Improving the food environment in UK schools: Policy opportunities and challenges

Facilitators and barriers to healthful eating among adolescents in high-income countries: A mixed-methods systematic review

Adolescent obesity continues to be a public health challenge with poor quality diets contributing to its etiology. As part of the process to plan health promotion and policy interventions, understanding adolescents perceived facilitators and barriers to healthful eating is important. An integrative convergent mixed-methods systematic review was used to synthesize qualitative and quantitative evidence from studies among adolescents aged 10-19 years in high-income countries. Medline, Embase, PsycInfo, and Scopus were searched for peer-reviewed articles published between 2010 and 2023 and exploring adolescents' perspectives on healthful eating and contemporary contextual factors. Transformed quantitative data were integrated with qualitative data. Text was coded into subthemes and themes using an inductive approach. Key facilitators included health and physical appearance; motivation; taste; nutrition knowledge, awareness, and skills; nutrition education access; availability and accessibility of healthful foods; family; and social influences and digital media. Key barriers included taste and cravings for unhealthful foods; mood; lack of motivation, awareness, knowledge, and skills; high availability and low cost of unhealthful foods; peers and social influences; ineffective school policies; high density of fast-food outlets; unhealthful food advertising; digital influences; and time constraints. Social, behavioral, digital, and food environmental factors should be considered from an adolescent perspective in the design of education, health promotion, and policy interventions.

School food hero and the battle of the food foes: A story of public health policy, power imbalance and potential

This paper explores the impact of school food policy from the perspective of school food workers to offer an alternative account of why school food may not be having the desired impact on child health or food choices. Drawing upon the findings from an institutional ethnography carried out in three UK primary schools, we argue that school food is being asked to perform an unrealistic task of luring children and families away from more unhealthy food options, without being given adequate resources or powers to do this job effectively. We theorise that the narrative depicting school food as a hero, combatting the harms of poor dietary choices and poor health outcomes, is inappropriate as a countermeasure to mitigate the effects of wider food industry forces. We revisit the narrative to consider the power imbalances within society that structure dietary choices, presenting our findings and the wider policy review in the form of a story about the evolution of school food set against a shifting food environment. We conclude with recommendations for policy makers who want to see school food have a greater impact in improving child health.

Adolescents' dietary behaviour: The interplay between home and school food environments

In the UK, school food standards have looked to improve the nutritional profile of school food provision and the choices made; however, adolescents' choices tend to bias towards micronutrient poor and energy dense options. This study aimed to explore how adolescents make their school food choices, along with how they engage with their environments whilst selecting food. Seven focus group interviews took place with adolescents (n = 28; 13-14 years) in a secondary school in Northern England. Discussions with participants were audio-recorded, transcribed verbatim and then analysed using an inductive thematic approach. Six themes emerged from the data: (1) parents' and adolescents' roles in the home food environment, (2) burgeoning food autonomy, (3) school food choice factors, (4) social aspects of school food, (5) home versus school, (6) food knowledge & beliefs. Adolescents identified two distinct environments during the focus group discussions: the home and school environments. Adolescents juxtaposed the two, in terms of food provision, food choices, rules and customs surrounding food choice. This juxtaposition emerged as an indirect but important influence on adolescents' school food choices. The school and home environments both (in)directly influence adolescents' school food choices, which involve an integration of multiple, often conflicting influences. Adolescents may adopt a number of unhelpful dietary rationalisations as they try to manage and reconcile these influences. Consultation, together with consideration of relevant food choice models, is required to identify opportunities to influence adolescents' food choices at school.

Identifying barriers and facilitators in the development and implementation of government-led food environment policies: a systematic review

CONTEXT

Policy-specific actions to improve food environments will support healthy population diets.

OBJECTIVE

To identify cited barriers and facilitators to food environment policy (FEP) processes reported in the literature, exploring these according to the nature of the policy (voluntary or mandatory) and country development status.

DATA SOURCES

A systematic search was conducted of 10 academic and 7 grey-literature databases, national websites, and manual searches of publication references.

DATA EXTRACTION

Data on government-led FEPs, barriers, and facilitators from key informants were collected.

DATA SYNTHESIS

The constant-comparison approach generated core themes for barriers and facilitators. The appraisal tool developed by Hawker et al. was adopted to determine the quality of qualitative and quantitative studies.

RESULTS

A total of 142 eligible studies were identified. Industry resistance or disincentive was the most cited barrier in policy development. Technical challenges were most frequently a barrier for policy implementation. Frequently cited facilitators included resource availability or maximization, strategies in policy process, and stakeholder partnership or support.

CONCLUSIONS

The findings from this study will strategically inform health-reform stakeholders about key elements of public health policy processes. More evidence is required from countries with human development indices ranging from low to high and on voluntary policies.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42018115034.

The impact of, and views on, school food intervention and policy in young people aged 11-18 years in Europe: A mixed methods systematic review

Understanding the social and environmental influencers of eating behaviours has the potential to improve health outcomes for young people. This review aims to explore the effectiveness of school nutrition interventions and the perceptions of young people experiencing a nutrition focused intervention or change in school food policy. A comprehensive systematic search identified studies published between 1 December 2007 to 20 February 2020. Twenty-seven studies were included: 22 quantitative studies of nutrition related outcomes and five qualitative studies reporting views and perceptions of young people (combined sample of 22,138 participants, mean ages 12-18 years). The primary outcome was nutrition knowledge/dietary behaviours, with secondary outcomes exploring body mass index (BMI) and wellbeing. Due to the heterogeneity of studies, a narrative results description is presented. The findings demonstrate that school nutrition programmes can be effective in reducing sugar, sugar sweetened beverages (SSB) and saturated fat and increasing fruit and vegetable (FV) intake. The lived experiences of young people in a school context provide valuable insights that should be considered in the development of effective school food policy and interventions. This review affirms the significant role that schools can play in supporting good nutrition in all young people and provides opportunities to inform the school food agenda.

Basic school pupils' food purchases during mid-morning break in urban Ghanaian schools

BACKGROUND

Unhealthy food vending can expose children to malnutrition and other diet related challenges such as obesity. This study sought to describe types and sources of food in basic schools in urban Accra, and to describe food purchases by pupils.

METHODS

This was a cross-sectional study of five basic schools (3 public; 2 private) and 644 pupils in the Ga-East Municipality in Ghana. Check-lists were used to document available sources of foods during school hours. Pupils were intercepted after making purchases during breaktime and the type, cost and sources of foods purchased documented. Energy content of foods were read from labels when available or estimated using the Ghana Food Composition database when unlabelled. Frequencies and crosstabs were used to compare food type by source and school type.

RESULTS

Foods were purchased from school canteen, school store, private stores, and 'table-top' vendors. Meals were most frequently purchased (38%) although single purchases were sweetened drinks, savoury snacks and confectioneries. About 53% of retailers located within the schools sold relatively healthier food options. Similar foods with comparable energy content were purchased within and outside of school.

CONCLUSIONS

Basic schools in urban Ghana provide ready access to energy dense food options, which are purchased by pupils both within and outside of school premises. Timely interventions inclusive of school food policies can encourage healthier diets among pupils.

The impact of hot food takeaways near schools in the UK on childhood obesity: a systematic review of the evidence

BACKGROUND

Obesity is the greatest health issue for this generation; schools have improved food offered within their grounds. The built environment surrounding schools and pupils' journeys home have not received the same level of attention. This review identified papers on impacts of hot food takeaways surrounding schools in the UK.

METHODS

Methods were informed by the PRISMA (QUORUM) guidelines for systematic reviews. Searches were completed in 12 databases.

RESULTS

A total of 14 papers were included and quality assured before data extraction. Three descriptive themes were found; descriptions of hot food takeaway's geography and impacts concerning schools, strategic food policy and pupils reported food behaviour.

CONCLUSIONS

Most included studies compared anthropometric measures with geographical location of hot food takeaways to find correlations between environment and childhood obesity. There was good evidence of more hot food takeaways in deprived areas and children who spend time in deprived neighbourhoods tend to eat more fast food and have higher BMIs. Few studies were able to quantify the correlation between school's environment and obesity amongst pupils. This lack of evidence is likely a factor of the studies' ability to identify the correlation rather than lack of a correlation between the two variables.

The Impact of a Gradual Healthier Assortment among Vocational Schools Participating in a School Canteen Programme: Evidence from Sales and Student Survey Data

Many adolescents have poor eating habits. As a major part of their caloric intake takes place at school, the present study aims to examine the effect of increasing the availability of healthier foods in school canteens on sales, student attitude and self-reported behaviour. A quasi-experimental study was carried out at two vocational schools in the Netherlands over a 10-month period, where the visible share of healthier products was gradually or abruptly increased from 60% to 80%. Outcome measures were sales data for healthier and less healthy foods and drinks in the canteens, as well as surveys. The proportion of healthier products sold increased from 31.1% during the baseline period to 35.9% in the final period. A gradual increase led to higher relative sales of healthier products (40%) than an abrupt change (34.5%). Survey data showed that students’ moderate satisfaction remained insensitive to the changes over time. Overall, results suggest that increasing the availability of healthier products in school canteens leads to small positive changes in sales of products, particularly in the product groups beverages and sandwiches. A gradual introduction may ensure that students slowly get used to assortment changes.

Examining school-level implementation of British Columbia, Canada's school food and beverage sales policy: a realist evaluation

OBJECTIVE

To identify key school-level contexts and mechanisms associated with implementing a provincial school food and beverage policy.

DESIGN

Realist evaluation. Data collection included semi-structured interviews (n 23), structured questionnaires (n 62), participant observation at public events (n 3) and scans of school, school district and health authority websites (n 67). The realist heuristic, context + mechanism → outcome configuration was used to conduct the analysis.

SETTING

Public schools in five British Columbia (BC), Canada school districts.

PARTICIPANTS

Provincial and regional health and education staff, private food vendors and school-level stakeholders.

RESULTS

We identified four mechanisms influencing the implementation of BC's school food and beverage sales policy. First, the mandatory nature of the policy triggered some actors' implementation efforts, influenced by their normative acceptance of the educational governance system. Second, some expected implementers had an opposite response to the mandate where they ignored or 'skirted' the policy, influenced by values and beliefs about the role of government and school food. A third mechanism related to economics demonstrated ways vendors' responses to school demand for compliance with nutritional Guidelines were mediated by beliefs about food preferences of children, health and food. The last mechanism demonstrated how resource constraints and lack of capacity led otherwise motivated stakeholders to not implement the mandatory policy.

CONCLUSION

Implementation of the food and beverage sales policy at the school level is shaped by interactions between administrators, staff, parent volunteers and vendors with contextual factors such as varied motivations, responsibilities and capacities.

Parents' and Teachers' Views of Food Environments and Policies in Indian Private Secondary Schools

School food environments and policies can play a pivotal role in inculcating healthy food habits among young people. This cross-sectional survey explored teachers’ and parents’ views of the role of school food environments and policies in promoting healthy food consumption among Indian adolescents. Thirty-two teachers and 280 parents from five private, English-speaking, secondary schools in Kolkata, India took part in a short questionnaire survey which included closed and open answer questions. Descriptive and chi-square analyses were performed to compare the responses of parents and teachers. Thematic data analysis underpinned by Template Analysis Technique was employed to examine the qualitative responses. The easy availability and accessibility of energy-dense, nutrient-poor foods, the limited availability of nutritious foods, the absence of written food policies, and inflated prices of nutritious foods were reported as problems in the Indian school food environment. However, the respondents also noted that schools restricted the sale of sugar-sweetened beverages and adopted hygienic food practices. Novel ideas for creating healthy school food environments and effective school canteen policies were also captured during the survey. These findings point to the need to create effective school food policies in Indian secondary schools to help adolescents eat healthily at school. Future research is required to test the feasibility of the implementation of school food policies.

Barriers to Nutrition Promotion in Private Secondary Schools in Kolkata, India: Perspectives of Parents and Teachers

School-based nutrition promotion is critical to the development of healthy eating habits in adolescents. Unfortunately, most Indian secondary schools do not support healthy eating among adolescents. Therefore, this study was designed to understand the perspectives of teachers and parents regarding the potential barriers to nutrition promotion in Indian secondary schools. Thirty-two teachers and 280 parents from five private English-speaking secondary schools in Kolkata, India took part in a cross-sectional survey. The paper-based survey instrument included both quantitative and qualitative items which were derived from previously published evidence. Descriptive and chi-square analyses were conducted on the quantitative data. Qualitative data were evaluated by thematic data analysis underpinned by the template analysis technique. Five main barriers to nutrition promotion emerged from the study. These included the perceived strong preference for energy-dense, nutrient-poor foods among students; lack of government canteen guidelines; limited engagement of parents, teachers, and adolescents in canteen operations; the widespread display of eye-catching food advertisements; and poor knowledge among canteen personnel with regards to healthy food preparation. These findings about the potential barriers to nutrition promotion provide useful directions for healthy school food policy implementation. Successful implementation of healthy school food policies can inculcate lifelong healthy eating habits among adolescents.

Institutional sustainable purchasing priorities

Purpose

This purpose of this paper is to understand the environmental impacts of stakeholder-driven sustainable purchasing policies in institutional settings.

Design/methodology/approach

The research is framed using stakeholder and life cycle assessment (LCA) theories. The study uses a multi-method approach. Starting with interviews to understand the breadth of sustainability issues and significant food purchases facing institutional purchasing managers, the authors subsequently perform LCA of these various policies using the most popular food item in different categories.

Findings

From the interview results, the authors found that food purchasers focus predominately on cost, thus, are committed to food and packaging reduction. They are driven to buy local foods based on their consumer stakeholders but share their commitment to buying local products if the cost is appropriate. In the LCA of popular food items in multiple scenarios, avoiding food waste of various forms had significantly higher carbon emissions savings than packaging reduction or transportation minimizing (buy local) strategies.

Research limitations/implications

The sample relied solely on the perceptions of institutional purchasing managers in university dining services. Future research should involve collecting data from other stakeholder groups such as the customers themselves, institutional leaders, and in other types of institutional settings such as hospitals and government agencies.

Practical implications

The research provides managers with insights concerning the trade-offs between different sustainability objectives. In particular, findings show that reducing waste related animal protein has a bigger impact on environmental performance than many other popular sustainability objectives such as buying local or reducing packaging waste.

Social implications

The paper focuses on the purchasing trade-offs of buying local vs national food products, different packaging solutions, and food waste generation. These decisions offer some social benefits (improve the economic situation for local farms vs consolidated food producers) as well as multiple environmental benefits.

Originality/value

The paper presents new findings on the sustainability purchasing priorities of stakeholders in institutional food settings and subsequent LCA of those policies to show which might have the most environmental impact.

Secondary school pupils' food choices around schools in a London borough: Fast food and walls of crisps

The objective was to observe and document food behaviours of secondary school pupils from schools in a London borough. The research design combined a number of methods which included geographic information system (GIS) mapping of food outlets around three schools, systemised observations of food purchasing in those outlets before, during and after school, and focus groups conducted with pupils of those schools to gather their views in respect to those food choices. Results are summarised under the five 'A's of Access, Availability, Affordability and Acceptability & Attitudes: Access in that there were concentrations of food outlets around the schools. The majority of pupil food purchases were from newsagents, small local shops and supermarkets of chocolate, crisps (potato chips), fizzy drinks and energy drinks. Availability of fast food and unhealthy options were a feature of the streets surrounding the schools, with 200 m the optimal distance pupils were prepared to walk from and back to school at lunchtime. Affordability was ensured by the use of a consumer mentality and pupils sought out value for money offers; group purchasing of 'two for one' type offers encouraged this trend. Pupils reported healthy items on sale in school as expensive, and also that food was often sold in smaller portion sizes than that available from external food outlets. Acceptability and Attitudes, in that school food was not seen as 'cool', queuing for school food was not acceptable but queuing for food from takeaways was not viewed negatively; for younger pupils energy drinks were 'cool'. In conclusion, pupils recognised that school food was healthier but provided several reasons for not eating in school related to the five 'A's above.

How cooks navigate nutrition, hunger and care in public-sector foodservice settings

OBJECTIVE

To examine the perspectives and practices of cooks responsible for carrying out healthy meal programmes in publicly funded foodservice, in order to better understand what they consider to be 'good' food and where nutrition and nutritional standards fit into this conceptualization.

DESIGN

A qualitative, exploratory study involving in-depth interviews that were conducted with cooks and their supervisors about their work practices and perspectives on providing healthy food for clients.

SETTING

Participants were recruited from child-care, after-school, senior-centre and shelter settings that had participated in healthy menu training in New York City, USA.

SUBJECTS

Eighteen cooks and nine supervisors working in the aforementioned settings.

RESULTS

The views and practices of both cooks and supervisors about what constitutes 'good' food extend beyond a purely nutritional view of goodness to include the importance of addressing hunger and clients' food preferences, among other factors. Cooks address these by interacting with clients and altering recipes and menus in a range of ways to maximize the likelihood of food consumption and enjoyment. These approaches are often, but not always, compatible with setting-specific nutritional guidelines that may be set at the national, state, local or organizational level.

CONCLUSIONS

Cooks play a key role in translating nutritional guidelines into what is served. In doing so, they engage in skilled labour and forms of care that increase the ability of public-sector foodservice to address food security and other goals, but these aspects of their work are not widely recognized.

Modifying the food environment for childhood obesity prevention: challenges and opportunities

The prevention of childhood obesity is a global priority. However, a range of complex social and environmental influences is implicated in the development of obesity and chronic disease that goes beyond the notion of individual choice. A population-level approach recognises the importance of access to and availability of healthy foods outside the home. These external food environments, in restaurants, supermarkets, and in school, or recreation and sports settings, are often characterised by energy dense, nutrient-poor food items that do not reflect the current nutritional guidelines for health. In addition, our understanding of these broader influences on nutritional intake is still limited. Particularly, lacking is a clear understanding of what constitutes the food environment, as well as robust measures of components of the food environment across different contexts. Therefore, this review summarises the literature on food environments of relevance to childhood obesity prevention, with a focus on places where children live, learn and play. Specifically, the paper highlights the approaches and challenges related to defining and measuring the food environment, discusses the aspects of the food environment unique to children and reports on environmental characteristics that are being modified within community, school and recreational settings. Results of the review show the need for a continued focus on understanding the intersection between individual behaviour and external factors; improved instrument development, especially regarding validity and reliability; clearer reported methodology including protocols for instrument use and data management; and considering novel study design approaches that are targeted at measuring the relationship between the individual and their food environment.

Meeting school food standards - students' food choice and free school meals

OBJECTIVE

To examine students’ school food choice in relation to school food standards and entitlement to free school meals (FSM).

DESIGN

Cross-sectional analysis of students’ school food choices.

SETTING

Two large secondary schools in Yorkshire, England.

SUBJECTS

Students (n 2660) aged 11–18 years.

RESULTS

Sandwiches and pizza were the most popular main food items: 40·4 % and 31·2 %, respectively, in School A; 48·3 % and 27·3 %, respectively, in School B. More nutritionally valuable ‘dishes of the day’ accounted for 8·7 % and 8·3 % of main foods for School A and School B, respectively. FSM students were more likely (P < 0·0 0 1) to choose main foods (School A: FSM 87·04 %, non-FSM 70·28 %; School B: FSM 75·43 %, non-FSM 56·13 %). Dishes of the day were chosen on a significantly greater (P < 0·0 0 1) percentage of days by FSM v. non-FSM students (School A: FSM 15·67 %, non-FSM 7·11 %; School B: FSM 19·42 %, non-FSM 5·17 %).

CONCLUSIONS

Despite the availability of nutritionally valuable dishes of the day, the most popular food items were sandwiches, pizza and desserts. FSM students were more likely to choose the more nutritionally valuable dish of the day. School food standards should be reassessed in light of students’ preferences.

A healthy trend: less food used in fundraising and as rewards and incentives in Minnesota middle and high schools

OBJECTIVE

To assess change in the 4-year prevalence (2006-2009) of the use of food in school fundraising and as rewards and incentives for students, following implementation of federal legislation in the USA in 2006.

DESIGN

Serial cross-sectional design using trend analysis to assess school-level data collected over four consecutive years from 2006/2007 to 2009/2010.

SETTING

Minneapolis/St. Paul, MN.

SUBJECTS

Convenience sample of middle and high schools participating in two longitudinal, aetiological studies that examined youth, their environment and obesity-related factors.

RESULTS

A significant and sustained decrease was demonstrated in the use of low-nutrient, energy-dense foods in school fundraising activities and the use of food and food coupons as rewards and incentives by teachers and school staff.

CONCLUSIONS

Results support the utility of policy and legislative action as a tool for creating healthy, sustainable environmental change.

Changes in dietary behavior among adolescents and their association with government nutrition policies in Korea, 2005-2009

OBJECTIVES

This study was conducted to observe recent changes in adolescents' dietary behavior and indirectly evaluate the effects of the government's nutritional policies in Korea.

METHODS

We analyzed the secular trends in seven dietary behaviors using the Korea Youth Risk Behavior Web-based Survey data from 2005 to 2009. Through literature review, we included the policies implemented for the improvement of adolescents'dietary behaviors during the same periods.

RESULTS

The significant linear trends were observed in all dietary behaviors (p<0.05). Overall, all behaviors except the fruit intake rate were desirably changed during five years but undesirable changes were observed between 2008 and 2009 in all behaviors. Within those periods, several policies were implemented including 'Ban on carbonated-beverages in school', 'Green Food Zone', etc. Despite confirmed evidence of their effects, the policies on individual behavior such as nutrition education didn't influence the prevalence of dietary behaviors because they were conducted to too limited persons. Policies on the school environmental improvement, such as ban on carbonated beverage in school, were more effective because they decreased the exposure of undesirable food environment. However, for effect of Green Food Zone improving community environment we couldn't come to a conclusion because of too short period after full implementation.

CONCLUSIONS

Among government nutrition policies conducted from 2005 to 2009, those on environmental improvement, especially in school, were more effective than those on individual behavior. Therefore, the development and implement of policies on school environmental improvement are needed in Korea.

American Cancer Society Guidelines on nutrition and physical activity for cancer prevention: reducing the risk of cancer with healthy food choices and physical activity

The American Cancer Society (ACS) publishes Nutrition and Physical Activity Guidelines to serve as a foundation for its communication, policy, and community strategies and, ultimately, to affect dietary and physical activity patterns among Americans. These Guidelines, published approximately every 5 years, are developed by a national panel of experts in cancer research, prevention, epidemiology, public health, and policy, and they reflect the most current scientific evidence related to dietary and activity patterns and cancer risk. The ACS Guidelines focus on recommendations for individual choices regarding diet and physical activity patterns, but those choices occur within a community context that either facilitates or creates barriers to healthy behaviors. Therefore, this committee presents recommendations for community action to accompany the 4 recommendations for individual choices to reduce cancer risk. These recommendations for community action recognize that a supportive social and physical environment is indispensable if individuals at all levels of society are to have genuine opportunities to choose healthy behaviors. The ACS Guidelines are consistent with guidelines from the American Heart Association and the American Diabetes Association for the prevention of coronary heart disease and diabetes, as well as for general health promotion, as defined by the 2010 Dietary Guidelines for Americans and the 2008 Physical Activity Guidelines for Americans.