A national school food and nutrition policy is being drawn up. Suzanne Piscopo looks at how a healthier choice of foods can be provided in schools.

A well-planned curriculum with excellent learning activities and relevant homework assignments will be ineffective if students lack access to a variety of healthful and appealing foods. Nutrition education is only the beginning of teaching nutrition to children and adolescents. A healthy school nutrition environment goes far beyond mere classroom instruction.

Healthy eating patterns in childhood and adolescence promote healthy growth and intellectual development; prevent immediate health problems such as juvenile obesity, non-insulin dependent diabetes, elevated serum cholesterol, iron deficiency anaemia, eating disorders and dental caries; and may prevent long-term health problems, such as adult obesity, hypertension, stroke, coronary heart disease, osteoporosis and cancer.

A co-coordinated school food and nutrition policy provides the framework for helping students to attain full educational potential and good health, as well as receive nutrition education messages that are reinforced throughout the school environment.

It is generally accepted that the education system provides an ideal conduit for health promotion. But are Maltese schools truly conducive to healthy eating? Local research in primary schools has shown that less than one half (43.8 per cent) of the respondent schools had some form of written food-related policy. (Attard, 2001)

These ranged from one-sentence statements on foods recommended for school packed lunches, to multiple references regarding permissible and prohibited foods and beverages, duration of lunch breaks and school milk provision.

To date, no official data is available on school food policies at the secondary level, though research in this regard is planned to start soon. Meanwhile, other local studies (Fenech, 2001), personal communication with school administrators and an informal survey of the media reports on school events show that promotion of healthy eating is a frequent item in School Development Plans.

'Breakfast Days', 'Ftira Days', 'Healthy Eating' exhibitions are some of the events held during the scholastic year. Yet these one-off activities, while serving to raise awareness of new and traditional foods available locally, as well as the relationship between food and health, have little potential for long-term positive impact on food behaviours if they are not accompanied by a supportive school environment.

While reading an article recently about school food policies in England, I came across the acronym SNAG. Instinctively I thought "Yes, research has shown that there are various snags in establishing a healthy school nutrition environment".

Ironically, however, the acronym was much more positive in orientation. SNAG stands for School Nutrition Action Groups. These are school-based alliances in which staff, pupils and caterers, supported by health and education professionals, work together to review and expand the range of food and beverages in schools in order to increase the uptake of a healthier diet and ensure consistent messages from the curriculum and the school food consumption setting.

In the US, the equivalent of SNAGs are SNACs - School Nutrition Advisory Councils. Recent and ongoing research shows that both have resulted in a number of success stories.

In each case, the concerted effort of various stakeholders was required to develop an effective school food and nutrition policy, to establish a framework for its implementation and to ensure regular monitoring of compliance. (For more details visit www.nutrition.org.uk and www.ActionForHealthyKids.org)

In 2002, the Maltese National Curriculum Council approved the setting up of a Task Force for Appropriate School Nutrition Environments (TASNE) with the remit of formulating the first draft of a National School Food and Nutrition Policy.

The task force comprises representatives from the academic field, the Education Division, the Consumer Department, the Health Promotion Department, as well as school administrators, teachers and parents. The intention is for the policy document to be a work in progress as additional factors will eventually be included in order to make it as comprehensive as possible. At this stage the task force is focusing on three key issues: Nutritious and safe provision of foods in schools; marketing of foods in schools and the school food consumption setting.

Various lengthy discussions have ensued, also involving consultations with different experts and interested parties. A series of questions are being pondered and researched, including among others: How prescriptive should school food rules be? What should be the role of tuck shops in schools? Should schools allow the commercial marketing of foods and beverages on school premises?

Formal and less formal interviews with Maltese parents have revealed their feelings about school food rules and tuck shops (See box).

Yet once again data from the secondary school sector is scarce. What information is available reveals that there is no clear-cut orientation. The majority of parents with children in primary schools do feel that some rules should exist with regard to permissible and prohibited foods; but opinions differ as to the extent of imposition of rules by schools.

Similarly, the majority of parents feel that provision of food by tuck shops, where these are present, should be strictly regulated to ensure that healthier fare is available.

However, some parents have gone so far as to question the 'taken for granted' existence of a school tuck shop, especially at the secondary level. To quote one task force member: "It is time for the education authorities to seriously reflect on whether school tuck shops are a social service or a commercial entity."

While both parents and school administrators have pronounced that tuck shops are necessary for those children who turn up at school without any school packed lunch, or in order to provide a hot food or beverage item on cold winter days, others have made reference to the fact that tuck shops have a commercial monopoly in schools.

The latter statement has a number of ethical implications in relation to freedom of choice, health outcomes and economic power. While these ethical issues merit a much lengthier discussion, at this point I shall merely comment that children are often faced with only a limited array of healthier foods or beverages from school tuck shops or vending machines, and that many parents admit feeling disempowered as they fund their children's requests to buy foods or beverages from these commercial food outlets on school premises.

Both in England and in the US, studies have shown that school administrators and school councils are often torn between the lucrative prospect of major financial benefits from school tuck shops and/or vending machines, and the concerns of nutritionists, health officials and educators who believe that schools should not contribute to the serious epidemic of obesity and ancillary health problems.

Local heads of schools have frequently confessed to facing a similar dilemma. While struggling to work with restricted school budgets, they are not oblivious to tuck shop realities.

When students enter the school tuck shop, what grabs their attention? Do they just see shelves upon shelves of salty packet snacks, sweets and chocolates, trays filled with cream-laden pastries, crates of highly-sweetened beverages and frying baskets bubbling over with artery-clogging golden liquid? Or is the tuck shop a place where children can recognise the WHO Food Guide as more than a mere poster on the school notice board or Home Economics classroom wall? Is there emphasis on healthy sandwiches and snacks, low fat dairy products, tasty fruits and pure fruit juices, or is the show stolen by fried foods in a bun, chocolate-covered sponges and nutrient-void coloured and sugared water?

Unfortunately, studies confirm that the negative rather than the more positive scenario is the norm (Camilleri, 2001). However, informal enquiry has also revealed that in some schools (especially where teacher, staff or parent volunteers have taken over) the tuck shop does offer healthier alternatives, such as rolls with healthy fillings, popcorn, fruit and yoghurt. It seems that in many cases these items have sold well, though very little is known about what contributed to this success and what barriers had to be overcome.

In a similar vein, research from the US has shown that offering healthier foods and beverages in school tuck shops and/or vending machines does not automatically result in a decline in profits; on the contrary, revenue levels are maintained or even increase. (See Action for Healthy Kids, 2003) General conclusions are that:

¤ Students will buy and consume healthful foods and beverages when these options are tasty, easily accessible and priced right;

¤ School food providers can continue to make money while offering healthful food and beverage options to students;

¤ Some schools have actually made more money from healthful options than from their usual offerings;

¤ Students, parents and communities support healthy school nutrition environments, and are willing to get involved in making changes.

Examples of nutritious-food-related fundraising initiatives implemented abroad include Healthy Breakfast Clubs for children arriving at school early, Fruit Tuck Shops complementary to regular tuck shops and Snacks-On-The-Go consisting of bags of raw vegetables grown in the school garden. The revenue from these initiatives typically goes towards the purchase of school equipment and curriculum materials. (See also www.healthedtrest.com/pages/snag and the website of Action for Healthy Kids: What Works)

Yet while this creative marketing of healthier foods and beverages is lauded from an educational perspective, internationally there is still widespread concern amongst parents and educators regarding the more commercial marketing of foods and beverages in schools. Even locally, over the past few years we have witnessed an increasing presence of food or beverage companies in schools (Fenech, 2000). While there seems to be some regulation of this commercial intrusion in the state school sector, there seems to be less control in the non-state school sector. For example, individual food or beverage manufacturers, importers or retailers sometimes offer schools educational supplies with their logos to distribute for free to their students. Schools have also been known to distribute coupons encouraging students to visit food outlets with their families in exchange for points towards books, computers or sports equipment. Similarly, students have been encouraged to collect tokens from breakfast cereals, salty packet snacks, sweets, chocolates or juices also in exchange for a variety of school resources.

Without wanting to sound as if I am treating this ethical issue lightly, apart from the commercial exploitation of students as a vulnerable and captive audience, a main problem with the promotion of food and beverage products in schools is that almost without exception, the items marketed contain high levels of fat and/or salt and/or sugar. These are the very products that a primary or secondary level student is likely to be told to eat less of in Health, Home Economics, PSE, PSHE or PE lessons. In fact, many parents have told me that they are disturbed by the kinds of materials creeping into the education system. Some say that without expert vigilance these commercial messages may skew children's understanding of food and nutrition. Others state outright that they don't understand why these commercial promotions of foods and beverages are allowed in schools at all. They assert that schools should remain one of the few places where a child can hope to receive accurate unbiased information about what constitutes a healthy diet and the effects of food on health. While agreeing with this latter sentiment, one must keep in mind however that many foreign schools have forged beneficial alliances with food and beverage manufacturers, suppliers and retailers where the health of school children has not been compromised. (See the BNF and AFHK websites.) The potential for win-win situations also exists locally, as long as certain nutritional standards and criteria are made clear at the outset.

Considering the above discussion, perhaps the question heading this article should be modified to read: 'How can local schools offer a healthy menu?' As explained earlier, the proposed National School Food and Nutrition Policy is still in its draft stages, so input is welcome from parents, school administrators, teachers, students, food and beverage retailers and other interested parties. Parents and schools have the joint responsibility of teaching children and adolescents about the principles of a healthy diet and how this is key to a happy and healthful future. Readers of this article are invited to participate in drafting national policy with this goal in mind.

Ms Piscopo is the chairperson of the Task Force for Appropriate School Nutrition Environments. Unless stated otherwise, the opinions expressed in this article are solely those of the author and do not necessarily reflect the views of other TASNE members.

School rules proposed by Maltese parents

¤ Rules must be suitable for children to follow.

¤ Schools should only allow healthy foods.

¤ Children should be encouraged to bring a variety of foods.

¤ Children should not be allowed to bring a lunch consisting only of packets.

¤ Children should be encouraged to drink school milk .

¤ Teachers should monitor that all children eat all their packed lunch.

¤ Teachers should not allow children to eat any sweets if they have not eaten the rest of their lunch.

¤ Children should be taken to brush their teeth after consuming their school lunch.

¤ Limit the amount of food money allowed per child (e.g. enough to buy just one salty packet snack).

¤ Tuck shops should preferably be banned.

¤ If tuck shops are allowed they should sell more than just 'junk food', but they should not be allowed to sell fried foods or hamburgers.

¤ Prohibited foods: Salty packet snacks, chocolates, sweets, carbonated soft drinks, orange squashes, fruit juices, fruit drinks, messy foods, oily foods.

¤ Permitted foods: Some biscuits, squash, white milk flavoured with essence, daily limit of one salty packet snack.

¤ Recommended foods: Fruit (one piece daily), tomatoes (with bread or salads), cereals (instead of packet snacks), cereal bars (instead of chocolate), water (instead of fruit juices).

(Suzanne Piscopo; unpublished doctoral research data obtained from interviews with parents of primary school children)

Can you help?

By responding to any or all of the following questions, you will help in developing a valuable national policy targeting the health and well-being of children and adolescents.

1. Does the school you work for, or which your child attends, have clear recommendations regarding permissible and/or prohibited foods and beverages? Are these presented as guidelines, or are they enforced rigorously? How do you feel about this?

2. Would you like to see changes in the foods and beverages on sale from the school tuck shop and/or vending machines? Can you give specific examples? What is your general feeling about school tuck shops?

3. Does the school use educational materials sponsored by food or beverage companies? (Eg company-sponsored exercise books, worksheets, information booklets, etc.) Can you describe examples?

4. Has the school taken part in a 'points/tokens for goods' scheme run by a food or beverage company? Which scheme(s)?

5. Is there a positive or negative story you'd like to share about food and beverage school rules, food and beverage school promotions, or the food consumption setting?

Please address any correspondence to Suzanne Piscopo: TASNE chairperson, c/o Rm. 324, Faculty of Education, University of Malta, Msida MSD06; suzanne.piscopo@um.edu.mt.

All correspondence will be treated with the strictest confidence.