School Menu Review Programme (PReME): evaluation of compliance with dietary recommendations during the period 2006–2020 in Catalonia

Pre-post study designed to assess school meals in Catalonia.

In Catalonia, 2332 primary schools (most secondary schools do not offer cafeteria service) were able to join the PReME programme during the period 2006–2020. The sample is made up of data and assessments obtained from the evaluation of 6,387 school meal plans and their respective questionnaires in PReME phases 1 and 2, conducted between 2006 and 2020. Table 1, shows the main characteristics of the centers involved in the study.

For the present study, data of all schools that took part in the PReME during the period 2006–2020 were analyzed. Schools in the city of Barcelona were excluded, as they are managed by the Barcelona Public Health Agency. The programme was offered to all primary and secondary schools, whether state, subsidised or private, through the publication of the programme’s availability on the ASPCAT website and during the course of hygiene and sanitary inspections that were carried out. Since 2006, the PReME programme has been featured in a separate section of the ASPCAT website. As such, the requests for school meal reviews were received spontaneously. However, from 2009 onwards, the PReME programme was also offered to all schools visited by public health specialists throughout Catalonia during the course of hygiene and sanitary inspections conducted in school kitchens and cafeterias. An assessment was offered every three years in order to cover the maximum number of schools in Catalonia, which also allowed schools enough time to implement improvement strategies. Assessments could be more frequent if warranted by special circumstances (change of kitchen management, change of catering company, specific problems, etc.). A 4-week meal plan was collected for each seasonal cycle (spring–summer and autumn–winter), along with the information requested in an initial questionnaire.

The information obtained in the PReME programme is coded in two phases.

In phase 1, the schools that spontaneously ask to take part in the programme and the PHSs that carry out the inspections in the schools send the application questionnaire and the meal plans (four weeks of the summer season and four weeks of the winter season) to the central services’ DN team. The data detailing the features of the school, school cafeterias, characteristics of the meal plan and the results of the meal assessments are entered in an Access database by the DN team. The DN team then generates a report with suggestions for improving meal planning, in accordance with the criteria of the National Health System’s “Consensus document on nutrition in schools (DoCACE)” (NAOS, 2010) [60] and the ASPCAT’s guide “Healthy eating at school” (with the version available at the time meals were assessed), which comprises the initial report. It is sent to all the stakeholders (school, parent-teacher association, catering company, and sometimes also the municipal council and the county council).

Phase 2, the follow-up phase, which began in 2012, is offered to all schools that have completed phase 1. Accordingly, the initial report is resent to the schools, together with the invitation to submit, within 2–3 months, a new 4-week meal plan for each season and a new questionnaire that will be evaluated. In the case of schools that take part in this second phase, the new meal plans are assessed and the DN team draws up a follow-up report, based on the same structure and criteria as the initial report.

For the present study, the application questionnaires provided the school’s identifying data (category – state, private or subsidised –, educational level – ‘primary’ or ‘primary and secondary’ –, contact details, etc.); information about the cafeteria service (number of students, number of students using the cafeterias, cafeteria management and type of catering service: a) Own kitchen- schools with their own kitchen that plan the meals, b) Company in school—external company that cooks at the school, c) Company with centralized kitchen—external company supplying schools from a centralized kitchen–); presence of food and beverage vending machines; types of oils used for cooking, frying and dressing; and menus for special situations such as illnesses (allergies or intolerances) or ethical or religious issues (pork-free, meat-free and vegetarian).

Based on the DN team’s evaluation of each school’s monthly meal plan, information was obtained about the weekly frequency of foods offered in the first courses: rice, pasta, pulses, salads and vegetables (including potatoes); in the second courses: meat, fish, eggs, plant-based protein; as side dishes: salad, potatoes and other side dishes (pulses, pasta, rice, cooked vegetables, mushrooms, etc.); and as desserts: fresh fruit, dairy and other desserts (canned fruit, nuts) along with data about fried foods, both in main courses and side dishes. Information was also collected on the number of precooked foods and sweet desserts served per month. The evaluation of compliance with the PReME recommendations was based on the description of the dishes, ingredients and culinary technique used in the meal plans. Table 2 shows the items evaluated and the recommended frequencies of foods that were applied in PReME during the study period. Compliance was considered to be adequate when the food count and cooking technique offered in the meal plan coincided with the recommendations of the current PReME guide and year: 2006 recommendations for meal plans received from 2006 until August 2010; 2010 recommendations for meal plans received from September 2010 until August 2015; 2015 recommendations for meal plans received from September 2015 until August 2016; 2016 recommendations for meal plans received from September 2016.

Five PReME indicators were established as key variables for evaluating the quality of the meal plans: fresh fruit for dessert, pulses as a first course, vegetables on the daily menu, fresh food (raw fruit and/or vegetables) in the daily menu, and olive oil for dressing (Table 3). These data were also assessed by the DN team based on the school’s meal plan. The data for fresh fruit for dessert and pulses were the percentage of weeks that the school complies with the recommendation in the meal plan provided. With respect to the daily presence of vegetables and fresh food in menus, unique variables were defined that integrated the information obtained from the evaluation of the monthly meal plan. In this case compliance was considered adequate (yes/no) when the meal plan showed fewer than five days per month without including either of these items. The data on the use of olive oil for dressings was extracted from the application questionnaires that had been completed by the school (yes/no).

The PReME indicators are described in terms of the absolute and relative frequency of schools that comply with the indicator in the case of monthly indicators (with regard to vegetables, fresh food and olive oil), and as means and standard deviations in the case of indicators based on the percentage of weeks complying with recommendations (for fresh fruit and pulses). The same statistics are provided for the other variables depending on whether they are binary/categorical or numerical, respectively.

In order to evaluate possible differences between years, or according to school category or type of kitchen, bivariate chi-squared tests were used for categorical variables, and t-test for numerical variables (ANOVA for the comparison between years).

A significance level of 0.05 was considered as an indicator of statistically significant differences. Data was compiled in an Access database and analysed with R statistical software, version R 3.6.1.

The percentage of schools complying with the dietary recommendations encompassed in the five PReME indicators has followed an upward trend since the beginning of the programme. Compliance was seen to be higher in state schools with respect to the inclusion of fruit and cooked and uncooked vegetables as part of the daily menu. Regarding the presence of red and processed meats and olive oil for cooking and dressing, the results are given for the period comprising 2015–2020. This is due to the fact that changes were made in 2015 to the meal plan review criteria that affected these indicators (Table 2).

In line with our evaluation, the study analysing compliance with NAOS indicators (DoCACE) in Guipuzcoa (fresh fruit ≥ 4 portions/week; vegetables ≥ 4 portions/week; pulses ≥ 1 portion/week; fish ≥ 1 portion/week; and precooked foods ≤ 1 portion/week), also showed that state schools attained the highest compliance rates for vegetables and precooked foods, while in the case of pulses, fish and fruit, compliance was identical for both state and private schools [73]. In a study assessing meals offered in school cafeterias comparing state, private and subsidised schools in Seville in 2014, and based on the recommendations of the PERSEO guide (Pilot School Reference Programme for Health and Exercise against Obesity) [74], it was observed that the state schools aligned more closely with the established recommendations. However, a higher proportion of state schools offered excessive quantities of meat products compared with subsidised or private schools, and the differences with respect to state schools were significant. With respect to the provision of pasta and rice, state and private schools delivered the recommended amount, while 35% of subsidised schools exceeded the recommendation. On the other hand, private schools showed closer alignment with recommendations addressing vegetables. This difference was significant with respect to the other two types of school. In addition, significant differences were observed in the three types of school with respect to pulses, with subsidised schools showing the closest alignment to recommendations [74]. In a study conducted in Asturias that assessed the availability of different food groups in school meals in the 2015–2016 academic year, a higher compliance rate was observed in state schools regarding the availability of fried foods, lower availability of fatty meats, greater availability of vegetables as a first course and a lower presence of animal protein in the first course [75].

The type of cafeteria management had a significant influence on compliance with the indicators. Thus, companies that prepared meals onsite at schools showed statistically significant higher compliance rates, except for pulses and the presence of fruit and uncooked vegetables on the menu. Contrary to our results, in the studies carried out in Madrid [76] and Granada [71], no significant differences were found in the overall quality of meals prepared in school kitchens or by catering services. However, the latter offered more meat and less fish, eggs and fruit. In the Asturian study and in another study carried out in the region of Marina Alta in the Valencian Community, better results were obtained with meals prepared in school kitchens [75, 77]. In a later study by Llorens-Ivorra et al. in the Valencian Community, it was observed that the meals designed by the school itself contained more meat; and the meals prepared by catering companies contained more salad, vegetables, pulses, fish, oily fish, precooked foods and eggs. This difference could be due to the fact that the latter employ professional dieticians [27]. In contrast, a study conducted in 209 schools in 19 Spanish provinces in 2011, using criteria similar to those of the DoCACE, found that the quality of the meals prepared by catering services was superior to those prepared in-house, and improved when they were prepared jointly [78]. In the Asturian study, which assessed the availability of the different food groups in school meals during the 2015–2016 academic year, a higher level of compliance was observed for in-house preparation of precooked foods, pulses, greater availability of salads and vegetables as well as a lower availability of processed meat and animal protein in the first course. In addition, a higher level of compliance was observed for catering companies with respect to the availability of canned foods and fatty meat [75]. In the study by Arroyo et al. on the nutritional composition of school meals in Alicante, better quality was observed in the schools with their own kitchen [79]. On the other hand, in the nutritional comparison of the meals prepared in Granada, based on whether or not catering services were used, a higher calorie and carbohydrate content was seen in the schools with their own kitchen. However, no differences are observed with respect to other macronutrients [71].

Compliance with the recommended frequencies of foods improved throughout the period, attaining statistical significance for all items except pulses, whose compliance had been high since the beginning of the study. Unlike our evaluation, an assessment conducted in schools in a municipality of Madrid in 2011 to assess the trend in the inclusion of vegetables in school meals (2004–2008) showed a decrease in the number of first courses with vegetables throughout the study period (26.2% in 2005; 11.9% in 2008) [80]. Likewise, in a 2014 study conducted in Madrid assessing compliance with the DoCACE recommendations, compliance rates lower than ours were observed for rice, pasta, fish, eggs, salad as a side dish and fruit as dessert, although the results were similar with respect to the availability of meat, which was above the recommended level [76]. Unlike our study, the availability of vegetables, fruit and pulses in school cafeterias in Seville and Asturias was insufficient. However, the findings were similar with respect to excessive amounts of meat [74, 81]. In the case of Asturias, the positive trend in most food items during the period 2011–2016 was attributed to the implementation of the “Healthy and organically produced food programme in school canteens”, based on the DoCACE [81]. In the study subsequently carried out in Asturias that assessed the availability of different food groups in school meals during the 2015–2016 school year, all schools obtained high compliance rates in all variables, except for the availability of precooked foods, vegetables as a first course, processed meat and the use of olive oil [75]. In a study conducted in the Valencian Community to evaluate dietary balance, it was observed that more than 60% of meals complied with the recommendations for salad, cooked vegetables, meat derivatives, precooked fish, eggs and sweet desserts, while less than 40% of meals complied with the recommendations for pulses, meat, oily fish, fried foods, dairy products and fruit [27]. However, this study used a questionnaire developed ad hoc as an instrument for evaluating the dietary balance of meals provided. This questionnaire did not coincide exactly with the NAOS indicators or with those of our study or the guides used in other autonomous regions of Spain. A study conducted in the Community of Castile and Leon, which used a questionnaire based on a regional guide and the DoCACE, non-compliance was observed with the recommendation regarding excessive intake of meat derivatives, dairy products and precooked food; non-compliance was also due to insufficient intake of fish, fruit, pulses and vegetables and salads as side dishes; there was also elevated use of fried, battered and breaded foods [82]. In the study of school cafeterias in the province of Vizcaya in the Basque Country, based on the DoCACE recommendations, it was observed that 100% of meals complied with the indicators relating to pulses, fish, meat, meat products and precooked dishes; however, non-compliance was observed with indicators relating to fresh fruit and vegetables [83]. Similarly, the study of school meals in the province of Granada concluded that the availability of the different food groups in the evaluated meals was largely in line with DoCACE guidelines, except for fruit [84]. For six canteens in the metropolitan area of Bilbao, analysed in 2010, it was found that the availability of vegetables, fish, eggs and fruit was below the recommendations and that of meat and dairy products exceeded recommendations [85].

However, school meals provided in the province of Guipuzcoa complied with the recommendations for meat portions and meat derivatives [73]. There are few studies that categorise processed meats or meat derivatives as a separate food group. In our study, an improvement in compliance was observed since red and processed meats were differentiated from white meats, with 67% of schools complying with the recommendation. Llorens-Ivorra et al. [27] observed a similar situation in the Valencian Community, with 70.2% of meals complying with the recommendation (≤ 3 portions of meat derivatives per week). In their study of school meals in Castile and Leon, De Mateo et al. observed a non-compliance rate of 97.2% (≤ 2 portions of meat derivatives per week) [82].

Most studies recommend an increase in the availability of fresh fruit, vegetables, pulses, fish and eggs, and a decrease in the provision of meat [27, 71, 73‐76, 79‐83, 85‐87]. Globally, the average intake of fruit and vegetables is below the World Health Organisation’s recommendations in all WHO regions [88]. Interventions applying the social-ecological model acknowledge the importance of structural influences on children’s fruit and vegetable intake, for example, in the availability or accessibility of fruit and vegetables at home or in settings frequented by children, such as schools [38]. Combined with policies to limit availability of other less healthy foods, such interventions may be more effective in augmenting the consumption of recommended foods [89]. Despite strategies to increase fruit and vegetable consumption, fruit intake among Spanish children is still insufficient [31, 90‐92]. Most school meals served in cafeterias show insufficient inclusion of fresh fruit, which are replaced by an excessive availability of dairy or sweet desserts [83, 86, 87, 93]. However, in our study, 95% of the schools complied with the recommendation of 4–5 portions of fruit per week. A similar finding was obtained in the city of Barcelona, where compliance was 82% [94]. On the other hand, only 37% of meals complied with the recommendation of fresh fruit offered as dessert in the study of the Valencian Community [27], 32.4% in the Community of Madrid [76], and in the Guipuzcoa study, compliance was nil [73].

It should be considered that part of the differences in results presented by the distinct studies could be due to the variety of methodological instruments used to assess the meals. Both Asturias and Bilbao used the PERSEO programme’s school cafeteria guide. In contrast, in the study of school meals in the city of Barcelona, which is based on PReME criteria, slightly lower compliance was observed for most food items compared with our study for the same year [94].

The comparison of the results obtained in the phase 1 report (initial review) and the phase 2 report (follow-up review) showed an improvement in the level of compliance with the recommendations in the follow-up report. This would indicate that the recommendations and suggestions for improvement of the meal plans reviewed after the initial report were implemented successfully. Another study that assessed school meals from 2007 to 2010 demonstrated the effectiveness of the strategy of assessing school meals and sending the results to schools, complemented by a series of individual recommendations. As a result, the nutritional features of the meals provided at the schools have improved significantly [79].

In our study, an increase was observed in the percentage of schools that offered special menus in response to requests based on medical considerations or those related to ethical or religious aspects. Public or private ownership of schools did not have a significant influence on the overall availability of special menus for medical conditions, plans to avoid cross-contamination or the willingness to plan special menus for families. Private schools presented a greater range of options for food allergies or intolerances and they also made it possible to bring food prepared at home in a lunch box. However, they offered fewer menus adapted to ethical or religious considerations. On the other hand, the results of a study by Ramos evaluating school cafeterias in the city of Barcelona showed a higher percentage of schools that offered special menus for all menu typologies, compared to our results for 2019 [94]. One possible explanation could be that the sample in our study comes from centers in both urban and rural areas, while Ramos' study exclusively includes the city of Barcelona. Studies have shown the differences in eating patterns among populations living in rural versus urban areas [95‐98], which would lead to the adaptation of school menus to these distinct patterns.

Our study presents certain limitations. As it applied a pre-post study design, causality cannot be established, and the results on compliance with the recommendations should be interpreted with caution. The results reported each year were derived from different schools which were not followed every year and as such, yearly outcomes are not strictly comparable. However, the results are useful for assessing which aspects of school meals need to be improved. As a result, it is possible to suggest potential interventions for increasing compliance. Neither serving sizes nor the real consumption of portions were assessed, and evaluations were based on the information given in theoretical monthly meal plans provided by the schools. Our study did not include information on the meals’ nutritional or organoleptic aspects but was limited to analysing the types of food provided. The assessment of existing dietary interventions, standards or policies in schools was also exempt in our evaluation. Furthermore, the changes made in the review criteria applied during the study period prevented assessing the evolution of certain items from the onset of the programme.

The discrepancies observed between this study’s results and those of other studies may be due to the fact that the same criteria were not used to assess the meals, as well as differences in recommendations, varying food item grouping or categorisation criteria or the exclusion of given items. The present study does not present data of a cohort of schools followed over a period of years, but rather “cross-sectional” information gathered serially over a period of years. However, given the low figures of percentages with repeated observations, it was hypothesized that the impact of such a violation of assumed independence would be residual in the statistical tests. Lastly, due to the pandemic situation in 2020, PReME was not able to fully maintain planned assessments for all schools involved in the programme.

Among the study’s strengths is the fact that it constitutes the first comprehensive review of school meals over a period of fifteen years in a large sample of schools in Catalonia. Although it is hard to longitudinally estimate the coverage of our data, at 2020, 2221 out of the 2332 Catalan schools had participated in the programme at some point.