School food policy at Dutch primary schools: room for improvement? Cross-sectional findings from the INPACT study

Childhood obesity is a major public health concern in many countries [1, 2]. Globally, in 2010 more than 40 million children aged ≤ 5 years were overweight [3]. In the Netherlands, obesity is also a health concern; not necessarily because the prevalence rates are high (they are lower compared with some other European countries [4, 5]), but mainly because the prevalence rates of overweight among Dutch children and adolescents have increased over the years. Among Dutch boys (aged 2–21 years) the prevalence rate of overweight almost tripled from 5.1% in 1980 to 13.3% in 2010, and for Dutch girls these rates increased from 7.2% in 1980 to 14.9% in 2010 [6]. Overweight and obesity are related to a range of both short and long-term negative health outcomes such as hypertension, diabetes mellitus type II, pulmonary disorders and cardiovascular disease [7‐10]. Furthermore, childhood obesity tracks into adulthood [11]. One of the main causes of obesity is unhealthy dietary behaviour, such as high consumption of sugar-sweetened beverages, large portions of food, and skipping meals [12]. Eating habits established in childhood also track into later life [13, 14]. Therefore, it is important to study the determinants of eating habits of children and develop interventions and policies to establish healthy dietary habits at an early stage.

Parents have a strong influence on children’s dietary behaviour and the development of their eating habits [15‐17]. For example, parents determine the availability and accessibility of food at home, set rules and regulations concerning food consumption, and also act as role models.

The school is also considered an important place for the prevention of childhood obesity as children spend a significant part of their time there and often consume food/beverages during school time [18]. Moreover, school staff are able to reach both children and parents, and schools can be an environment that stimulates healthy eating habits [19]. A school food policy can be the basis of such a healthy eating environment. School food policy is a broad concept and includes nutrition guidelines (e.g. nutrition standards for menu planning), regulation of the availability of food and beverages at schools (e.g. types of food sold in the school canteen or vending machines), food rules (e.g. rules about the types of food children are allowed to consume during school time), and price interventions regarding food and beverages sold in school canteens (subsidised provision of specific foods or control of the price of foods and beverages for sale to children). Several studies examined the effectiveness of a school food policy. For example, Jaime et al. reviewed the effectiveness of school food policies in the USA and Europe (focusing on nutritional guidelines, regulation of food and beverages availability and price interventions) with regard to improving the school food environment, children’s dietary intake, and decreasing overweight/obesity of children. In that review, most evidence for effectiveness was found for the impact of nutritional guidelines, i.e. 8 out of 9 studies showed a positive change in decreasing fat intake and increasing fruit and vegetable availability at school [20]. A Belgium-Flanders study examined the influence of the school food policy (availability of food items, food rules, nutrition education program) on the consumption of fruit, soft drinks, crisps and sweets at primary and secondary schools. That study showed that only at secondary schools did the school food policy have an impact on adolescents’ consumption of soft drinks, crisps and sweets [21]. Moreover, it was found that school-based interventions can improve the dietary behaviour of children. For example, Van Cauwenberghe et al. reviewed school-based interventions across Europe and found strong evidence that multi-component interventions that combine improved availability of fruit and vegetables with a nutrition education curriculum delivered by the teacher and at least some parental involvement can improve children’s fruit and vegetable consumption [22]. De Bourdeaudhuij et al. reviewed school-based interventions that combined nutrition and physical activity approaches among children and adolescent’s in Europe and concluded that multi-component interventions might be preferable in school-based nutrition and physical activity interventions to reduce obesity in European children and adolescents [23].

The Dutch school system is different from school systems in other countries, both in general and regarding food policy. In the Netherlands, compulsory education starts at age 5 years, but in practice most children start school at age 4 years. Children aged 4–12 years attend primary school (some primary schools differentiate between infant school and junior school). In the Netherlands, schools are autonomous regarding fostering a healthy food environment and there is no legal obligation to implement a school health promotion program or food policy. Because almost no primary schools offer school meals, Dutch primary schools play a smaller role in fostering healthy eating habits among children than in countries where schools offer cooked meals during the lunch breaks. On the other hand, many Dutch primary schools implement school food rules (e.g. ‘children are not allowed to drink sugar-sweetened beverages during school time’) and have some kind of food policy.

As stated before, schools are considered as important settings to promote healthy eating habits among children and a school food policy can be an important tool to create a healthy eating environment at school. Although a range of studies has focussed on the development and evaluation of school-based interventions [22‐24] only a few studies have explored the food environment and school food policies at primary schools [20, 21], while such knowledge is required to improve the school food environment. The effectiveness of school food policies depends on the content of the policy and on the way it is implemented. Furthermore, the support of teachers, principals and parents is essential for the policy to work, as all are stakeholders in childhood obesity prevention. Insight in the perspectives of the schools (teachers and principals) and of the parents regarding the school food policy can provide valuable knowledge that can be used to improve the policy.

The overall aim of this study is to explore opportunities to improve the school food policy and/or implementation of the policy in the Netherlands. Therefore, we describe the presence, content and implementation of the school food policy (e.g. communication, enforcement and compliance with the policy). Furthermore, this study explores schools’ (teachers and principals) and parents’ opinion on the school food policy (including appreciation of the policy and the role that schools play in fostering healthy eating habits among children).

We studied a broad range of aspects related to school food policy, such as the content of the policy, communication about the policy with children and parents, compliance with the policy by parents and children, enforcement of the policy by the school, and appreciation of the policy by parents. In addition, we investigated the attention schools paid to the subject ‘nutrition and health’ in their curriculum, and the opinion of teachers, principals and parents regarding the role that schools play in the encouragement of healthy eating habits among children. In the present study, school food policy mainly refers to food rules (e.g. ‘children are not allowed to drink sugar-sweetened beverages during school time’), or recommendations (e.g. ‘we prefer that children eat fruit during the morning break’), which reflect the food environment at primary schools in the Netherlands.

A total of 72 teachers and 74 principals from 83 primary schools were interviewed. Most teachers were female (63.9%) and most principals were male (64.9%). The majority (92.1%) of the parental questionnaires was completed by the mother.

This study investigated schools’ and parents’ perspective about the school food policy in Dutch primary schools. The study shows that most primary schools paid attention to nutrition and health. Most schools had a written food policy and informed parents about the food rules. Furthermore, in most schools education on nutrition was part of the school curriculum and most schools participated in specific nutrition projects. In general, parents appreciated the school food rules. Most principals believed that they had only a supportive role to foster healthy eating behaviour among children and considered parents to be primarily responsible. About half of the parents believed that schools should play a role in encouraging healthy food habits among children.

Only few studies have examined schools’ or parents’ view on the school food policy. For example, a USA study among teachers and parents of middle-school students found that both parents and teachers were concerned about the school food environment and believed that schools should offer students healthier food and beverages and limit low-nutrient food products [25]. However, the results of that study are not comparable with ours, since the school food environment at Dutch primary schools is very different (e.g. at Dutch primary schools no school meals are offered). A European study also found that parents and teachers considered the school food policy to be important, and the majority agrees that there should be a school policy restricting consumptions of snacks and soft drinks [26].

The majority of the principals reported that their school had a food policy: 57.1% reported to have food rules and 37.1% of the principals reported that their school had recommendations about the food and/or beverages children were allowed to consume during school time. Surprisingly, even more parents (78.2%) reported that the school of their child had rules about the food and beverages children were allowed to consume during the morning break. An explanation for the differences in reported school food rules by principals and parent could be that in the semi-structured interviews with principals and teachers a distinction was made between “rules” and “recommendations”, while the parent questionnaire did not. It is possible that parents reported that the school of their child had food rules, while the school in fact had recommendations. Another notable difference concerns the reported food rules for the morning break and for the lunch break by parents. Of the parents, 72.8% reported that their child’s school had rules about the food and drinks that children were allowed to consume during the morning break, but only 42.8% of the parents reported food rules for the lunch break. An explanation for this may be that some of the parents are not aware of the rules about the food and beverages that could be consumed during lunch break, because their child goes home for lunch.

However, it is a positive sign that the majority of the primary schools in our study sample had a written food policy and informed parents about the policy. However, having a food policy does not ensure monitoring and compliance with the policy. The content of the policy, implementation, communication, enforcement and support of stakeholders are important factors that influence the effectiveness of a policy. Our results show that the food rules were not always clearly formulated. Some schools argued that they had food rules while other schools referred to ‘recommendations’. In daily practice, however, there was little difference between so-called rules or recommendations about food and beverages. However, due to the vaguely formulated food rules, enforcement of these rules is difficult. Well-formulated rules provide clarity and help to ensure their enforcement. In addition, most schools had no clear approach of how to deal with children who brought food to school that was not allowed in school. In most cases the approach depended on the supervising teacher. Furthermore, supervision was difficult because children often eat their snacks while playing outside.

It is remarkable that most schools did not have food rules regarding birthday celebrations. Several USA studies reported that classroom celebration treats consist of low-nutrient calorie-dense snacks [27]. For example, the mean calorie intake during classroom celebrations for first-grade school children was estimated at 550 ± 212 calories [28]. Also, in the Netherlands, most birthday celebration treats are low-nutrient calorie-dense snacks such as potato chips, candy bars and cake [29]. Because on average there are ± 20–30 children in a classroom, a classroom celebration occurs regularly. Some principals stated that children at an infant school (children aged 4–7 years) sometimes offered fruit as a birthday celebration, however older children (junior school) rarely chose fruit for a birthday celebration. A possible explanation for this difference might be peer pressure: i.e. fruit or healthy snacks do not have a ‘cool’ image. However, birthday celebrations are a tradition at primary schools in the Netherlands and schools apparently have difficulty in adopting a restrictive policy regarding treats offered in birthday celebrations. A restrictive policy may be a promising way to provide a more healthy school food environment, because birthday celebration treats are mostly low in nutrient and high in calories, and such foods are also provided during other occasions at school, such as sports events, Christmas and other holiday celebrations.

Also notable is the difference between infant and junior schools: some principals mentioned that at infant school it was more obligatory for children to eat fruit during morning breaks. Also there was more supervision regarding the foods and beverages children bring to school (most younger children eat their morning break snack in the classroom). Some of the schools organised meetings to inform parents about school issues including the food policy, these meetings were only for parents of children at infant school and not for parents of children at junior school. An explanation for these differences may be that schools expect children and parents in junior schools to be more familiar with the food policy and thus better comply with the food rules during the remainder of their stay at school. However, schools could be more active and structured in bringing the food policy to the attention of parents and children, especially in junior school where peer pressure may increase.

The majority of principals and teachers believed that parents are primarily responsible for the acquisition of healthy eating habits in children and that schools play a supportive role in fostering children’s healthy eating habits. However, schools should consider themselves fully responsible to encourage healthy eating habits among children during school time. Dutch primary schools could be more involved in fostering healthy dietary behaviour among children by offering school meals, as often occurs in the UK and other countries; however, in the Dutch culture this may be difficult to implement. In addition to the school, parents can also take responsibility for fostering healthy eating habits among their children by, for example, supporting the school food policy.

Besides schools and parents, the government can also play a role in encouraging school food policies and a healthy eating environment at schools. Governments can encourage schools to have a food policy, to provide programs to stimulate healthy foods, set nutritional standards for the foods that are available at schools or provide national lunch programs. For example, national distribution schemes which provide free fruit and vegetables to children at schools have been implemented in the UK and USA [30, 31]. Several years ago, the Australian government recommended that all primary schools implement a fruit and vegetable program (called ‘Crunch&Sip’) that provides a time in the class that children consume fruit and vegetables they bring from home [32]. Also in the Netherlands, there are some programs, such as Schoolgruiten (an initiative of the Dutch government in cooperation with other stakeholders such as The Netherlands Nutrition Centre Foundation), which is a program to stimulate children to eat fruit or vegetables during the morning break [33]. Governments can provide and support initiatives to improve the school food policy and environment; however the success of such initiatives depends on the adaptation and implementation of all relevant stakeholders including the school staff and parents.

This study investigated schools’ and parents’ perspective of the school food environment to detect opportunities to improve the school food policy. Most primary schools in this study had a school food policy and parents generally appreciated the school food rules. However, improvement is possible: schools should formulate clear rules about which food and beverages may be consumed during school time. Since teachers and principals may find it difficult to determine which food products are healthy and which are not, we recommend schools to cooperate with nutrition experts (e.g. dieticians, or The Netherlands Nutrition Centre Foundation). Within the food policy, special attention should be paid to birthday celebrations. In addition, supervision of the food and beverages that children bring to school can be simplified if children have to consume their food and/or beverages inside the classroom instead of while playing outside. Furthermore, schools should also clearly define how the school food policy will be enforced and the policy should be enforced by the entire school staff, rather than relying on teacher-dependent enforcement.

Finally, school food policy will only have an impact on children’s dietary behaviour if it is fully embraced by both the school and the parents. Dutch primary schools could play a more a significant role in fostering healthy dietary behaviour among children. However, teachers and principals, as well as parents, should take more responsibility in encouraging healthy eating habits among children and should fully support a school food policy.