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Diet, food and eating and the health promoting school
Article Type: Editorial From: Health Education, Volume 115, Issue 2
This special edition is the first of three on the health promoting school. The original impetus came from an inspiring European Conference on Health Promoting Schools: Equity, Education and Health which was held in Odense, Denmark in October 2013. Papers have flowed in from that conference, initially from Europe and, following a call for papers, from right across the world.
The world is in a time of economic crisis and change and the conference subtheme of “Equity, Education and Health” reflected a concern for one of the main impacts, the increase in health inequalities among children and young people, and a particular focus on how schools, working with families and local communities, can play an active role in challenging this trend.
Seven of the papers submitted focused on the theme of diet, food and eating in the school setting, and have been clustered together in this first special edition, for the illumination and novel approaches they provide on this vital topic.
Health, diet and eating: two key problems
Food and eating, so basic to life, are in the modern context proving highly problematic in a range of ways. Obesity is the most obvious health-related problem, bringing with it a host of serious medical and social problems, and is of epidemic proportions throughout the western world. So severe is the epidemic that some epidemiologists fear that the increase in life expectancy, which has been continuous for more than a century, will go into reverse. Childhood obesity, and its accompanying short- and long-term consequences such as bullying, self-image, diabetes, heart disease, and cancer, affects low-income communities disproportionally. Basically the affluent are more likely to eat to a regular pattern and healthily, with a more varied diet with plenty of fruit and vegetables than those on a lower income. Obesity is, however, not the only food-related issue and the overriding focus on diet and weight may even be contributing to the level of eating disorders and problems with body image that is growing rapidly across the western world, particularly in the young. Papers from this edition look at both of these key issues.
The role of the health promoting school in promoting healthy eating
Schooling, which in many countries is compulsory, can be key in responding to these challenges. The health promoting school movement is thriving: at least 34,000 schools in the WHO European Region were identified as health promoting schools in the 2012/2013 school year and the movement is worldwide. Health promoting schools use a whole-school approach to enhance the health and educational outcomes of children and adolescents through teaching and learning experiences initiated in the schools. They combine a range of complimentary approaches directed towards knowledge and action that enable individuals and communities to increase control over determinants of health. It is recognised that how children develop and how they behave in terms of their self-concept, self-efficacy, and sense of control over their lives is strongly influenced by their years at school, and that positive experiences in the context of health promotion contribute to their independence, strength, social awareness, and psychosocial resilience. Diet, eating, food choices, and their connection with physical and mental health have long been a strong theme within the health promoting school movement.
The contribution of the papers in this volume
The first three papers in this edition examine the interconnected and complex links between food choices, eating, and wider aspects of children’s environment. The papers explore children’s eating habits and preferences, the largely unhealthy options available to them in schools, particularly but not exclusively in low-income neighbourhoods, and the association of unhealthy eating with not only low levels of physical activity but also, and less predictably, with poor school performance.
Waddingham et al. focus on how Australian children make food choices. We have long known that eating habits established early in life continue into adulthood, but we lack much inner understanding of what children prefer and why. The research used qualitative approaches to discover children’s view on why they make the food choices they do. The researchers found that understanding about what foods were healthy was limited, that children’s food preferences were mostly for unhealthy foods, and these were readily available in the canteen. Despite being asked to develop a “healthy” menu, the majority of choices made by the children were not healthy. Children went for the unhealthy choices on the grounds of taste, speed, availability, and price, as well as being influenced by outside factors such the peer group. The authors comment that the challenge lies around producing healthy options that match the children’s food choice criteria, to support children to have more control over their health.
The paper by Snelling et al. moves to a wider perspective to explore the relationship between eating and a range of features of children’s lives. It looks at the relationship between television viewing time, physical activity level, food consumption patterns, and academic performance of adolescents in a large urban school district in the USA where health disparities are prevalent. Students with higher grades had higher levels of physical activity and less screen time compared to students who reported grades low grades and ate more healthy food. As grades decreased the consumption of soda and fast food increased. The paper is particularly interesting in associating lifestyle and food choices with academic performance, a much needed link if schools are going to take health promotion more seriously and see it as part of their core mission of promoting learning.
Callaghan et al. look at availability and access to food in a large sample of secondary schools in Ireland, and paints a worrying picture. Data on the internal school food environment were collected, while the external school food environment was assessed by mapping food businesses within one kilometre of schools, using a Geographic Information System (GIS). It is the first time that both environments have been explored simultaneously. The research found that schools from more advantaged neighbourhoods had more healthy food choices available than disadvantaged schools, while all boys schools were less healthy than mixed or girls schools. One-third of schools had no canteen; half had a food shop and one-third a vending machine. Such food as was available from all sources was not particularly healthy: a third sold french fries in their canteen and nearly half energy-dense nutrient-poor foods in their school shop. There were more healthy food options available at schools that had a healthy eating policy in place, although even here unhealthy food dominated. A geographic picture of schools emerged as besieged by alternative food outlet options in their neighbourhoods, most of them unhealthy.
The remaining four papers explore some school-related strategies to tackle these problems.
There is an increasing gap in our modernised mechanised world between food production and its consumption, with children increasingly alienated from the process and unaware of how food arrives on their plate. Ellsworth et al. report on a case study of efforts to bring a touch of reality into the school. They examined the impact of a nutrition-education intervention delivered at low-income middle schools in Washington, DC in the USA, using a mobile farmers’ market in the form of a converted school bus, which particularly focused on fruit and vegetables. Seven low-income middle schools received the intervention, which included lessons focused on nutrition education and sustainable farming concepts. Children’s knowledge about nutrition increased as a result, providing support for this innovative and colourful approach to changing behaviour.
However, changing behaviour in the longer term is not easy, and the evidence for doing so far from clear.Taylor et al. evaluated the evidence base of the well-known “Food Dudes” healthy eating programme, specifically the short and long-term effectiveness of the intervention for the consumption of fruit and vegetables both at school and at home and the displacement of unhealthy snack consumption. The systematic literature review they used showed that programme was moderately effective in the short term; however, the long-term effectiveness of the programme proved to be unknown, while the ability of the programme to generalise to the home setting and to displace unhealthy snack foods also requires further investigation.
Schools in the UK provide free school means (FSM) to those on low incomes, but getting families and children to take this offer up is problematic, due particularly to the problem of stigma. An estimated 300,000 UK children do not take FSMs they are entitled to, with many schools unaware of the issue. Woodward aimed to design and implement interventions to increase FSM uptake. This paper describes the interventions, reports on acceptability and explores the process of implementing change. Five primary and five secondary schools in a northern city in England each established a working party, examined current claiming processes, and implemented individualised action plans. The effort showed some success, with critical factors being having individualised action plans that allowed flexibility in implementation, reflecting on current claiming processes, and setting up working parties. It proved, however, hard to tackle the underlying problem of bullying and stigma.
Food and eating are intimately connected with eating disorders and body image. Joram et al. report on a radically different approach to diet, the called “intuitive eating”, which aims is to promote healthy eating attitudes without increasing an unhealthy focus on restrictive eating or promoting a poor body image. “Intuitive eating” approaches encourage individuals to focus on internal body signals as a guide for eating, and have been shown to have a positive impact on eating-related psychological outcomes in adults: this is the first study of such an approach in a school setting. In a quasi-experimental study, high school students in a Midwest town in the USA received instruction on intuitive eating or a comparison programme over seven days during health classes. Students who received the intuitive eating programme made significantly greater gains in overall positive eating attitudes. The results are promising and suggest that this may be a fruitful area for future research in nutrition education.
The reasons why children and young people eat as they do are highly complex. They relate to the cost and availability of healthy foods, the actions of the food industry, media pressures to conform to a certain body type, the cultural transmission of dietary patterns, changes in family and peer group life that affect eating patterns and habits, and emotional and mental health issues such as poor self-image and mood. Some of these factors, and some suggested responses in the school context, are explored by the varied papers in this edition but, as the papers make clear, there is much we still do not know, and the pressures on the young to eat unhealthily appear to be increasing. It is hoped that this edition will both inform and kindle interest in some of the newer challenges ahead of us on this fundamental issue.