Australian school canteens: menu guideline adherence or avoidance?

Comparative analysis of school food policies in Australian jurisdictions: Insights for more effective policy action

ISSUE ADDRESSED

School food policies in Australia have the potential to positively impact healthy eating in schools. While the policies are reviewed regularly, it is unknown if revised school food policies have incorporated the recommendations from a 2020 review of nutrition policies in publicly funded institutions. This review aims to examine the current state of Australian school food policy environment, including national-level guidelines, food safety, allergy, and anaphylaxis management policies.

METHODS

School food policy documents were identified by searching the federal government, and Departments of Health and Education websites of Australian jurisdictions. The L'Abbé framework for monitoring and evaluation of nutrition policies guided the data analysis.

RESULTS

Eleven policies/guidelines from Australian national and state/territory governments were reviewed in 2023. Four state/territory policies had major updates since 2020. The consistency of nutrition standards improved across five jurisdictions, although a common nutrient classification system would have allowed better comparison. Implementation guides/tools and supporting resources were provided in all policies although their comprehensiveness varied. Policy monitoring and evaluation guide/tools, and local food procurement were incorporated in two additional policies. School principals were responsible for policy implementation and schools for independent compliance monitoring.

CONCLUSION

Continued improvement in monitoring and evaluation plans, policy review timelines, and support systems for schools is needed to enhance implementation and impact of school food policies. External stakeholder support may help school leadership in more effective policy implementation. SO WHAT?: Limited progress in incorporating recommendations into current school food policies calls for additional support and strategies to enhance policy implementation and monitoring.

Unpacking the cost of the lunchbox for Australian families: a secondary analysis

Ninety per cent of Australian school children bring a home-packed lunch to school, with 44% of the food consumed during school hours being unhealthy. Among other factors, cost is a key consideration for food provision; however, the costs to Australian families are not well understood. Therefore, we aimed to determine what families are currently paying for school lunchboxes in Australian primary schools and to examine associations between food costs and socio-demographic factors with dietary quality. An audit of local retail outlets was used to determine the food costs of lunchbox contents. Costs (AUD) were adjusted for inflation as of early 2023. The lunchboxes of 1026 children aged 4-12 years at 12 Catholic primary schools in New South Wales, Australia, were assessed at the start of the day, using photography assessment methods and a validated School Food Checklist. The mean cost of lunchbox contents was $4.48 AUD (SD 1.53), containing a mean energy of 2699 kJ (SD 859), with 37.3% (SD 23.9) of energy sourced from unhealthy foods. Multiple linear regression analyses found that the strongest predictors of higher lunchbox cost (P < 0.05) were a higher proportion of energy from unhealthy foods (B = 0.016) and lower Socio-Economic Indexes for Areas (B = -0.178), when controlling for child socio-demographics. The results indicated that lunchbox food costs to Australian families are comparable to alternative school food service models in Australia and internationally. Results demonstrate the cost of food is not the only barrier to providing a healthy school lunchbox. Demonstrating a need for cost-considerate systematic interventions addressing food provision challenges and socio-economic disparities faced by families.

How healthy and affordable are foods and beverages sold in school canteens? A cross-sectional study comparing menus from Victorian primary schools

OBJECTIVE

Government policy guidance in Victoria, Australia, encourages schools to provide affordable, healthy foods in canteens. This study analysed the healthiness and price of items available in canteens in Victorian primary schools and associations with school characteristics.

DESIGN

Dietitians classified menu items (main, snack and beverage) using the red, amber and green traffic light system defined in the Victorian government's School Canteens and Other School Food Services Policy. This system also included a black category for confectionary and high sugar content soft drinks which should not be supplied. Descriptive statistics and regressions were used to analyse differences in the healthiness and price of main meals, snacks and beverages offered, according to school remoteness, sector (government and Catholic/independent) size, and socio-economic position.

SETTING

State of Victoria, Australia.

PARTICIPANTS

A convenience sample of canteen menus drawn from three previous obesity prevention studies in forty-eight primary schools between 2016 and 2019.

RESULTS

On average, school canteen menus were 21 % 'green' (most healthy - everyday), 53 % 'amber' (select carefully), 25 % 'red' (occasional) and 2 % 'black' (banned) items, demonstrating low adherence with government guidelines. 'Black' items were more common in schools in regional population centres. 'Red' main meal items were cheaper than 'green'% (mean difference -$0·48 (95 % CI -0·85, -0·10)) and 'amber' -$0·91 (-1·27, -0·57)) main meal items. In about 50 % of schools, the mean price of 'red' main meal, beverages and snack items were cheaper than 'green' items, or no 'green' alternative items were offered.

CONCLUSION

In this sample of Victorian canteen menus, there was no evidence of associations of healthiness and pricing by school characteristics except for regional centres having the highest proportion of 'black' (banned) items compared with all other remoteness categories examined. There was low adherence with state canteen menu guidelines. Many schools offered a high proportion of 'red' food options and 'black' (banned) options, particularly in regional centres. Unhealthier options were cheaper than healthy options. More needs to be done to bring Victorian primary school canteen menus in line with guidelines.

The efficacy of a multi-strategy choice architecture intervention on improving the nutritional quality of high school students’ lunch purchases from online canteens (Click & Crunch High Schools): a cluster randomized controlled trial

Background

High school canteens are an ideal setting for public health nutrition intervention, and choice architecture strategies that facilitate the purchase of healthier foods and beverages from school canteens are recommended by the World Health Organization. The rapid uptake of online lunch ordering within school canteens provides a unique opportunity to implement choice architecture strategies that support healthier food choices with high fidelity. Despite this, no trial has tested the efficacy of choice architecture strategies within an online lunch ordering system on improving the nutritional quality of high school student lunch purchases. The objective of this study was to assess the impact of embedding choice architecture strategies into an online lunch ordering system on the nutritional quality of the school canteen lunch purchases of high school students (aged 12–19 years).

Methods

A cluster randomized controlled trial was conducted with nine high schools in one Australian state. Schools were randomized to receive either a 2-month choice architecture intervention (involving menu labelling, prompts, item positioning, and feedback), or usual online ordering. Nutrient quality of online canteen lunch purchases was assessed using routine data collected by the online ordering system. Primary outcomes were the proportion of ‘Everyday’, ‘Occasional’, and ‘Should not be sold’ items purchased, categorized using the state healthy canteen policy. Secondary outcomes were the mean energy, saturated fat, sugar, and sodium content of purchases and the mean weekly revenue from online lunch orders. Linear mixed models were analyzed to assess outcomes.

Results

Analysis of the student cohort (Intervention: 4 schools, 656 students; Control: 5 schools, 675 students) showed significant between group differences over time for the intervention group for the mean percentage of online lunch items per student that were ‘Everyday’ (+ 5.5%; P < 0.001) and ‘Should not be sold’ (− 4.4%; P < 0.001). There were no between group differences over time in the mean percentage of online lunch items that were ‘Occasional’; the average energy, saturated fat, sugar, or sodium content of lunch orders. There was also no difference in mean weekly revenue from high school student online lunch orders (P = 0.23).

Conclusions

These findings suggest that a low intensity, choice architecture intervention embedded within an online ordering system can increase the purchase of healthier food items for high school students in one Australian state without any adverse impact on canteen revenue.

Trial registration

This trial was prospectively registered on Open Science Framework on 23rd October 2020 as osf.io/h8zfr.

Understanding Enablers and Barriers to the Implementation of Nutrition Standards in Publicly Funded Institutions in Victoria

Effective implementation of nutrition standards in publicly funded institutions can facilitate healthy food and beverage consumption by communities and populations, which can enable improvements in dietary intake and reduce disease burden. This study aimed to understand stakeholder perspectives on the implementation of government nutrition standards in publicly funded institutions in the Australian state of Victoria, as well as to determine enablers and barriers to successful implementation. Pre-interview questionnaires and semi-structured interviews were administered to stakeholders involved in the implementation of nutrition standards in publicly funded institutions in Victoria. The Interactive Systems Framework, which allows understanding of the infrastructure and systems needed to implement policies, was used to design the survey instruments and guide the data analysis. Forty-four stakeholders were interviewed, including program implementers, support personnel and food providers, across public sector hospitals and health services, workplaces, sport and recreation centres and schools. Though translated materials and resources have been developed for end-users to facilitate uptake and implementation, current nutrition standards were perceived to be long and complex, which hindered implementation. The existence of a government-funded implementation support service enabled action by providing technical support, troubleshooting and capacity-building. A specific pathway for successful guideline implementation was determined through the analysis. Opportunities to close the policy-implementation gap were identified. This will be crucial to maximising the impact of nutrition standards on population diets and reducing diet-related disease. Strengthening the guidelines and their governance, streamlining the support system and overcoming barriers within and outside of implementing organisations, are urgently required to propel statewide progress.

Identification and Evaluation of Tools Utilised for Measuring Food Provision in Childcare Centres and Primary Schools: A Systematic Review

BACKGROUND

Children aged 2-11 years spend significant hours per week in early childhood education and care (ECEC) and primary schools. Whilst considered important environments to influence children's food intake, there is heterogeneity in the tools utilised to assess food provision in these settings. This systematic review aimed to identify and evaluate tools used to measure food provision in ECEC and primary schools.

METHODS

The Preferred Reporting Items for Systematic Reviews (PRISMA) was followed. Publications (2003-2020) that implemented, validated, or developed measurement tools to assess food provision within ECEC or primary schools were included. Two reviewers extracted and evaluated studies, cross checked by a third reviewer and verified by all authors. The Academy of Nutrition and Dietetics Quality Criteria Checklist (QCC) was used to critically appraise each study.

RESULTS

Eighty-two studies were included in the review. Seven measurement tools were identified, namely, Menu review; Observation; Weighed food protocol; Questionnaire/survey; Digital photography; Quick menu audit; and Web-based menu assessment. An evidence-based evaluation was conducted for each tool.

CONCLUSIONS

The weighed food protocol was found to be the most popular and accurate measurement tool to assess individual-level intake. Future research is recommended to develop and validate a tool to assess service-level food provision.

Content analysis of school websites: policies and programs to support healthy eating and the environment

Preschools and primary schools are important settings for the development of healthy eating habits and awareness of environmentally friendly practices. This study explored South Australian government schools' policies and programs in relation to healthy eating and environmentally friendly aspects of food choice (such as packaging), and whether any schools approached these issues in combination. Websites of 18 government preschools and primary schools in the Greater Adelaide region, stratified by low, medium and high socioeconomic status were reviewed for publicly available policies and other relevant content. A content analysis was undertaken, with policies and programs analysed deductively and thematically. Healthy eating (n = 8) and environment (n = 3) related policies were found on preschool websites only. The main themes observed across the three categories of interest (healthy eating, environmentally friendly practices and low-waste healthy foods) included the presence/absence of formal policy, promotional strategies and implementation. Expectations of children bringing healthy 'nude' foods that were environmentally friendly were mentioned informally on the websites but were not part of policy documents. Policies and programs around healthy eating and environmentally friendly practices (in combination) were lacking. There is scope to address this gap to improve health and sustainable outcomes within the school environment context.

The effectiveness of canteen manager audit and feedback reports and online menu-labels in encouraging healthier food choices within students' online lunch orders: A pilot cluster randomised controlled trial in primary school canteens in New South Wales, Australia

Online school canteen lunch ordering systems may offer a unique opportunity to support the implementation of school canteen nutrition polices, while delivering behavioural interventions directly to consumers to influence healthy student purchasing. This cluster randomised controlled trial aimed to test the effectiveness of a menu audit and feedback strategy alone, and in combination with online menu labels in encouraging healthier purchasing from an online school canteen ordering system. Five intervention schools received a menu audit and feedback strategy, plus online menu labels; and five control schools received a delayed menu audit and feedback strategy. Data from 19,799 student lunch orders, containing over 40,000 items were included in the evaluation. Outcomes were assessed at baseline (pre-intervention), follow-up 1 (menu audit and feedback vs control), and follow-up 2 (menu audit and feedback plus online menu labels vs menu audit and feedback alone). From baseline to follow-up 1, the menu audit and feedback strategy alone had no significant effect on the proportion of healthy ('Everyday') and less healthy ('Occasional' or 'Should not be sold') items purchased. From baseline to follow-up 2, schools that received menu audit and feedback plus online menu labels had significantly higher odds of students purchasing 'Everyday' items (OR: 1.19; p = 0.019), and significantly lower odds of students purchasing 'Occasional' (OR: 0.86; p = 0.048) and 'Should not be sold' (OR: 0.52; p < 0.001) items. Menu audit and feedback with the addition of online menu labels was effective in increasing the proportion of healthy items purchased relative to menu audit and feedback in isolation. There may be a greater role for online menu labelling as part of a suite of strategies to improve public health nutrition in schools.

A Cross-Sectional Study of the Nutritional Quality of New South Wales High School Student Food and Drink Purchases Made via an Online Canteen Ordering System

Unhealthy dietary patterns in adolescence are associated with an increased risk of future chronic disease. This study aimed to assess online canteen lunch purchases made by high school students to identify: (1) the nutrient composition of purchases (energy, saturated fat, sugar, sodium, percent energy from saturated fat and total sugar); (2) the proportion of items classified as healthier (‘Everyday’) and less healthy (‘Occasional’ or ‘Should not be sold’) according to the New South Wales Healthy Canteen Strategy; (3) the frequency of purchases by product type (e.g., salty snacks), their classification and nutrient composition; and (4) associations between student characteristics and the nutrient composition and classification of purchases. The average order contained 2075 kJ of energy, 6.4 g of saturated fat, 18.4 g of sugar and 795 mg of sodium. Less healthy (‘Occasional’ and ‘Should not be sold’) items combined accounted for 56% of purchases. The most frequently purchased products were burgers and crumbed/coated foods. Students in higher grades purchased a significantly higher mean percent of ‘Everyday’ items, compared to students in grades 7 or 8. The majority of high school student purchases were less healthy (‘Occasional’ or ‘Should not be sold’) items, warranting further investigation of factors influencing online canteen purchasing behaviour in this setting.

Essential food and nutrition knowledge and skills for primary school children: Australian parents' opinions

Purpose

This paper examines the views of Australian primary school parents regarding the food and nutrition education (FNE) curriculum. Associations with personal values (Universalism and Hedonism) and demographic measures were also explored.

Design/methodology/approach

An online survey was conducted among 787 parents in March 2021. Parents rated the importance of 17 FNE topics. They were also asked about their support for six curriculum improvements and to state their own improvement suggestions.

Findings

Parents viewed the “Effect of food on health” and “Food hygiene” as the most important topics. Three FNE components were derived: (1) food safety and preparation, (2) health and nutrition information, (3) food origins and environmental sustainability. The “Food safety and preparation” component score was associated with both universalism-nature and hedonism values but negatively associated with parental education. The “Health and nutrition information” component score was associated with universalism-nature value and main language spoken at home. Lastly, the “Food origins and environmental sustainability” component score was associated with universalism-nature value. The two personal values, universalism-nature and hedonism, were more strongly associated with parents' views of curriculum topics than parental demographic characteristics. Parents had several criticisms of current FNE, including school food environments not resonating with FNE taught in the classroom and that FNE might increase the risk of eating disorders. They also suggested that the FNE curriculum should support both parents and teachers by providing relevant resources and training.

Originality/value

Australian parents' views of the importance of FNE topics and how to improve FNE in primary schools have been under-examined.

Menu Audit of Vegetable-Containing Food Offering in Primary School Canteens in Sydney, Australia: A Preliminary Study

Children’s vegetable intakes are too low, and school canteens could provide an equitable environment to improve their intake. This study aimed to develop and apply a systematic method to quantify the proportion and variety of vegetable-containing items on primary school canteen menus and examine differences between schools of different socio-economic statuses, sizes and types. Online canteen menus from 112 primary schools in Sydney, Australia, were collected, and data were extracted on a total number of items and vegetable-containing items across different menu categories. Further, data on preparation type and variety were extracted. Differences in the proportion of vegetable items between socio-economic status, school size and type were tested. On average, 80.4 ± 34.0 items were listed, with 30% of items containing vegetables. Most sandwiches (60%) and hot foods (54%) contained no vegetables. The variety of raw vegetables (4.9 ± 1.8 types) was greater than for cooked vegetables (1.3 ± 1.2 types; p < 0.01). Limited differences were observed by socio-economic status and school type. Small schools offered fewer vegetable-containing items than large schools. While primary school canteen menus listed a large variety of items, only one-third contained vegetables. Data from this study can be used to track changes and to develop new opportunities to increase the vegetable supply in schools.

Parents' and teachers' views of the promotion of healthy eating in Australian primary schools

BACKGROUND

Primary schools have long been identified as appropriate settings for improving the healthy eating behaviours of children and helping them develop food skills. This qualitative study explored the views of Australian primary school parents and teachers about schools' strengths and weaknesses in promoting healthy eating and equipping children with food skills.

METHODS

Nineteen parents and 17 teachers from Victoria participated in semi-structured interviews. Audio recordings were transcribed and underwent thematic analysis using Nvivo.

RESULTS

This study demonstrated that parents and teachers believed that several facilitators helped promote children's healthy eating. These included food and nutrition education (FNE) programs, the community-based nature of schools, and teacher role modelling and the authority schools possess over children. Time scarcity, lack of teacher expertise, lack of leadership and funding were reported as barriers. School food environments such as canteens, lunch orders, fundraising events and school fairs were identified as both weaknesses and strengths by parents and teachers, which indicated inconsistent implementation of school nutrition policies across schools.

CONCLUSIONS

Australian primary schools demonstrate some useful efforts to promote healthy eating among children. However, there are numerous facilitators and barriers which impact on the promotion of healthy eating. These factors need to be addressed in order to develop healthy eating habits further among elementary students. These results provide directions for policymakers and school managers, as they point to the areas that need to be improved to assist the design of schools that better promote healthy eating among children.

Australian School Stakeholders' Perceived Strategies for Preventing Adolescent Obesity

Adolescent obesity is a complex multifactorial disease with a combination of environmental, behavioral, psychosocial, biological, cultural and genetic determinants. It remains a global public health issue that presents a major challenge to chronic disease prevention and health into adulthood. Schools have a rich opportunity to improve youth health and tackle obesity, yet they face barriers in fulfilling this function. This study investigated school stakeholders' beliefs and perceptions of the barriers and enablers currently experienced by schools, as well as their recommendations towards preventing adolescent obesity. A sequential explanatory mixed-methods study design was utilised with surveys administered for the quantitative phase and individual interviews for the qualitative phase. Descriptive statistics and inductive thematic analyses were utilised for the survey and interview data, respectively. Triangulation of findings from the quantitative and qualitative phases aided in the better understanding and integration of the overall results. In total, 60 school stakeholders (52 subject teachers, 3 senior teachers and 5 heads of department) from both independent and public high schools in Queensland, Australia responded to the survey, while 14 respondents participated in the interviews. The main perceived causes of obesity were poor eating habits and sedentary lifestyle. Highlighted barriers were busy timetables, shortage of trained staff and funding, lack of robustness in the introduction and implementation of school interventions and insufficient motivation of learners to participate in obesity prevention programs. Enabling factors included parental support, easy access to fitness equipment during recess, supportive government policies, provision of healthier school tuck shop menu options and elimination of sugary drinks from vending machines. A model for the prevention of adolescent obesity was developed based on participants' perceptions. Tripartite collaboration between the school, government and parents was perceived as fundamental to preventing adolescent obesity. Strategies targeting nutrition, physical activity and overall health, including parental education on health, formal health talks in schools by health professionals and better-targeted advertisement encouraging healthy lifestyle choices, were identified as essential for improved adolescent health outcomes.

Scrutinize of healthy school canteen policy in Iran's primary schools: a mixed method study

BACKGROUND

Schools provide an opportunity for developing strategies to create healthy food environments for children. The present study aimed to analyze the Healthy School Canteen (HSC) policy and identify challenges of its implementation to improve the school food environment in Iran.

METHODS

This mixed method study included two qualitative and quantitative phases. In the qualitative phase, triangulation approach was applied by using semi-structured interviews with key informants, documents review and direct observation. Data content analysis was conducted through policy analysis triangle framework. In the quantitative phase, food items available in 64 canteens of primary schools of Tehran province were gathered. The food's nutrient data were evaluated using their nutrition facts label. The number and proportion of foods that met the criteria based on Iran's HSC guideline and the World Health Organization nutrient profile model for the Eastern Mediterranean Region (WHO-EMR) were determined.

RESULTS

The main contextual factors that affected adoption of HSC policy included health (nutritional transition, high prevalence of non-communicable diseases and unhealthy food environment in and around the schools), political (upstream supportive policies and joint memorandums about health children between the Ministry of Health and Medical Education and Ministry of Education), structural (the lack of unified stewardship, inadequate human resource capacity, poor inter-sectional cooperation), economic (school financial problems, poor fiscal supportive of food policies), and socio-cultural (mothers working outside the home, the role of children's peer group, low nutrition knowledge of school principals) factors. Assessment of the school canteens showed that a large proportion of available foods did not comply with the national guidelines (54.7 ± 2.54%) and WHO-EMR model (85.6 ± 2.34%). The main reasons identified for incomplete implementation of the policy were inadequate physical and economic infrastructure to set up standard school canteens, lack of scientific criteria for food categorization, poor monitoring, high price of healthy foods, and conflict of interest among the actors.

CONCLUSION

The majority of foods and beverages available in the school canteens did not comply with national and regional standards. Iran HSC policy needs to be improved by using an evidence-based approach and active interaction between all key actors.

The barriers and enablers to implementing the NSW Healthy School Canteen Strategy in secondary schools in the Illawarra and Shoalhaven region - A qualitative study

ISSUE ADDRESSED

In 2017, the New South Wales Healthy School Canteen Strategy (Strategy) was introduced into primary and secondary schools. Studies have reported that secondary schools have a lower level of compliance with healthy canteen policies compared with primary schools. This study aims to identify and describe the barriers and enablers to implementing the Strategy in Department of Education (DoE) secondary schools in the Illawarra and Shoalhaven regions.

METHODS

The framework underpinning the study was the systems theory. Canteen managers (CM) and principals from the 21 DoE secondary schools in the Illawarra and Shoalhaven regions were invited to participate in semi-structured interviews. The interviews were structured around the five focus areas of the Strategy, including questions on school nutrition policies and the role of the canteen. Data were collated using the interview guides as a framework and qualitative content analysis, using manual coding, was undertaken.

RESULTS

Eight (38%) schools participated with seven CMs and six principals interviewed. Barriers to implementing the Strategy included the changing role of the canteen, the increased demands placed on CMs and inconsistencies between the school food environment and the Strategy. Enablers included monitoring implementation, and internal and external support. This study also recognised that previously identified barriers to healthy canteen strategy implementation are ongoing.

CONCLUSIONS

The school canteen is an integral part of the school environment and therefore needs whole-of-school support if successful implementation of the Strategy is to occur.

SO WHAT

Addressing the barriers and promoting the enablers identified in this study will support better nutrition policy implementation in secondary schools.

An exploratory analysis to identify behavior change techniques of implementation interventions associated with the implementation of healthy canteen policies

Empirical studies to disentangle the effects of multicomponent implementation interventions are needed to inform the development of future interventions. This study aims to examine which behavior change techniques (BCTs) primarily targeting canteen manager are associated with school's healthy canteen policy implementation. This is a secondary data analysis from three randomized controlled trials assessing the impact of a "high," "medium," and "low" intensity intervention primarily targeting canteen managers on school's implementation of a healthy canteen policy. The policy required primary schools to remove all "red" (less healthy items) or "banned" (sugar sweetened beverages) items from regular sale and ensure that "green" (healthier items) dominated the menu (>50%). The delivery of BCTs were retrospectively coded. We undertook an elastic net regularized logistic regression with all BCTs in a single model. Five k-fold cross-validation elastic net models were conducted. The percentage of times each strategy remained across 1,000 replications was calculated. For no "red" or "banned" items (n = 162), the strongest BCTs were: problem solving, goal setting (behavior), and review behavior goals. These BCTs were identified in 100% of replications as a strong predictor in the cross-validation elastic net models. For the outcome relating to >50% "green" items, the BCTs problem solving, instruction on how to perform behavior and demonstration of behavior were the strongest predictors. Two strategies were identified in 100% of replications as a strong (i.e., problem solving) or weak predictor (i.e., feedback on behavior). This study identified unique BCTs associated with the implementation of a healthy canteen policy.

Facilitating Factors and Opportunities for Local Food Purchases in School Meals in Spain

The objective of this study is to explore the facilitating factors and opportunities that can promote the implementation of local food purchase (LFP) in Spanish school meals in the opinions of key informants (IK). A qualitative study was carried out based on in-depth interviews with 14 KI capable of influencing Spanish food policy (Representatives of consumers and/or producers, representatives of organizations that promote LFP, and representatives of the government and/or academics). They were asked about opportunities and facilitating factors for implementation of LFP. Interviews were recorded and transcribed. A qualitative content analysis was carried out with Atlas ti. The analysis of the interviews produced two categories that include factors that- in the interviewees' opinions- can promote LFP (social fabric and policy) and three categories that bring together the factors that represent opportunities for implementation in school meal programs in Spain (the policy agenda, regional characteristics and regional context). The overlap between social and political demands were considered to be facilitating factors for LFP. Furthermore, in the opinions of KI, the presence of health and sustainability issues on the public agenda, the existence of a structured productive system and political changes represent an opportunity to implement LFP.

Facilitators to healthy canteen policy implementation: A qualitative approach

ISSUE ADDRESSED

Governments across the world use guidelines and policy to support improving the quality and nutrition in school canteens, yet little is known about what makes for success in supporting school canteens. This study aimed to investigate the factors influencing the implementation of a healthy school canteen policy.

METHODS

A qualitative descriptive approach using interviews with a purposive sample of Victorian schools that had successfully implemented a healthy school canteen was conducted. Twelve interviews were conducted with principals (n = 4), assistant principal (n = 1), canteen managers (n = 5), food services manager (n = 1) and canteen staff members (n = 3) across six Victorian schools. Data were analysed using a content analysis approach.

RESULTS

Three key themes explained the adoption of policy: Values - emphasising service over profit; Knowledge - understanding of nutrition and the policy; and Support - from within and external to the school.

CONCLUSIONS

Implementation of school canteen policy is more likely to be achieved when a school can focus on the service and educative component of the policy and where there is a shared priority for healthy eating across the entire school community. SO WHAT?: Creating a culture of service and community engagement with a healthy school canteen may increase policy implementation and should be the focus of future health promotion efforts.

Adolescents' views on high school food environments

ISSUE ADDRESSED

This study explored adolescents' views on high school food environments and potential strategies to help them to make informed food choices.

METHODS

Fifteen focus groups were conducted with 131 adolescents aged 12-17 years from three high schools in South East Queensland, Australia. Adolescents were asked how their school food environment (dis)encouraged them to eat healthy and what schools could do to help them eat healthier. All focus groups were audio recorded. Data were analysed using content and thematic data analysis methods.

RESULTS

Four major themes emerged: food availability and affordability; food related policy and regulations; nutrition education; and attitudes, preferences and practices. Adolescents stated that nutrition education within the school curriculum and positive role modelling by peers and school staff in healthy eating were the major factors in helping them to make informed food choices. In contrast, high availability, affordability, fundraising, peer pressure, positive attitudes and negative role modelling towards unhealthy foods impacted unhealthy dietary behaviours.

CONCLUSIONS

Emerging results indicate that adolescents do not perceive the current high school food environments as helping them to make healthy food choices. Adolescents suggested limiting unhealthy foods in high schools by implementing strict food and beverage policies, compulsory nutrition education classes and changing attitudes towards healthy foods as strategies to improve high school food environments. SO WHAT?: This study highlights the importance of high school food environments in impacting adolescents' food choices. Strategies identified by adolescents inform public health practitioners and school authorities on how high school food environments could be tailored to help them in making better food choices.

Secondary school canteens in Australia: analysis of canteen menus from a repeated cross-sectional national survey

OBJECTIVE

The current study aimed to assess the nutritional quality of Australian secondary school canteen menus.

DESIGN

Stratified national samples of schools provided canteen menus in 2012-2013 and 2018, which were systematically assessed against a 'traffic light' classification system according to the National Healthy School Canteen Guidelines. Items were classified as green (healthiest and recommended to dominate canteen menus), amber (select carefully) or red (low nutritional quality, should not appear on canteen menus), and pricing and promotional strategies were recorded.

SETTING

Australia.

PARTICIPANTS

Canteen menus from 244 secondary schools (2012-2013 n 148, 2018 n 96).

RESULTS

A total of 21 501 menu items were classified. Forty-nine percent of canteen menus contained at least 50 % green items; however, nearly all (98·5 %) offered at least one red item and therefore did not comply with national recommendations. Snacks and drinks had the least healthy profile of all product sectors, and a large proportion of schools supplied products typically of poor nutritional quality (meat pies and savoury pastries 91·8 %, sugary drinks 89·5 %, sweet baked goods 71·5 %, ice creams 64·1 % and potato chips 44·0 %). Red items were significantly cheaper than green items on average, and many schools promoted the purchase of red items on canteen menus (52·8 %). There were few differences between survey waves.

CONCLUSIONS

There is considerable room for improvement in the nutritional quality of canteen menus in Australian secondary schools, including in the availability, pricing and promotion of healthier options. Additional resources and services to support implementation of national guidelines would be beneficial.

A comprehensive overview and qualitative analysis of government-led nutrition policies in Australian institutions

BACKGROUND

Institutions are a recommended setting for dietary interventions and nutrition policies as these provide an opportunity to improve health by creating healthy food environments. In Australia, state and territory governments encourage or mandate institutions in their jurisdiction to adopt nutrition policies. However, no work has analysed the policy design across settings and jurisdictions. This study aimed to compare the design and components of government-led institutional nutrition policies between Australian states and territories, determine gaps in existing policies, and assess the potential for developing stronger, more comprehensive policies.

METHODS

Government-led institutional nutrition policies, in schools, workplaces, health facilities and other public settings, were identified by searching health and education department websites for each Australian state and territory government. This was supplemented by data from other relevant stakeholder websites and from the Food Policy Index Australia website. A framework for monitoring and evaluating nutrition policies in publicly-funded institutions was used to extract data and a qualitative analysis of the design and content of institutional nutrition policies was performed. Comparative analyses between the jurisdictions and institution types were conducted, and policies were assessed for comprehensiveness.

RESULTS

Twenty-seven institutional nutrition policies were identified across eight states and territories in Australia. Most policies in health facilities and public schools were mandatory, though most workplace policies were voluntary. Twenty-four included nutrient criteria, and 22 included guidelines for catering/fundraising/advertising. While most included implementation guides or tools and additional supporting resources, less than half included tools/timelines for monitoring and evaluation. The policy design, components and nutrient criteria varied between jurisdictions and institution types, though all were based on the Australian Dietary Guidelines.

CONCLUSIONS

Nutrition policies in institutions present an opportunity to create healthy eating environments and improve population health in Australia. However, the design of these policies, including lack of key components such as accountability mechanisms, and jurisdictional differences, may be a barrier to implementation and prevent the policies having their intended impact.

Prevalence of current school-level nutrition policies and practices of secondary schools in NSW, Australia

ISSUE ADDRESSED

Lowering the rates of adolescent overweight and obesity is a public health priority. The implementation of nutrition policies and practices in schools is recommended by various health organisations, but there is little information on the extent of their implementation. The aim of this study is to describe the prevalence of the implementation of recommended school-level nutrition policies and practices in secondary schools in New South Wales (NSW), Australia, and reported barriers and facilitators to the adoption of such policies and practices in school plans.

METHODS

A cross-sectional study was undertaken with school principals and canteen managers. All eligible secondary schools in NSW were approached to participate in a telephone survey (n = 440). Descriptive statistics were used to describe prevalence, and associations between school characteristics and implementation were examined using univariate statistics.

RESULTS

A total of 137 school principals and 80 canteen managers completed the survey. The implementation of practices on drinking water during class, healthy food and beverage marketing and learning opportunities regarding healthy eating was high (>90% of participating schools). The implementation of practices regarding the restriction of unhealthy drinks in school canteens, healthy school fundraisers and staff training related to healthy eating was reported in under 25% of participating schools. There were no significant differences in implementation by school sector, socio-economic status and geographic location. The main barrier to inclusion of nutrition policies and practices in the school plan was having other priorities and commitments (28.5%), and the main facilitator was support from stakeholders, the staff, students and their parents (37.2%).

CONCLUSIONS

There is opportunity to improve the implementation of nutrition policies and practices in NSW secondary schools. SO WHAT?: Strategies are needed for targeting barriers. These include: gaining support from school staff, students and parents, provision of resources and funding and staff training.

Enablers and barriers to implementation of and compliance with school-based healthy food and beverage policies: a systematic literature review and meta-synthesis

OBJECTIVE

Schools have been recognised as a potential setting for improving young peoples' food and beverage choices; however, many schools fail to adhere to healthy food and beverage policy standards. The current study aimed to explore the enablers and barriers to effective implementation of and compliance with school-based food and beverage policies.

DESIGN

Systematic review and meta-synthesis. Eight electronic databases were searched for articles in June 2019. Studies were eligible for inclusion if they reported on implementation and/or compliance of school-based food and/or beverage policies with outcomes relating to enablers and/or barriers. This review had no restrictions on study design, year of publication or language. Seventy-two full-text articles were assessed for eligibility, of which twenty-eight were included in this review.

SETTING

Studies conducted globally that focused on schools.

PARTICIPANTS

School-based healthy food and beverage policies.

RESULTS

Financial (cost of policy-compliant foods, decreased profit and revenue), physical (availability of policy-compliant foods, close geographical proximity to unhealthy food outlets) and social (poor knowledge, understanding, and negative stakeholders' attitudes towards policy) factors were the most frequently reported barriers for policy implementation. Sufficient funding, effective policy communication and management, and positive stakeholders' attitudes were the most frequently reported enablers for policy implementation.

CONCLUSIONS

There is a need for better communication strategies, financial and social support prior to school-based food policy implementation. Findings of this review contribute to a thorough understanding of factors that underpin best practice recommendations for the implementation of school-based food policy, and inform those responsible for improving public health nutrition.

Measurement Methods Used to Assess the School Food Environment: A Systematic Review

Children consume approximately half of their total daily amount of energy at school. Foods consumed are often energy-dense, nutrient-poor. The school food environment represents an effective setting to influence children’s food choices when dietary habits are established and continue to track into adulthood. The aim of this review was to: (1) group methods used for assessing the school food environment according to four food environment dimensions: Physical, economic, socio-cultural and policy and (2) assess the quality of the methods according to four criteria: Comprehensiveness, relevance, generalizability and feasibility. Three databases were searched, and studies were used to assess food and beverages provided at school canteens, tuck shops or cafeterias were included. The review identified 38 global studies (including 49 methods of measuring the food environment). The physical environment was the primary focus for 47% of articles, aspects of policy environment was assessed by 37% articles and a small number of studies assessed the economic (8%) and socio cultural (8%) environment. Three methods were rated ‘high’ quality and seven methods received ‘medium’ quality ratings. The review revealed there are no standardized methods used to measure the school food environment. Robust methods to monitor the school food environment across a range of diverse country contexts is required to provide an understanding of obesogenic school environments.

The relative price of healthy and less healthy foods available in Australian school canteens

School canteens have an important role in modelling a healthy food environment. Price is a strong predictor of food and beverage choice. This study compared the relative price of healthy and less healthy lunch and snack items sold within Australian school canteens. A convenience sample of online canteen menus from five Australian states were selected (100 primary and 100 secondary schools). State-specific canteen guidelines were used to classify menu items into 'green' (eat most), 'amber' (select carefully) and 'red' (not recommended in schools). The price of the cheapest 'healthy' lunch (vegetable-based 'green') and snack ('green' fruit) item was compared to the cheapest 'less healthy' ('amber/red') lunch and snack item, respectively, using an un-paired t-test. The relative price of the 'healthy' items and the 'less healthy' items was calculated to determine the proportion of schools that sold the 'less healthy' item cheaper. The mean cost of the 'healthy' lunch items was greater than the 'less healthy' lunch items for both primary (AUD $0.70 greater) and secondary schools ($0.50 greater; p < 0.01). For 75% of primary and 57% of secondary schools, the selected 'less healthy' lunch item was cheaper than the 'healthy' lunch item. For 41% of primary and 48% of secondary schools, the selected 'less healthy' snack was cheaper than the 'healthy' snack. These proportions were greatest for primary schools located in more, compared to less, disadvantaged areas. The relative price of foods sold within Australian school canteens appears to favour less healthy foods. School canteen healthy food policies should consider the price of foods sold.

Secondary school implementation of a healthy eating policy

ISSUE ADDRESSED

Healthy canteen policies regulating the sales of food and beverages are available across all the states and territories in Australia. The aim of this study was to assess the compliance with a newly updated healthy school canteen policy in New South Wales (NSW) among a sample of secondary schools.

METHODS

A cross-sectional study of secondary school canteen menus was undertaken in selected regions across NSW (September 2017-November 2017). Government and Catholic secondary schools with a canteen menu publicly available on school websites were eligible for inclusion. Menus were classified according to the NSW Healthy School Canteen Strategy using a Quick Menu Audit tool, previously validated in primary schools.

RESULTS

Of 62 Catholic and 128 Government secondary schools located in the study region, 53 secondary schools (25 Catholic and 28 Government) were eligible to participate. The average percentage of "everyday" (healthy) items on secondary school menus was 54% (strategy criteria is >75%). Twenty-eight per cent of menus had no "sugary drinks" (should not be sold). None of the 53 menus assessed met all strategy criteria regarding the availability of foods and beverages. There was no statistically significant difference in meeting; (a) 75% minimum "everyday" items and (b) no "sugary drinks," by socio-economic region, remoteness, school enrolments or school type.

CONCLUSIONS

If public health benefits of healthy eating policies are to be realised, secondary schools need to be supported to implement such policies. SO WHAT?: Future research assessing the impact of intervention strategies to support policy implementation in secondary schools is recommended.

Cluster randomised controlled trial of an online intervention to improve healthy food purchases from primary school canteens: a study protocol of the 'click & crunch' trial

INTRODUCTION

School canteens are the most frequently accessed take-away food outlet by Australian children. The rapid development of online lunch ordering systems for school canteens presents new opportunities to deliver novel public health nutrition interventions to school-aged children. This study aims to assess the effectiveness and cost-effectiveness of a behavioural intervention in reducing the energy, saturated fat, sugar and sodium content of online canteen lunch orders for primary school children.

METHODS AND ANALYSIS

The study will employ a cluster randomised controlled trial design. Twenty-six primary schools in New South Wales, Australia, that have an existing online canteen ordering system will be randomised to receive either a multi-strategy behavioural intervention or a control (the standard online canteen ordering system). The intervention will be integrated into the existing online canteen system and will seek to encourage the purchase of healthier food and drinks for school lunch orders (ie, items lower in energy, saturated fat, sugar and sodium). The behavioural intervention will use evidence-based choice architecture strategies to redesign the online menu and ordering system including: menu labelling, placement, prompting and provision of feedback and incentives. The primary trial outcomes will be the mean energy (kilojoules), saturated fat (grams), sugar (grams) and sodium (milligrams) content of lunch orders placed via the online system, and will be assessed 12 months after baseline data collection.

ETHICS AND DISSEMINATION

The study was approved by the ethics committees of the University of Newcastle (H-2017-0402) and the New South Wales Department of Education and Communities (SERAP 2018065), and the Catholic Education Office Dioceses of Sydney, Parramatta, Lismore, Maitland-Newcastle, Bathurst, Canberra-Goulburn, Wollongong, Wagga Wagga and Wilcannia-Forbes. Study results will be disseminated through peer-reviewed publications, reports, presentations at relevant national and international conferences and via briefings to key stakeholders. Results will be used to inform future implementation of public health nutrition interventions through school canteens, and may be transferable to other food settings or online systems for ordering food.

TRIAL REGISTRATION NUMBER

ACTRN12618000855224.

Associations between School Food Environments, Body Mass Index and Dietary Intakes among Regional School Students in Victoria, Australia: A Cross-Sectional Study

(1) Background: Childhood overweight and obesity is a significant and preventable problem worldwide. School environments have been suggested to be plausible targets for interventions seeking to improve the quality of children's dietary intake. The objective of this study was to determine the extent to which the current characteristics of the school food environment were associated with primary school students' dietary intake and Body Mass Index (BMI) z scores in a representative sample in regional Victoria. (2) Methods: This study included 53 schools, comprising a sample of 3,496 students in year levels two (aged 7-8 years), four (9-10 years) and six (11-12 years). Year four and six students completed dietary questionnaires. Principals from each school completed a survey on school food environment characteristics. Mixed-effects logistic regression was used to assess the relationship between students' dietary intake and school food environment scores, controlling for confounders such as socio-economic status, school size and sex. Food environment scores were also analysed against the odds of being healthy weight (defined as normal BMI z score). (3) Results: Mixed associations were found for the relationship between students' dietary intake and food environment scores. Meeting the guidelines for vegetable intake was not associated with food environment scores, but students were more likely (OR: 1.68 95% CI 1.26, 2.24) to meet the guidelines if they attended a large school (>300 enrolments) and were female (OR: 1.28 95% CI: 1.02, 1.59). Healthy weight was not associated with school food environment scores, but being a healthy weight was significantly associated with less disadvantage (OR: 1.24 95% CI 1.05, 1.45). Conclusion: In this study, the measured characteristics of school food environments did not have strong associations with dietary intakes or BMI among students.

A cross-sectional study of the nutritional quality of student canteen purchases from New South Wales primary-school canteens

Objective:

To assess the nutritional quality of student canteen purchases at recess and lunch, including: (i) the mean energy (kilojoules), saturated fat (grams), total sugar (grams) and Na (milligrams) and percentage of energy from saturated fat and total sugar; and (ii) the proportion and types of foods purchased that are healthier (green) and less healthy (amber/red) according to a state school canteen policy.

Design:

A cross-sectional study of student canteen food and beverage recess and lunch purchases.

Setting:

Twenty-six randomly selected government primary schools that were non-compliant with a state school canteen policy from a region of New South Wales, Australia, were approached to participate.

Participants:

Students (aged 5–12 years) of participating schools.

Results:

Eighteen schools (69 %) consented to participate. On average students’ recess purchases contained 571·2 kJ energy, 1·6 g saturated fat, 11·6 g total sugar and 132·4 mg Na with 10·0 % of energy from saturated fat and 37·8 % of energy from total sugar. Students’ lunch purchases contained 685·4 kJ energy, 1·8 g saturated fat, 12·7 g total sugar and 151·4 mg Na with 9·5 % of energy from saturated fat and 31·8 % of energy from total sugar. Less healthy items represented 72 and 76 % of all items purchased at recess and lunch, respectively, with ‘savoury snacks’ and ‘sugar-sweetened ice blocks and slushies’ being the most common recess and lunch purchases, respectively.

Conclusions:

There is considerable scope to improve the nutritional quality of student purchases from primary-school canteens, with a high percentage of energy from total sugar. Future research is required to identify effective strategies to enhance compliance with canteen policies and support the purchase of healthier foods from school canteens.

Eat, play, live: a randomized controlled trial within a natural experiment examining the role of nutrition policy and capacity building in improving food environments in recreation and sport facilities

Background

Recreation and sport facilities often have unhealthy food environments that may promote unhealthy dietary patterns among children. In response, some Canadian provinces have released voluntary nutrition guidelines for recreation and sport facilities, however implementation has been limited. Organizational capacity building may overcome barriers to implementing guidelines. Eat, Play, Live was a randomized controlled trial embedded within a natural experiment that tested the impact of an 18 month capacity building intervention (CBI) in enhancing implementation of provincial nutrition guidelines, and whether nutrition guidelines were associated with positive changes. Primary outcomes were facility capacity, policy development and food environment quality.

Methods

Recreation and sport facilities in three guideline provinces were randomized into a guideline + CBI (GL + CBI; n = 17) or a guideline only comparison condition (GL-ONLY; n = 15). Facilities in a province without guidelines constituted a second comparison condition (NO-GL; n = 17). Facility capacity, policy development, and food environment quality (vending and concession) were measured and compared at baseline and follow-up across conditions using repeated measures ANOVA and Chi-square statistics. Healthfulness of vending and concession items was rated as Do Not Sell (least nutritious), Sell Sometimes or Sell Most (most nutritious).

Results

There were significant time by condition effects, with significant increases in facility capacity (mean ± SD: 30.8 ± 15.6% to 62.3 ± 22.0%; p <  0.01), nutrition policy development (17.6% developed new policies; p = 0.049), overall quality of the concession food environment (14.7 ± 8.4 to 17.5 ± 7.2; p <  0.001), and in the proportion of Sell Most (3.7 ± 4.4% to 11.0 ± 9.0%; p = 0.002) and Sell Sometimes vending snacks (22.4 ± 14.4% to 43.8 ± 15.8%; p <  0.001) in GL + CBI facilities, with a significant decline in Do Not Sell vending snacks (74.0 ± 16.6% to 45.2 ± 20.1%; p <  0.001).

Conclusions

Significant improvements in facility capacity, policy development and food environment quality occurred in recreation and sport facilities that were exposed to nutrition guidelines and participated in a CBI. Outcomes did not improve in facilities that were only passively or not at all exposed to guidelines. Ongoing capacity building may enhance implementation of voluntary nutrition guidelines, however food environments remained overwhelmingly unhealthy, suggesting additional scope to enhance implementation.

Trials registration

Clinical trials registration (retrospectively registered): ISRCTN14669997 Jul 3, 2018.

Electronic supplementary material

The online version of this article (10.1186/s12966-019-0811-8) contains supplementary material, which is available to authorized users.

Ultra-processed food consumption by Brazilian adolescents in cafeterias and school meals

This cross-sectional study utilized the National School Health Survey 2015 database to assess the association between school cafeterias; the meals offered by the Brazilian School Food Program (PNAE); and the consumption of industrialized/ultra-processed salty foods, sweets, and soft drinks among Brazilian adolescents. A sample of 102,072 adolescents, aged 11-19 years, who were enrolled in the 9th grade completed the survey. The evaluated outcome was the consumption of industrialized/ultra-processed salty foods, sweets, and soft drinks. A Poisson regression model-based multivariate analysis was performed. The effect measure was the prevalence ratio (PR) with its respective 95% confidence intervals (CIs). The results indicated that Brazilian adolescents who attended schools without meals offered through the PNAE had a higher probability of regularly (≥5 times/week) consuming ultra-processed salty foods [PR = 1.06, CI = 1.01-1.11] and soft drinks [PR = 1.08, CI = 1.03-1.14] compared to those who attended schools that offered PNAE meals. Moreover, the presence of a school cafeteria was associated with a higher probability to consume industrialized/ultra-processed salty foods [PR = 1.05, CI = 1.02-1.08], sweets [PR = 1.09, CI = 1.07-1.11], and soft drinks [PR = 1.10, CI = 1.07-1.13]. School meals appear to be associated with the consumption of ultra-processed foods by Brazilian adolescents, indicating areas for health promotion programs.

Characteristics of Canteens at Elementary Schools, Upper Secondary Schools and Workplaces that Comply with Food Service Guidelines and Have a Greater Focus on Food Waste

Policy actions to improve the nutritional environment include the provision of official food service guidelines. This study aimed to examine compliance with food service guidelines for hot meals as well as self-evaluated focus on food waste reduction across settings, i.e., elementary schools, upper secondary schools and workplaces, and different canteen characteristics. The same five criteria for hot meals were applied for all settings with regard to serving of fruit and vegetables, fish, wholegrain product and high fat meat and dairy products. A self-administered questionnaire survey was conducted as a cross-sectional study among 680 Danish canteens. Canteens having a high degree of organic food procurement were more likely to comply with the five criteria for hot meals combined (OR 2.00 (Cl 1.13,3.53)). Also, the use of organic food together with having a meal policy was associated with reported focus on food waste reduction (OR 1.91 (CI 1.12,3.25) and 1.84 (Cl 1.31,2.59), respectively). Compliance with individual criteria varied across settings with elementary schools being more likely to comply with criteria on, e.g., maximum serving of non-wholegrain products, whereas workplaces were more likely to comply with criteria on, e.g., minimum fruit and vegetable content and serving of fish. In addition, specific characteristics, e.g., serving system, were found to predict compliance with some of the criteria. These findings highlight the need to address differences in canteen characteristics when planning implementation support for both guideline and food waste reduction initiatives.

Two-year follow-up of a randomised controlled trial to assess the sustainability of a school intervention to improve the implementation of a school-based nutrition policy

ISSUE ADDRESSED

School-based nutrition policies can have a positive effect on the school food environment. The primary aim of this study was to assess the primary school adherence to a mandatory state-wide healthy canteen policy 12 months after an effective multi-strategic implementation intervention concluded.

METHODS

Primary schools were randomised to (a) a 12-14 months multi-strategic intervention or (b) no-intervention (control). The intervention aimed to improve implementation of a state-wide canteen policy by encouraging schools to remove unhealthy food and beverages (classified as ''red'' or ''banned'') from canteen menus and replace with healthy items (classified as ''green''). No implementation support was provided to either group by the research team between the 12 and 24 months data collection period.

RESULTS

Seventy schools participated, of which 56 schools were assessed at 24-month follow-up. Intervention schools were less likely to have a menu which contained ''red/banned'' items at 24-month follow-up (RR = 2.28; 95% CI: 1.18-4.40; P = 0.01). Intervention schools, however, were not more likely than controls to have a menu which contained >50% ''green'' items at 24-month follow-up (RR = 1.29; 95% CI: 0.98-1.70; P = 0.10). Intervention schools were more likely to adhere to both policy components (no red/banned items and >50% green items on the menu) than control schools (RR = 2.61; 95% CI: 1.29-5.29; P = 0.006). Among intervention schools that were fully adherent to the policy following implementation support (12-month post baseline), all were also adherent at the 24-month follow-up.

CONCLUSION

The intervention was effective in achieving long-term school adherence to a state-wide canteen policy at 24-month follow-up. SO WHAT?: The findings suggest that sustained improvements in implementation of school nutrition policies is possible following a period (12 months) of comprehensive implementation support.

Factors underlying compliance with a healthy snacking initiative in the school environment: accounts of school principals in Montevideo (Uruguay)

OBJECTIVE

To evaluate the implementation of the Uruguayan healthy snacking initiative in primary and secondary schools in the capital, and to explore the factors underlying compliance from the perspective of school principals.

DESIGN

A mixed-method approach was used, which included semi-structured interviews with school principals and a survey of the foods and beverages sold and advertised in the schools.

SETTING

Primary and secondary schools in Montevideo (the capital city of Uruguay).

PARTICIPANTS

School principals.

RESULTS

The great majority of the schools did not comply with the initiative. Exhibition of non-recommended products was the main cause for non-compliance, followed by advertising of non-recommended products through promotional activities of food and beverage companies. Although school principals were aware of the healthy snack initiative and showed a positive attitude towards it, the majority lacked knowledge about its specific content. Factors underlying compliance with the healthy snacking initiative were related to its characteristics, characteristics of the schools, and external factors such as family habits and advertising.

CONCLUSIONS

Results showed that the rationale underlying the selling of products at schools favours the availability of ultra-processed products and constitutes the main barrier for the promotion of healthy dietary habits among children and adolescents. Strategies aimed at facilitating the identification of unhealthy foods and beverages and provision of incentives to canteen managers to modify their offer are recommended.

Objective assessment of compliance with a state-wide school food-service policy via menu audits

OBJECTIVE

The Healthy Food and Drink Policy was implemented in Western Australian government schools in 2007. The aim of the present study was to assess the compliance of Western Australian school canteen menus with the policy a decade after its introduction.

DESIGN

The traffic-light system that underpins the Healthy Food and Drink Policy categorises foods and drinks into three groups: 'green' healthy items, 'amber' items that should be selected carefully and 'red' items that lack nutritional value. Canteen menus were collected online and each menu item was coded as a green, amber or red choice.

SETTING

Western Australia.ParticipantsOnline canteen menus from 136 primary and secondary government schools.

RESULTS

The majority of audited school menus met policy requirements to include ≥60 % green items (84 %) and ≤40 % amber items (90 %), but only 52 % completely excluded red items. Overall, approximately half (48 %) of school canteen menus met all three traffic-light targets. On average, 70 % of the menu items were green, 28 % were amber and 2 % were red. Primary-school canteen menus were more likely than those from secondary schools to meet the requirements of the policy.

CONCLUSIONS

While the sampled Western Australian government school canteen menus were highly compliant with most of the requirements of the Healthy Food and Drink Policy, many offered red foods and/or drinks. Providing all schools with further education about identifying red items and offering additional services to secondary schools may help improve compliance rates.

Barriers to implementation of a healthy canteen policy: A survey using the theoretical domains framework

ISSUE ADDRESSED

Improving implementation of school healthy canteen policies requires a comprehensive understanding of implementation barriers. Therefore, the aim of this study was to assess a range of barriers, as reported by canteen managers, using a quantitative survey instrument developed based on a theoretical framework.

METHODS

A cross sectional survey of primary school canteen managers from the Hunter New England region of New South Wales was conducted of eligible schools in the study region identified as having an operational canteen. Survey items assessed canteen manager employment status, canteen characteristics and potential barriers to healthy canteen policy implementation, aligned to the 14 domains of the theoretical domains framework via a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). The mean domain scores of canteen managers were calculated, less than four indicating the canteen manager considered the domain was a barrier. Canteen managers were also asked to provide the current canteen menu for audit by a dietitian.

RESULTS

Of the 184 participants, 20% (n = 36) were assessed as having menus compliant with the state policy. The five most common domains identified as potential barriers to policy implementation were behavioural regulation (n = 117, 65%), skills (n = 105, 57%), beliefs about capabilities (n = 100, 55%), reinforcement (n = 95, 52%) and goals (n = 95, 52%). Canteen managers who reported optimism as a barrier had significantly lower odds of having a menu compliant with the state policy (OR = 0.39; 95% CI 0.16-0.95, P = 0.038).

CONCLUSIONS

This study provides further evidence of perceived and actual barriers that canteen managers face when attempting to implement a healthy canteen policy, and highlights the need to address differences in canteen characteristics when planning implementation support. SO WHAT?: For public health benefits of nutrition policies within schools to be realised, the barriers to implementation need to be identified and used to help guide implementation support strategies.

A cluster randomised controlled trial of a sugar-sweetened beverage intervention in secondary schools: Pilot study protocol

BACKGROUND

Due to the rising prevalence of overweight and obesity in children and adolescents, reducing childhood overweight and obesity rates is a public-health priority. A significant source of excess sugar and energy in children's diets comes from sugar-sweetened beverages (SSB), with adolescents having the highest intake of all age groups. However, existing interventions targeting SSB intake in adolescents have multiple limitations. Schools have proven to be an appropriate setting for improving student health.

AIM

To assess the effectiveness of a school-based SSB intervention in reducing daily SSB consumption and daily percentage energy from SSBs of secondary-school students.

METHODS

A pilot study ( switchURsip) was designed based on the Health Promoting Schools framework components. A convenience sample of schools in New South Wales, Australia will be used to recruit six schools (three intervention; three control). The study incorporates strategies that focus on factors associated with SSB intake in adolescents. These strategies include: lesson plans on SSB; communication with students and parents; school challenge to build peer support; and school nutrition environment modifications. Support strategies to facilitate implementation are executive leadership and school committees, auditing and feedback, providing resources, staff professional learning and communication and marketing.

CONCLUSION

The high intake of SSB in adolescents has been consistently linked to having overweight and obesity, hence, interventions in this area should be prioritised. This pilot study intends to address identified evidence gaps by piloting the first intervention in Australia of its kind to reduce SSB intake in adolescents.

Scale up of a multi-strategic intervention to increase implementation of a school healthy canteen policy: findings of an intervention trial

Background

Implementation interventions delivered in schools to improve food provision have been found to improve student diet and reduce child obesity risk. If the health benefits of food availability policies are to be realised, interventions that are effective need to be implemented at scale, across an entire population of schools. This study aims to assess the potential effectiveness of an intervention in increasing the implementation, at scale, of a healthy canteen policy by Australian primary schools.

Methods

A non-controlled before and after study was conducted in primary schools located in the Hunter New England region of New South Wales, Australia. Schools received a multi-component intervention adapted from a previous efficacious and cost-effective randomised control trial. The primary trial outcome was the proportion of canteen menus compliant with the state healthy canteen policy, assessed via menu audit at baseline and follow-up by dietitians. Secondary outcomes included policy reach and adoption and maintenance policy implementation.

Results

Of the 173 schools eligible for inclusion in the trial, 168 provided menus at baseline and 157 menus were collected at follow-up. At follow-up, multiple imputation analysis found 35% (55/157) of schools compared to 17% (29/168) at baseline (OR = 2.8 (1.6–4.7), p = < 0.001) had menus compliant with the state healthy canteen policy. As an assessment of the impact of the intervention on policy reach, canteen manager and principal knowledge of the policy increased from 64% (n = 76) and 38% (n = 44) respectively at baseline to 69% (n = 89) and 60% (n = 70) at follow-up (p = 0.393, p = 0.026). Adoption of the policy increased from 80% (n = 93) at baseline to 90% (n = 104) at follow-up (p = 0.005) for principals, and from 86% (n = 105) to 96% (n = 124) (p = 0.0001) for canteen managers. Multiple imputation analysis showed intervention effects were maintained six-months post intervention (33% of menus compliant OR = 2.6 (1.5–4.5), p = < 0.001 compared to baseline).

Conclusions

This study found school canteen compliance with a healthy food policy increased in association with a multi-strategy intervention delivered at scale. The study provides evidence for public health policy makers and practitioners regarding strategies and modes of support required to support improvement in nutrition policy implementation across entire populations of schools.

Economic analysis of three interventions of different intensity in improving school implementation of a government healthy canteen policy in Australia: costs, incremental and relative cost effectiveness

Background

No evaluations of the cost or cost effectiveness of interventions to increase school implementation of food availability policies have been reported. Government and non-government agency decisions regarding the extent of investment required to enhance school implementation of such policies are unsupported by such evidence. This study sought to i) Determine cost and cost-effectiveness of three interventions in improving school implementation of an Australian government healthy canteen policy and; ii) Determine the relative cost-effectiveness of the interventions in improving school implementation of such a policy.

Methods

An analysis of the cost and cost-effectiveness of three implementation interventions of varying support intensity, relative to usual implementation support conducted during 2013–2015 was undertaken. Secondly, an indirect comparison of the trials was undertaken to determine the most cost-effective of the three strategies. The economic analysis was based on the cost of delivering the interventions by health service delivery staff to increase the proportion of schools ‘adherent’ with the policy.

Results

The total costs per school were $166,971, $70,926 and $75,682 for the high, medium and low intensity interventions respectively. Compared to usual support, the cost effectiveness ratios for each of the three interventions were: A$2982 (high intensity), A$2627 (medium intensity) and A$4730 (low intensity) per percent increase in proportion of schools reporting ‘adherence’). Indirect comparison between the ‘high’ and ‘medium intensity’ interventions showed no statistically significant difference in cost-effectiveness.

Conclusions

The results indicate that while the cost profiles of the interventions varied substantially, the cost-effectiveness did not. This result is valuable to policy makers seeking cost-effective solutions that can be delivered within budget.

Assessing the potential impact of a front-of-pack nutritional rating system on food availability in school canteens: A randomised controlled trial

BACKGROUND

Front-of-pack graphical nutritional rating of products is becoming an important strategy in many countries to improve healthy food purchases by consumers. Evidence of the effectiveness of such on facilitating healthy food choices by school food service providers has not been reported. The primary aim of the study was to assess the impact of providing front-of-pack nutritional rating information on school canteen managers' likely food selections. Secondary outcomes were canteen manager awareness, attitudes and reported barriers to using the front-of-pack information.

METHODS

A randomised controlled trial involving primary school canteen managers was conducted in a single region in New South Wales, Australia. Eligible participants were randomised to an intervention or control group and asked in a telephone interview which of 12 common food products sold in school canteens they would sell. Both groups received product name and brand information. The intervention group also received information regarding the nutritional rating of products.

RESULTS

Canteen managers in the intervention group were significantly more likely than those in the control group to indicate they would sell three of the six 'healthier' products (p = 0.036, 0.005, 0.009). There was no difference between groups in the likelihood of making available for sale any of the six 'less healthy' products. The majority of canteen managers who had heard of a product nutritional rating system agreed that it was helpful in identifying 'healthier' foods (88%, n = 31).

CONCLUSIONS

The inclusion of product nutritional rating information has the potential to improve the availability of some 'healthier' items on canteen menus and contribute to improving child dietary intake. Further research is required to determine whether the use of product nutritional rating information actually makes a difference to canteen manager choices.

Stakeholder perceptions of a school food policy ten years on

Objective

To assess (i) the extent to which stakeholders have accepted and implemented a Healthy Food and Drink Policy for schools a decade after its introduction and (ii) any resulting implications for canteen profitability.

Design

Online survey distributed via electronic newsletter to school principals.

Setting

Western Australian public schools.

Subjects

Principals, teachers, canteen managers, and parents and citizens committee presidents (n307).

Results

Large majorities of respondents reported that the policy has made the foods and drinks provided in schools healthier (85 %) and that the policy constitutes a good opportunity to teach children about healthy eating (90 %). Only small proportions of respondents felt it had been difficult to implement the policy in their schools (13 %) or that the policy fails to accommodate parents’ rights to choose the foods consumed by their children (16 %). Most of the policy outcomes assessed in both the initial post-implementation evaluation (2008) and the 10-year follow-up evaluation (2016) demonstrated significant improvement over time.

Conclusions

The study results indicate that comprehensive school food policies can favourably influence the foods and drinks provided on school premises and can be highly acceptable to key stakeholders, without adversely affecting profitability. The results are encouraging for policy makers in other jurisdictions considering the implementation of similar policies.

Implementation lessons for school food policies and marketing restrictions in the Philippines: a qualitative policy analysis

BACKGROUND

The school environment can enhance children's skills, knowledge and behaviours in relation to healthy eating. However, in many countries, unhealthy foods are commonly available in schools, and children can be exposed to aggressive marketing by the food industry. Taking the perspective of policymakers, this study aimed to identify barriers and enablers to effective school food policy development and implementation in the Philippines.

METHODS

In May 2016, semi-structured interviews were conducted with 21 policymakers and stakeholders involved in school food policymaking and implementation in the Philippines. The Health Policy Analysis Triangle was used to identify interview questions and to guide the thematic analysis. These included the political and socio-environmental context, strengths and limitations of existing policy content, roles and behaviours of actors, implementation processes, policy outcomes, and opportunities to improve policy coherence.

RESULTS

The Department of Education's policy 'Orders' represented a relatively strong policy framework for the education sector of the Philippines. However, a lack of human and financial resources for implementation, planning, and policy enforcement limited the impact of the policy on the healthiness of school food provision. Ambiguity in policy wording allowed a wide interpretation of the foods eligible to be provided in schools, and led to difficulties in effective monitoring and enforcement. Food companies used existing relationships with schools to promote their brands and compromise the establishment of a stronger food policy agenda. We found a motivated group of actors engaging in policy-oriented learning and advocating for a stronger policy alternative so as to improve the school food environment.

CONCLUSIONS

The adoption of policy mechanisms being used to promote healthy dietary practices in the school setting will be strengthened by more robust implementation planning processes, and resources to support implementation and enforcement. Policymakers should ensure policy language clearly and unequivocally promotes healthier food and beverage options. Steps should be taken to achieve policy coherence by ensuring the objectives of one agency or institution are not undermining that of any others. Where there is reliance on the private sector for school resources, safeguards should be established to protect against conflicts of interest.

Validity of four measures in assessing school canteen menu compliance with state-based healthy canteen policy

Issue addressed In order to assess the impact of healthy school canteen policies on food availability for students, valid methods of measuring compliance are needed that can be applied at scale. The aim of this study is to assess the validity and direct cost of four methods to assess policy compliance: 1) principal and 2) canteen manager self-report via a computer-assisted telephone interview; and 3) comprehensive and 4) quick menu audits by dietitians, compared with observations. Methods A cross-sectional study took place in the Hunter region of NSW, Australia, in a sample of 38 primary schools that had previously participated in a randomised controlled trial to improve healthy canteen policy compliance. Policy compliance was assessed using the four methods specified above. Percentage agreement, kappa, sensitivity and specificity compared with observations was calculated together with the direct time taken and costs of each method. Indirect costs (including set-up costs) for all measures have not been included. Results Agreement with observations was substantial for the quick menu audit (kappa=0.68), and moderate for the comprehensive menu audit (kappa=0.42). Principal and canteen manager self-report resulted in poor agreement and low specificity with the gold standard. The self-reported measures had the lowest cost, followed by the quick menu audit and lastly the comprehensive menu audit. Conclusion The quick menu audit represents a valid and potentially low-cost method of supporting policy implementation at scale. So what? This study demonstrates that a quick menu audit represents a valid measure of undertaking assessment of school canteen policy compliance at a population level.

Online canteens: awareness, use, barriers to use, and the acceptability of potential online strategies to improve public health nutrition in primary schools

Issue addressed This study of primary school principals assessed the awareness, use, barriers to use and acceptability of online canteens. Methods A telephone survey of 123 primary school principals within the Hunter New England Region of New South Wales, Australia was conducted from September 2014 to November 2014. Results Fifty-six percent of principals were aware of the existence of online canteens, with 8% having implemented such a system, and 38% likely to do so in the future. Medium/large schools were more likely to be aware of or to use online canteens, however there were no differences in awareness or use in relation to school rurality or socioeconomic advantage. Principals cited parent internet access as the most commonly identified perceived barrier to online canteen use, and the majority of principals (71-93%) agreed that it would be acceptable to implement a range of consumer behaviour strategies via an online canteen. Conclusions Study findings suggest that despite relatively low levels of current use, online canteens have the potential to reach a large proportion of school communities in the future, across geographical and socioeconomic divides, and that the nutrition interventions which they have the capacity to deliver are considered acceptable to school principals. So what? Online canteens may represent an opportunity to deliver nutrition interventions to school communities. Future research should examine the feasibility and potential effectiveness of interventions delivered via this modality.

Factors that influence the implementation of dietary guidelines regarding food provision in centre based childcare services: A systematic review

Children attending centre based childcare services consume as much as two thirds of their daily dietary requirements while in care. However, such services often fail to provide foods that are consistent with guideline recommendations. Developing strategies to improve childcare service adherence to menu dietary guidelines requires a comprehensive understanding of factors that may impede or promote implementation. The primary aim of this systematic review is to describe factors (barriers and facilitators) that may influence the implementation of menu dietary guidelines regarding food provision in centre-based childcare services and to map these factors to a theoretical framework. Over 7000 citations were identified from all sources. Duplicate abstracts were removed and selection criteria applied. Twelve studies (1994-2015) were included in the review. Dual data extraction was conducted and the reported factors were synthesised using the theoretical domains framework (TDF). Barriers and facilitators identified in qualitative studies were classified into 8 and 10 of the 14 TDF domains. Barriers and facilitators reported in quantitative studies covered 6 and 3 TDF domains respectively. The most common domain of which both barriers and facilitators to the implementation of menu dietary guidelines were identified was 'environmental context and resources'. This is the first study that comprehensively assesses literature to identify factors that influence the implementation of menu dietary guidelines in childcare services utilising a theoretical framework. Findings provide guidance to support researchers and policy makers design strategies to improve menu dietary guideline implementation and, as such have the potential to improve food provision in care.

Preschool and School Meal Policies: An Overview of What We Know about Regulation, Implementation, and Impact on Diet in the UK, Sweden, and Australia

School meals make significant contributions to healthy dietary behaviour, at a time when eating habits and food preferences are being formed. We provide an overview of the approaches to the provision, regulation, and improvement of preschool and primary school meals in the UK, Sweden, and Australia, three countries which vary in their degree of centralisation and regulation of school meals. Sweden has a centralised approach; all children receive free meals, and a pedagogical approach to meals is encouraged. Legislation demands that meals are nutritious. The UK system is varied and decentralised. Meals in most primary schools are regulated by food-based standards, but preschool-specific meal standards only exist in Scotland. The UK uses food groups (starchy foods, fruit and vegetables, proteins and dairy) in a healthy plate approach. Australian States and Territories all employ guidelines for school canteen food, predominantly using a "traffic light" approach outlining recommended and discouraged foods; however, most children bring food from home and are not covered by this guidance. The preschool standards state that food provided should be nutritious. We find that action is often lacking in the preschool years, and suggest that consistent policies, strong incentives for compliance, systematic monitoring, and an acknowledgement of the broader school eating environment (including home provided food) would be beneficial.