School meals and policy on promoting healthy eating in schools in Poland.

Posiłki szkolne i polityka w zakresie promocji zdrowego żywienia w szkołach w Polsce

Barbara Woynarowska1, Agnieszka Małkowska-Szkutnik2, Joanna Mazur2, Anna Kowalewska1, Krystyna Komosińska1
1Department of Biomedical and Psychological Aspects of Education
Head of Department: prof. dr hab. med. B. Woynarowska
Pedagogiczny Uniwersytetu Warszawskiego
2Department of Child and Adolescent Health
Head of Department: dr hab. med. prof. IMiD K. Mikiel-Kostyra
Institute of Mother and Child, Warsaw
Director: S. Janus

Abstract
Aim: to diagnose the situation regarding the infrastructure, organization of school meals, the kind of products available for students at school and the school policy on the promotion of healthy eating in the context of the increasing frequency of obesity among children and young people.
Method and material: The research tool was the questionnaire “School environment and health”, including a section on the facilities, organization of meals and the school’s policy on healthy eating. It made use of the questions from the international HBSC (Health Behaviour in Schoolaged Children) school questionnaire. The anonymous questionnaire was sent out by post and was returned by 520 head masters of primary, lowersecondary and cluster schools. This means that 74.3% of the randomly chosen sample of schools responded.
Results: Almost 2/3 of the schools had a canteen and a school store. Hot meals were served in 84% of the schools but only in 28% of them to more than 50% of the students. School breakfast was organized by half of the schools of which 23% had it in all the classes. Almost all the schools served free meals for students with special needs. Most schools, particularly lowersecondary provided access to sweets, sweet drinks and salty snacks. Only 725% of schools have a written policy on limiting such products and increasing the consumption of fruits, vegetables, milk and wholegrain bread products. In on going national programmes: “A Glass of Milk” had a 74% participation rate (only 25% of the lowersecondary schools) and “Fruits in School” 38% (6% lowersecondary schools). The “Keep Fit” educational programme was implemented in 28% of primary schools and in 72% of lowersecondary schools.
Conclusions: The majority of schools in Poland still do not appreciate the need for all students to eat a meal in school and have not become involved in prophylactic activities designed to prevent obesity. The undertaken activities are incoherent. There is a need to create a policy on healthy nutrition at school at the national, regional, local and school level.

Key words: school meals, school policy on healthy eating, obesity prevention, children and adolescents

Streszczenie
Cel: Diagnoza sytuacji dotyczącej infrastruktury, organizacji posiłków szkolnych, rodzaju produktów dostępnych w szkole dla uczniów i polityki szkoły w zakresie promocji zdrowego żywienia, w kontekście zwiększającej się częstości otyłości wśród dzieci i młodzieży.
Metoda i materiał: Narzędziem badawczym był kwestionariusz „Środowisko szkoły a zdrowie”, zawierający część dotyczącą warunków, organizacji żywienia uczniów i polityki szkoły w zakresie zdrowego żywienia. Wykorzystano w nim pytania z międzynarodowego kwestionariusza szkolnego HBSC (Health Behaviour in Schoolaged Children). Anonimowy kwestionariusz wysłany poczta zwróciło 520 dyrektorów szkół podstawowych, gimnazjów i zespołów szkół. Realizacja losowo wybranej próby wynosiła 74,3%.
Wyniki: Prawie 2/3 szkół miało stołówkę i sklepik szkolny. Ciepłe posiłki wydawało 84% szkół, ale tylko 28% dla więcej niż połowy uczniów. Śniadania szkolne organizowała połowa szkół, 23% we wszystkich klasach. Prawie wszystkie szkoły wydawały bezpłatne posiłki dla potrzebujących uczniów. W większości szkół, zwłaszcza w gimnazjach, dostępne były słodycze, słodkie napoje i słone przekąski. Tylko 7-25% szkół miało na piśmie politykę w zakresie ograniczenia tych produktów i zwiększenia spożycia owoców, warzyw, mleka, ciemnego pieczywa. W ogólnopolskich programach: ”Szklanka mleka” uczestniczyło 74% szkół (tylko 25% gimnazjów), „Owoce w szkole” 38% szkół (6% gimnazjów). Program edukacyjny „Trzymaj Formę” realizowało 28% szkół podstawowych i 72% gimnazjów. Wnioski: Większość szkół w Polsce nadal nie dostrzega potrzeby spożywania przez wszystkich uczniów posiłku w szkole i nie włączyła się do działań w zakresie zapobiegania otyłości. Podejmowane działania są niespójne. Istnieje potrzeba tworzenia polityki w zakresie zdrowego żywienia w szkole na poziomie krajowym, regionalnym, lokalnym i szkolnym.

Słowa kluczowe: posiłki w szkole, polityka szkoły w zakresie zdrowego żywienia, profilaktyka otyłości, dzieci i młodzież

INTRODUCTION
School is a place where children, depending on their age, spend 4/5-8 hours daily nine months per year. During school hours they should drink and eat at least one meal. Eating at school should be considered in a broader context than only fulfilling physiological needs for nutrients and energy:
– there is a relatively high percentage of students who for many reasons are hungry and thirsty during school hours. The results of HBSC survey showed that in Poland in 2006, about 30% among 11-15-year-old adolescents have no breakfast every morning on school days and 20-30% have no meal during school hours (1). There is evidence that this can have a negative influence on their ability to learn and concentrate, aects their school achievements, well-being and behaviour.
– School age is a critical period for the development of health behaviour, including eating habits. Changes in eating habits can be associated with the need to express freedom from parental control. It is connected with an increased consumption of meals eaten outside the home which often comprise take-away fast food. Children and adolescents are also influenced by extensive marketing and advertising which targets them.
– School is obliged to carry out health education, of which nutritional education is a component. In the new core curriculum, implemented in Poland in 2008, there are many topics related to healthy eating (2). It should be supported by the possibility to practice healthy eating in school.
The new challenge for providing healthy food in schools is rapidly growing due to the prevalence of overweight and obesity among children and adults throughout the world. At present, about one in four of European children are overweight (3). In Poland 18% of children aged 7-19 years are overweight (4). Overweight children are more likely to become overweight adults, with a greater risk of cardiovascular diseases, diabetes, and other disorders (5). Obese adolescents suer many psychological, social and health related consequences (6, 7).
In Europe there is a great diversity of programmes and structures for healthy eating in schools but a national comprehensive policy regarding the prevention of obesity in schools does not yet exist in any European country. To help deal with this issue the Healthy Eating and Physical Activity in Schools (HEPS) project was developed to support countries in Europe in promoting healthy eating and physical activity at schools in a positive and sustainable way. This project is linked to the Schools for Health in Europe network (8). The general aim of this project is to develop, implement and evaluate an eective national policy and sustainable practices in healthy eating and physical activity in schools in all the European Union member states. In Poland organization of school meals for all students, as well as the participation of schools in obesity prevention are not satisfactory (9). There are plans to start the implementation of HEPS project in the Health Promoting Schools Network in 2011.

AIM
The aim of this paper is to present the results of the survey concerning: 1) facilities, school meals and the availability of beverages and food products at school and in its proximity; 2) school policy on promoting healthy eating in a representative sample of primary and lower secondary schools in Poland in the context of obesity prevention.

METHOD AND MATERIALS
The questionnaire “School environment and health” for school head teachers was used. It was based on the “School-level questionnaire” developed in the frame of the 2009/2010 international study on health behaviour HBSC (Health Behaviour in School Aged Children, A WHO Collaborative Cross-national Study). This questionnaire has been developed under the lead of the HBSC school focus group (10). The Polish “School environment and health” questionnaire included the HBSC optional package “Nutrition” with additional Polish questions related to this topic. It was piloted before going to the field.
There were questions on:
– facilities and equipment for eating and drinking at school and in proximity to the school,
– meals offered at school and the proportion of students who eat them,
– availability of beverages and food products at school,
– school policy on promoting healthy eating, – implementation in school of three national programmes on promoting healthy eating.
The anonymous questionnaire was sent by post to 700 randomly selected primary and lower-secondary schools in all 16 voivodships in April 2010. The head teacher or deputy head teacher was asked to complete the questionnaire and return it by post. Two reminder letters were sent to schools, with additional questionnaire in the second letter. The final sample size comprised 520 schools in total. The response rate was 74,3%. The majority of the questionnaires (78%) were completed by head teachers; 17% by their deputies and 5% by other people. Among the respondents 73 % were female, 27% male. e basic characteristics of the schools which returned completed questionnaires were as follows:
– type of school: 275 primary schools, 136 lower-secondary schools and 109 cluster schools (two or more schools of different levels e.g. primary and lower-secondary school together);
– location of school: 57% of schools in villages, 43% in towns,
– size of school: number of students: 19% – 100 and less; 44% – 101-300; 37% – 301 or more students.

RESULTS
1. Facilities and equipment for eating and drinking at school and in its proximity
The majority of schools had a canteen (74,1%) and school store (64,1%). Fewer than one in ve schools had one or more vending machines. ese facilities existed more frequently in lower-secondary schools than other types of schools. In the close proximity of 67,6% of schools there were grocery stores or supermarkets where students can buy food or drinks. Other places, such as fast food restaurants, cafeterias, bars were rarely reported in the school neighbourhood (tab. I).
2. Meals offered to students at school
The majority (83,9%) of schools offered students hot lunches or other hot meals. This offer was similar in different types of schools. In only 27,8% of the schools these meals were eaten on a typical school day by more than half of the students. e proportion of students who eat hot meals at school was higher in primary schools and clusters of schools than in lower-secondary schools (tab. II). Meals, the so-called “second breakfast” (drinks and sandwiches prepared at home and for some students at school), eating together in the classroom or another place was organized for all the classes only in 23,3% of the schools and in some classes in 36,2% of schools. This type of school meal was less often organized in lowersecondary schools than in others (tab. II). Almost all schools (97,5%) served free meals for students coming from poor families. In about one third of the schools these meals were offered to 26% or more students. e proportion of students who have free meals was the highest in primary schools (tab. II).
3. Availability of drinks and food products at schools
Table III presents the drinks and food products which students can buy or get at school. e analysis of this data indicates that there is a disproportion between the availability of healthy and unhealthy food products. The majority of the schools had junk food providing calories primarily through fat and added sugar and having minimal amounts of vitamins and minerals. Sweets – chocolate bars, candies, biscuits were available at 70% of schools, sweet rolls and doughnuts at 56.7%, regular soft drinks at 44.7% of schools. Salty snacks (potato crisps or chips, and French fries) were available in 42.6% of schools. All the unhealthy products were offered more often in lower-secondary schools. Bottled water and 100% fruit or vegetable juice were offered at 65-69% of schools but other healthy products were rarely available. Students could buy milk and dairy products at 10-20% of the schools, vegetables or salads at about 13%, whole-grain bread at about 18% of schools. Fruits were offered at 33.8% of the schools. All these healthy food and drinks were available more often in lower-secondary schools than in others.
4. School policy on promoting healthy eating
Head teachers were asked about the existence of nutrition policies concerning promoting healthy food and limiting unhealthy products at school and the forms of these policies: written or informal (verbal agreement). The percentage of schools which had no specific nutrition policy ranged between 13-36%, The majority of schools (54-74%) had informal policies (verbal agreement). Written policies (documents) were in place in only a small percentage of schools: 25,7% of the schools had a policy on the consumption of healthy food, 10% of the schools had policy on limiting sweets, chips and soft drinks and other junk food; while only 7% of the schools had policy stating that fruits and vegetables should be offered at school events. Policies on promoting healthy eating (written and informal) were more rarely in lower-secondary schools than in others (tab. IV). Over 60% of the schools had procedures to inform students, teachers and parents about policies concerning nutrition and healthy eating. There were no dierences between the types of schools. Only about 30% of the schools regularly informed parents about the importance of modelling healthy eating to their children. This practice was more often used in primary schools (tab. V).
5. Implementation programmes on promoting healthy eating in schools
The questionnaire included questions concerning three programmes promoting healthy eating which were developed at the national level during the last decade and widely disseminated in the whole country. Two of them were developed in the frame of the Common Agricultural Policy established by the European Commission and aimed to increase the consumption of milk and dairy products, fruits and vegetables at schools. The programme “A Glass of Milk” was implemented in 2004, the programme “Fruits at Schools” in 2009. They are coordinated by the Agency of Agricultural Market (www.arr.gov.pl). The third programme “Keep Fit” (promoting balanced diet and healthy lifestyles) was implemented in Poland in 2006 (www.trzymajforme. pl). It is generally an educational programme, addressed to adolescents and is coordinated by the Chief Sanitary Inspectorate and the Polish Federation of Food Industry. The results of the survey showed that in 2010 (tab. VI): – the programme “A Glass of Milk” was implemented in 74.4% schools, mainly in primary schools (95.1%). In 66.6% of the schools the majority of students (81% or more) were involved in this programme. It was less popular in lower-secondary schools – only one in four schools oered it and a small number of students drink milk and other dairy products;
– the programme “Fruits at Schools” was implemented in 38.3% of schools, more frequently in primary schools. The proportion of students participating was lower than in “A Glass of Milk” programme. Only in 38.1% of schools 61% or more students were involved; – the “Keep Fit” programme was introduced at 72.2% of the lower-secondary schools and at 28.1% of the primary schools.

DISCUSSION
Information obtained from 520 randomly selected primary, lower-secondary and cluster schools from all the voivodships makes it possible to diagnose the current situation regarding the infrastructure, the kind of meals for students and the school policy on promoting healthy nutrition. It also allows the assessment of the degree to which schools have become involved in the activities to prevent overweight. These activities were specified in the 2007-2015 National Health Programme (11), as well as the National Programme of Preventing Overweight and Obesity and Chronic Noninfectious Diseases through Improved Nutrition and Physical Activity for the years 2007-2011 (12).
In 2006 some of the data analysed in the present paper were collected in a similar way in primary and lower-secondary schools as part of the HBSC study (9). Comparing the data makes it possible to assess the dynamics of change in the past four years. Research results show that the infrastructure for organising student nutrition is relatively good. About 70% schools have a canteen and a school store, the figure being slightly higher for clusters of schools, which are attended by more students. Nearly every fifth school has food vending machines, more often in lower-secondary schools. In comparison to 2006, the percentage of schools equipped with these had increased. However, the schools with a school store and vending machine can be classied as a positive phenomenon only in case they sell healthy food.
The trend of only some of the students benefitting from school meals is continuing in Poland. The postulate that every student should eat a school meal has, so far, not been implemented: Hot meals were available to students in 84% of the schools (2% more than in 2006). These meals were consumed by more than half of the students in only 28% of the schools examined, twice as many as in 2006. The trend can, therefore, be interpreted as positive. A school breakfast, eaten by the students together either in their classrooms or in other places was organized by about 60% of the schools, of which only 23% organized it in all of the classes, more often in primary schools (especially in grades 1-3). Compared to 2006 the situation has not changed. A school breakfast can be organized in any conditions and schools have been encouraged to do so since 1992 (13). Free meals for students from families in a diffcult financial situation were served in almost all schools. In half of them more than 16% of the students benet from these meals, especially in primary schools. The number of schools organizing these meals for such large numbers of students has increased by 8% compared to 2006. This is a task which has been carried out in schools for a long time. It is an element of the social policy of the state and in recent years has been supported by many non-governmental organizations. As part of the “State Aid in Nutrition” programme, it has been possible to benet from free school lunches since January 2009 without the requirement of conducting an earlier diagnosis of the nancial and material situation of the child’s family. Such a situation helps to reduce the stigmatization of children from poor families at the same time fullling one of the child’s basic needs (14). Different kinds of activities promoting the prevention of overweight and obesity have been undertaken in Poland in recent years. Some of these were prevention programmes conducted on a nation-wide scale (12). In 2006 the whole country implemented the “Keep Fit” educational programme, which is now being carried out in 72% lower-secondary and 57% cluster schools. Research results indicate, however, that: – In most schools students can buy sweets, in almost half of them sweet rolls, fizzy drinks and salty snacks. The accessibility of these unhealthy products was greatest in lower-secondary schools, which means that the educational programme being carried out is not supported by other school activities;
– About 25% of the schools do not had a policy aiming at increasing the consumption of healthy products (vegetables, brown bread, fruit, etc.) and reducing the accessibility of unhealthy food and drinks (sweets, sweet drinks, salty snacks). Only 7-26% of the schools which adopted such a policy had stated it in writing and only 65% of the schools had procedures of informing students, teachers and parents about it.
There are many programmes in Poland being carried out in the area of nutrition and healthy eating education. These are programmes offered to schools by various food producers, foundations, NGOs, as well as authoring programmes developed in the schools themselves. The programmes which have the largest, nation-wide scope are as follows:
– Programmes coordinated by the Agency for the Agricultural Market (Agencja Rynku Rolnego). In 2010 a total of 2/3 of all the schools took part in the “A Glass of Milk” programme (95% primary schools and only 25% lower-intermediate schools), but the rate of students who actually drank the milk and dairy products varied. The “Fruit at School” programme boasts a much smaller range. A total of 38% schools implemented it, but only 6% lower intermediate schools and the actual percentage of the students eating fruit was also lower. these results show that many schools are not interested in using healthy products, which are free or sold at discount prices.
– the “Keep Fit” educational Programme. In 2010
– 72% lower secondary and primary schools benetted from it.
The results obtained indicate that a large proportion of schools undertake various activities in student nutrition, but the basic problem is the lack of coherence and coordination of various initiatives. Schools do not form their own policy in this respect. There is also a lack of a formal policy in the healthy nutrition of students on the part of education authorities at the national, regional and local level.
The limitation of the results presented in this paper connected with the sample of the schools that provided responses. The response rate was 74.3%. One of the reasons of this response rate could be the food which occurred three times in many regions of country during the spring of 2010, where the survey was carried out. Also there is some disproportion between school located in villages and towns in the sample, with the highest proportion of rural schools. It is likely probable that head teachers at rural schools were more eager to complete the questionnaire.

CONCLUSIONS
1. The organization of nutrition for all school children has not yet started being treated as an important task by most schools in Poland. It is still not appreciated that implementing school meals has a substantial influence on the development, health and behaviour of students and on their ability to learn.
2. Most schools have not joined the activities aiming at preventing overweight and obesity among students. Products and drinks which have an adverse effect on health are readily available and only a small number of schools have a formal (written) policy on limiting the supply of such products and increasing the consumption of health promoting products. In this respect a particularly unfavourable situation can be encountered in lower-secondary schools, which limits the effectiveness of the „Keep Fit” educational programme carried out in 72% of these schools. There is a burning need to develop a coherent nutritional policy in Poland at the regional, local and school level relating to the healthy nutrition of students, one that would incorporate the hitherto existing programmes. A chance to undertake such work and increase the effectiveness of such activities is offered by the HEPS project prepared within the network of Schools for Health in Europe, which provides the tools and guidelines to creating such a policy

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Adres do korespondencji / Address for correspondence:
Barbara Woynarowska
Department of Biomedical and Psychological Basis of Education
Faculty of Pedagogy Warsaw University
ul. Mokotowska 16/20, 00-561 Warsaw
tel./fax (48 22) 822-46-81
[email protected]