physical Activity Survey: Main findings. Canberra: Department of Health and Ageing, Baird DL et al. Public Health Nutr 2012;[in press]. 14. Nicklas T. J Am Coll Nutr 2003;22(5): Hendrie GA et al. Public Health Nutr Doidge JC et al. J Nutr 2012 [in press]. 17. Access Economics. The growing cost of obesity: three years on. Canberra: Access Economics, Access Economics. The burden of brittle bones: costing osteoporosis in Australia. Canberra: Access Economics, Australian Institute of Health and Welfare. Australia s food & nutrition 2012, Cat. no. PHE 163. Canberra: AIHW. 20. Australian Institute of Health and Welfare. Obesity and injury: a review of the literature. Canberra: AIHW, Wang YC et al. Lancet 2011;378(9793): Garden FL et al. Eur J Clin Nutr 2011;65(4): Moore LL et al. Obesity 2006;14(6): Louie JCY et al. Obes Rev 2011;12(7):e Rangan AM et al. Eur J Clin Nutr 2012 [in press]. 26. Malik VS et al. Am J Clin Nutr 2011;94(3): Tong X et al. Eur J Clin Nutr 2012;65(9): Peacock M. Am J Clin Nutr 1991;54(1):261S 65S. 29. Huncharek M et al. Bone 2008;43(2): Murphy S et al. Br Med J 1994;308(6934): Soroko S et al. Am J Public Health 1994;84(8): Teegarden D et al. Am J Clin Nutr 1999;69(5): Kalkwarf HJ et al. Am J Clin Nutr 2003;77(1): de Oliveira Otto et al. Am J Clin Nutr 2012; 96(2): Bowen J et al. Commonwealth Scientific Industrial Research Organisation, Secondary Analysis of the 2007 Australian National Children s Nutrition and Physical Activity Survey, Algazy J et al. McKinsey Quarterly 2010; Miller GD et al. J Am Coll Nutr 2001;20(Suppl. 2):168S 85S. 38. Dairy Australia. Dairy Monitor 2009;Wave Nolan-Clark DJ et al. BMC Public Health 2011;11: Fisher JO et al. Am J Clin Nutr 2004;79(4): Nature Market Research Kids Tracker Wave 1 Melbourne, Johnson RK et al. J Am Diet Assoc. 2002;102: Murphy MM et al. J Am Diet Assoc 2008;108(4): Albala C et al. Am J Clin Nutr 2008;88(3): Hardy LL et al. NSW Schools Physical Activity and Nutrition Survey (SPANS) 2010: Full report. Sydney: NSW Ministry of Health, Barton BA et al. J Am Diet Assoc 2005;105(9): Published by Dairy Australia Limited. Whilst all reasonable efforts have been taken to ensure the accuracy of the Steps towards reducing Australia s healthcare burden, use of the information contained herein is at one s own risk. To the fullest extent permitted by Australian law, Dairy Australia disclaims all liability for any losses, costs, damages and the like sustained or incurred as a result of the use of or reliance upon the information contained herein, including, without limitation, liability stemming from reliance upon any part which may contain inadvertent errors, whether typographical or otherwise, or omissions of any kind. Dairy Australia Limited All rights reserved. Dairy Australia Limited ABN Level 5, IBM Centre, 60 City Road, Southbank Victoria 3006 T: F: Wellmark DAA /12

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