What's for Lunch? Investigating the Experiences, Perceptions, and Habits of Parents and School Lunches: A Scoping Review

Packed Lunch Provision and Consumption in Early Years Settings in Sheffield: A Cross-Sectional Study

INTRODUCTION

In 2024, 95% of 3-4-year-old children in England attended early years settings (EYS). This study aimed to estimate energy and nutrient content of packed lunches provided for and consumed by children attending EYS, along with food type, cost and level of processing and whether these differed by area deprivation.

METHODS

An observational cross-sectional weighed intake and nutrient analysis of food and drinks in packed lunches provided to and consumed by children attending eight EYS over 5 days. Food type, packaging and processing were coded and lunch costs calculated.

RESULTS

A total of 67 children ate 185 packed lunches. Lunches included fruit (76.2%) more often than vegetables (38.9%). Lunches in areas of higher deprivation less frequently contained fruit (p = 0.003) or vegetables (p < 0.001), and more frequently contained meat products (p < 0.001), savoury snacks (p < 0.001), cakes/biscuits (p = 0.038) and confectionery (p < 0.001). Use of pre-packaged foods was common (40.1% items), and ultra-processed foods provided 65.5% energy. Overall, lunches provided sufficient fibre and micronutrients, but high protein and excess energy, fat, saturated fat, free sugars and sodium. Provision of most nutrients varied by area deprivation, but consumption in areas of higher deprivation was only higher for free sugars (p = 0.002) and lower for fibre (p = 0.003) and vitamin C (p = 0.003). Median packed lunch cost was £1.26, with no difference by area deprivation (p = 0.422). Healthier lunches were cheaper than less healthy lunches (p < 0.001).

CONCLUSIONS

Use of pre-packed, ultra-processed foods was high, and provision of vegetables low. Lunches were high in sodium and free sugars, with less healthy lunches provided in areas of higher deprivation.

Neighbourhood, school and home food environment associations with dietary behaviours in Hong Kong adolescents: the iHealth study

This study is the first to examine whether neighbourhood, school and home food environments were associated with dietary behaviours in Hong Kong adolescents; and whether off-campus lunch school policy, bringing lunch from home and parental rules for eating behaviours moderated the associations. We used data from the international Healthy environments and active living in teenagers - (Hong Kong) [iHealt(H)] study. Participants were healthy adolescents aged 11-18 years (N = 1299; Mage = 14.7 years; 57 % girls) and their parent/primary caregivers. Participants completed surveys with validated scales to assess dietary behaviours and perceived food environments. The Microscale Audit of Pedestrian Streetscapes and Geographic Information Systems data and software were used to objectively assess food environments. A higher number of bakeries, coffee shops, cafes and convenience stores in the neighbourhood was associated with higher consumption of vegetables and lower consumption of sugar-sweetened drinks in adolescents. Adolescents who frequently brought lunch from home to school consumed fatty foods and sugar-sweetened drinks less frequently and were more likely to eat fruits and vegetables. Greater availability of unhealthy food outlets at the school was associated with higher consumption of sugar-sweetened drinks, whereas more restaurants around the school was associated with higher consumption of fruits and vegetables. Home-made lunches and restrictive parental eating rules moderated the effects of food environments on adolescents' dietary behaviours. All food environmental contexts were associated with Hong Kong adolescents' dietary behaviours; however, the home and school environment appeared to be the most influential and should be targeted in public health interventions.

Parent/Caregiver Perceptions of the Good Food for Learning Universal School Lunch Program in Canada

The Good Food for Learning universal school lunch program is a two-year population health intervention research study in two elementary schools in Saskatoon, Saskatchewan to implement and evaluate a promising model for school food programs (SFPs) in Canada. A survey was administered to understand parent/caregivers' perceptions of the free, universal school lunch program, participation, and willingness to pay for a future school lunch program (n = 113). A healthy and cost-free lunch were the top two benefits recognized by parents/caregivers. The survey estimated student participation in the program at 77%. For future program planning, universal and cost-free were favoured program aspects to continue. In addition, 68% of parents/caregivers demonstrated a willingness to pay $2.00 per child per lunch. Understanding parental/caregiver expectations and attitudes towards SFPs can inform the planning, decision-making, and sustainability for future models and a national school food policy in Canada.

Global parent perspectives on school food service internationally: A mixed papers narrative review

AIMS

The views of parents/caregivers about food programs in schools internationally is not well understood. This review aimed to synthesise what parents/caregivers identify as the key features of school food programs and their perspectives of these programs globally.

METHODS

A mixed papers review was undertaken with a systematic search (January 2024) and screening of three databases (Scopus, Web of Science, PubMed). Eligible studies captured parent/caregiver perspectives across all school food models. Study findings were extracted using Bayesian methods to translate quantitative findings into qualitative data. Data was deductively categorised to identify features of school food models, and separately themed to identify parent perspectives.

RESULTS

Twenty-six eligible studies were identified from 11 countries. Fifteen features were identified, including cost, time, effort and convenience, child preferences, nutrition, policy and messaging, eating environment and food education. Parent perspective themes were: child is the priority, lunchbox procurement, preparation and provision is challenging, school-provided meals have strengths and limitations, and parents acknowledge they are central to feeding. An overarching theme was that compromises must be made to meet the needs of family members, when parents make decisions on school food.

CONCLUSIONS

This review found that globally parents perceive benefits and challenges to school food programs, regardless of provision model, with a range of features that influence parent acceptability. Considering parent/caregiver perspectives when developing or changing school food provision models is likely to increase caregiver acceptability, supporting children to engage with health promotion efforts.

Promoting healthy school food environments and nutrition in Canada: a systematic review of interventions, policies, and programs

CONTEXT

The school food environment is a critical interface for child and adolescent nutrition, and there is a need to understand existing literature on Canadian school food environments to identify equity gaps and opportunities, and empower decision-makers to plan for future action.

OBJECTIVE

Literature on Canadian school food and nutrition interventions, policies, programs, and their effects on diets and nutritional status are synthesized and appraised in this systematic review.

DATA SOURCES

A search strategy was developed for each database used (Medline, Embase, PsycINFO, ERIC, Cochrane Collaboration, Canadian Electronic Library, BiblioMap), with a combination of free text and controlled vocabulary, for articles published from 1990 to 2021. Unpublished data and grey literature were also searched.

DATA EXTRACTION

Quantitative and qualitative studies with an observational or intervention study design, reviews, or program evaluations conducted in Canadian schools with participants aged 5-19.9 years were included. Key study characteristics and risk of bias were extracted independently by 2 investigators using a standardized tool.

DATA ANALYSIS

A total of 298 articles were included (n = 192 peer reviewed and 106 from the grey literature), which were mostly conducted in Ontario (n = 52), British Columbia (n = 43), and Nova Scotia (n = 28). Twenty-four interventions, 5 nonevaluated programs, and 1 policy involved Indigenous populations. Overall, 86 articles measured and reported on effectiveness outcomes, including dietary intake; anthropometry; knowledge, attitudes, and practices; and physical activity. The literature remains largely heterogenous and primarily focused on nutrition education programs that use subjective assessments to infer changes in nutrition. A key facilitator to implementation and sustainability was community engagement, whereas key barriers were staff capacity, access to resources and funding, and consistent leadership.

CONCLUSIONS

This review provides insight into Canadian school food and nutrition interventions, programs, and policies and uncovers important evidence gaps that require careful examination for future evaluations. Governments must create supportive environments that optimize nutrition for children and adolescents through equitable policies and programs.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42022303255.

Getting school-provided meals to the table: an international multiple-case study of school food service

A school food service, which is the way children access food during the school day, is one of the many aspects in creating a health-promoting school environment. School-provided meal services differ greatly, depending on the country, region and school contexts, however, there is limited understanding of the diverse meal delivery within these settings. Therefore, the aim of this study was to understand different school-provided meal systems across different countries and contexts. This study used a qualitative, naturalistic observation, using an interpretative epistemology and a multiple-case design to explore food service across seven schools, mapped against a school meal food service framework. This included three schools with an established school-provided meal system (England, France and Sweden) and four schools with emerging school-provided meal systems (Australia). Mapping captured findings across the domains of Menu offering, Food service system, Administration, Eating environment, Mealtime experience and Post-meal. Results demonstrate the need for tailored school food programmes, designed appropriate to the country, region and school context, including considering cultural underpinnings and available resources. Furthermore, a positive eating environment and elements of student choice and responsibility were all noted as principles important in a school food service. This knowledge can be used to inform planning of future systems, particularly for regions transitioning into a school-provided meal model, and those looking to implement improvements to existing systems.

Evaluating the impact of the universal infant free school meal policy on the ultra-processed food content of children's lunches in England and Scotland: a natural experiment

BACKGROUND

The Universal Infant Free School Meal (UIFSM) policy was introduced in 2014/15 in England and Scotland for schoolchildren aged 4-7 years, leading to an increase in school meal uptake. UK school meals are known to be healthier and less industrially processed than food brought from home (packed lunches). However, the impact of the UIFSM policy on the quantity of ultra-processed food (UPF) consumed at school during lunchtime is unknown. This study aimed to evaluate the impact of the UIFSM policy on lunchtime intakes of UPF in English and Scottish schoolchildren.

METHODS

Data from the UK National Diet and Nutrition Survey (2008-2019) were used to conduct a difference-in-difference (DID) natural experiment. Outcomes included school meal uptake and the average intake of UPF (% of total lunch in grams (%g) and % total lunch in Kcal (%Kcal)) during school lunchtime. The change in the outcomes before and after the introduction of UIFSM (September 2014 in England, January 2015 in Scotland) in the intervention group (4-7 years, n = 835) was compared to the change in an unexposed control group (8-11 years, n = 783), using linear regression. Inverse probability weights were used to balance characteristics between intervention and control groups.

RESULTS

Before UIFSM, school meal uptake and consumption of UPFs were similar in the intervention and control groups. The DID model showed that after UIFSM, school meal uptake rose by 25%-points (pp) (95% CI 14.2, 35.9) and consumption of UPFs (%g) decreased by 6.8pp (95% CI -12.5,-1.0). Analyses indicated this was driven by increases in minimally processed dairy and eggs, and starchy foods, and decreases in ultra-processed salty snacks, bread and drinks. The differences were larger in the lowest-income children (-19.3 UPF(%g); 95% CI -30.4,-8.2) compared to middle- and high-income children. Analyses using UPF %Kcal had similar conclusions.

CONCLUSIONS

This study builds on previous evidence suggesting that UIFSM had a positive impact on dietary patterns, showing that it reduced consumption of UPFs at school lunchtime, with the greatest impact for children from the lowest-income households. Universal free school meals could be an important policy for long term equitable improvements in children's diet.

Parents face several barriers in providing a healthy school lunch for their primary school children: A survey of Victorian (Australian) parents

ISSUE ADDRESSED

This paper aims to explore Victoria parents' perceptions of their current practices and barriers in providing school lunches for their primary school children.

METHODS

Respondents were asked via an online survey about their lunch provision practices, perceptions of the healthiness of school lunches, and barriers to providing healthy school lunches. Data were analysed using different statistical techniques: Chi-square test, Spearman correlation analysis, Mann-Whitney U test, and Kruskal-Wallis test.

RESULTS

In total, 359 respondents completed the survey. Most respondents (84%) reported their child takes a home-packed lunch to school every day. Most respondents provided fruits (94%), vegetables (57%), and sandwiches (54%) every day for school lunches, whilst other core food items such as milk, meats, and legumes were provided less frequently. A substantial proportion of respondents provided some discretionary food items frequently (e.g., the proportion of respondents providing selected discretionary food items daily or 3-4 times/week: salty crackers-50%, sweet cookies/biscuits-40%, chips-20%). Respondents strongly agreed or agreed with several barriers; examples include not packing certain foods due to food spoilage concerns (50%) (school-related), the allocated time at their child's school is not enough to eat and enjoy school lunch (48%) (school-related), need more meal ideas (61%) (parent-related), healthy foods take more time to prepare (51%) (parent-related), and children request easy-to-eat food for school lunches (50%) (child-related). Core food score (an indicator of frequency of preparing/packing core food) was negatively correlated with parent-related and child-related barrier scores, whilst discretionary food score (an indicator of frequency of preparing/packing discretionary food) was positively correlated with these barrier scores.

CONCLUSIONS

Overall, home-packed lunches remain the main option in primary schools in Victoria, and parents face several challenges in providing healthy lunches for their primary school children. SO WHAT?: The findings suggest the need for strategies from school leaders, education authorities, and policymakers to improve the quality of lunch content and address the barriers faced by parents.

Unpacking the cost of the lunchbox for Australian families: a secondary analysis

Ninety per cent of Australian school children bring a home-packed lunch to school, with 44% of the food consumed during school hours being unhealthy. Among other factors, cost is a key consideration for food provision; however, the costs to Australian families are not well understood. Therefore, we aimed to determine what families are currently paying for school lunchboxes in Australian primary schools and to examine associations between food costs and socio-demographic factors with dietary quality. An audit of local retail outlets was used to determine the food costs of lunchbox contents. Costs (AUD) were adjusted for inflation as of early 2023. The lunchboxes of 1026 children aged 4-12 years at 12 Catholic primary schools in New South Wales, Australia, were assessed at the start of the day, using photography assessment methods and a validated School Food Checklist. The mean cost of lunchbox contents was $4.48 AUD (SD 1.53), containing a mean energy of 2699 kJ (SD 859), with 37.3% (SD 23.9) of energy sourced from unhealthy foods. Multiple linear regression analyses found that the strongest predictors of higher lunchbox cost (P < 0.05) were a higher proportion of energy from unhealthy foods (B = 0.016) and lower Socio-Economic Indexes for Areas (B = -0.178), when controlling for child socio-demographics. The results indicated that lunchbox food costs to Australian families are comparable to alternative school food service models in Australia and internationally. Results demonstrate the cost of food is not the only barrier to providing a healthy school lunchbox. Demonstrating a need for cost-considerate systematic interventions addressing food provision challenges and socio-economic disparities faced by families.

Barriers and enablers to a healthy food environment in Australian childcare services: Exploring directors' perspectives

ISSUE ADDRESSED

Early childhood education and care (ECEC) settings are ideal environments to optimise nutrition and positively influence children's food behaviours. However, recent research has identified the need to improve nutrition policies, food provision, and mealtime environments in Australian ECEC settings. This study explored the perceptions of ECEC directors regarding barriers and enablers to a health-promoting food environment within ECEC services.

METHODS

Eleven directors from ECEC services in Nerang, Queensland, and surrounding areas, participated in qualitative interviews between March and May 2021. Transcripts were analysed using qualitative content analysis that followed a deductive-inductive approach employing nutrition-related domains from the Wellness Child Care Assessment Tool, these being: (i) nutrition policy; (ii) nutrition education; (iii) food provision; and (iv) mealtimes. Transcripts were coded independently by two researchers in NVivo and consensus for barriers and enablers was achieved through discussion.

RESULTS

Barriers and enablers were reported across four domains (nutrition policy, nutrition education, food provision, and mealtimes). Comprehensive nutrition-related policies were an enabler to a healthy nutrition environment but were sometimes described as lacking detail or customisation to the service. Nutrition education for children was described as competing with other activities for time and resources in an already-crowded curriculum. Financial and time pressures faced by families were a barrier to healthy food provision in services where families provided food for children. The ability of staff to sit with children and engage in conversation during mealtimes was an enabler; however, competing demands on time and the unavailability of food for staff were cited as barriers to health-promoting mealtimes.

CONCLUSIONS

Directors in ECEC services report both barriers and enablers to a healthy food environment. Nutrition policies were an enabler when comprehensive and relevant but a barrier when vague and not tailored to the service environment. ECEC services should be supported to develop and implement service-specific nutrition policies and practices by engaging with parents and staff. SO WHAT?: The barriers and enablers reported in this study should be considered when designing and implementing future evidence-based interventions to improve the nutrition environment in ECEC services.

How healthy are Australian lunch box snacks with child-directed marketing?

ISSUE ADDRESSED

The diets of Australian children, including their lunch boxes have a disproportionate amount of discretionary foods. Packaged snacks have marketing directed to both children and parents.

METHODS

Packaged school lunch box snacks were identified on supermarket websites. Nutrition information and child-directed and parent-directed marketing on the package were analysed. The "healthiness" of products was analysed using the Health Star Rating (HSR) (presently on packaging in Australia), two criteria designed for assessing food suitable for marketing to children (the Australian Health Council and the World Health Organization Western Pacific region) and Chilean criteria (used for broad food regulation).

RESULTS

The average HSR of the 135 products was 2.2% and 79% had a HSR <3.5. About 39% of products had child-directed marketing. Child-directed marketing would be removed from 89% sweet snacks, and 91% savoury snacks if products with a HSR <3.5 were not allowed to carry that marketing. This is less than the proportion not allowed using criteria from Chile (100%), World Health Organization Western Pacific Region (99%) and the Australian Health Council (93%).

CONCLUSIONS

A policy that disallows marketing tactics on unhealthy food based on any of the criteria studied would remove most of both child-directed and parent-directed marketing on packaged lunch box snacks. SO WHAT?: Removing child-directed marketing from unhealthy products would help parents when shopping and contribute to addressing the high proportion of discretionary foods eaten by children at school. Child-directed marketing on packaging should be a part of comprehensive regulation to protect children from the marketing of unhealthy foods.

Impact of COVID-19 School-Related Policies in Ontario on Parents' School Lunch Packing Habits

Purpose: COVID-19 has disrupted the daily routines of many Canadian families. In Ontario, provincially mandated public health measures have resulted in significant changes to school policies, including those related to food. The impact of COVID-19 related school food policies on parental lunch packing habits is unknown; therefore, this study investigated how school-related COVID-19 policies have impacted parental school lunch packing habits.Methods: Parents (N = 287) of school-aged children were recruited from parent-specific Facebook groups across Ontario, Canada, to complete an online survey regarding lunch packing habits. This survey was developed based on findings from a previously conducted scoping review. Open-ended survey responses were inductively analyzed.Results: Three over-arching themes were constructed: (1) Food Programs and COVID-19; (2) Schedule Changes; and (3) School Policy Changes. Parents explained that the cancellation or modification of food programs at schools, changes to the length of time children are given to eat at school, and removal of access to microwaves, garbage cans, and teacher assistance during lunch have forced parents to change their lunch packing habits.Conclusion: Findings from this study demonstrate a need for better support to help ease the burden parents experience when packing their child's school lunch, during an already extremely stressful time.

School lunchboxes as an opportunity for health and environmental considerations: a scoping review

Very little research has focussed on children's school lunchboxes from both a health and environment standpoint. This scoping review explores studies that considered children's lunchbox food consumption trends at school and the environmental impacts of lunchbox contents. We conducted a scoping review of peer-reviewed literature with a focus on lunchboxes of children in preschool or primary school settings that contained food packed from home, through the lens of food and nutrition in combination with environmental outcomes-particularly food and/or packaging waste. The review included 10 studies, with articles from Australia, USA, Spain, New Zealand and the UK. Half of them were intervention studies aiming to shift knowledge levels and attitudes of teachers, parents and children with regard to reducing packaged food choices and food waste, and improving dietary habits. Acknowledging the complexity of lunchbox packing and consumption practices, this review recommends the consideration of socio-ecological influences on children's health and sustainability behaviour, and mobilizing their pro-environmental agency.

'Pizza every day - why?': A survey to evaluate the impact of COVID-19 guidelines on secondary school food provision in the UK

The nutritional requirements of adolescence and the reported poor UK eating behaviours of young people are a significant public health concern. Schools are recognised as an effective 'place' setting to enable improvement to nutrition outcomes. The COVID-19 pandemic resulted in UK school closures from March 2020. In re-opening in September 2020, schools were required to meet guidelines to ensure the minimised impact of COVID-19 on the population (DfE 2020). We aimed to evaluate the impact of COVID-19 school guidelines on secondary and post-16 (16-18 years) food provision. An online survey was posted on 8th October to 1st December 2020, targeted at young people, parents and staff of secondary/post-16 education establishments in the UK. Two hundred and fifty-two responses were received, of which 91% reported a change in their school food provision, 77% reported time for lunch was shortened and 44% indicated the provision was perceived as less healthy during September 2020 (post-lockdown school return) compared with March 2020 (pre-lockdown). Analyses demonstrated that time, limited choice and healthiness impacted negatively upon young people's school food experience. The COVID-19 pandemic has presented a huge challenge to the delivery of healthy school food to young people. Therefore, schools require more support in following national food standards and incorporating nutrition education and behaviour change strategies within current guidelines.

Using behavioural insights to reduce sugar in primary school children's packed lunches in derby; A cluster randomised controlled trial

Children's packed lunches contain more sugar than school-provided meals. Interventions to improve the provision of healthier packed lunches have modest effects on lunch contents. This cluster randomised controlled trial tested an intervention to encourage healthier provision of packed lunches by parents of primary school children in Derby. Schools were randomised to intervention (n = 8) or control (n = 9) using blocked random allocation. In the intervention group, parents of children who brought packed lunches to school in years 3-6 (age 7-11 years) received three bundles of materials (including packed lunch planner, shopping list, information on sugar content of popular lunchbox items and suggestions for healthier swap alternatives) in bookbags/lunchboxes over a 4-week period. Control parents received no materials. Photos of lunchbox contents were taken at baseline, immediately post-intervention and at three-month follow-up. A parental survey aimed to assess capability, opportunity and motivation for packing a healthier lunchbox. No intervention effects were observed for primary outcomes (presence and number of sugary snacks or chilled sugary desserts). The intervention had a significant impact on one secondary outcome (increased number of healthier "swap" items suggested in intervention materials) immediately post-intervention, but this effect had disappeared at three-month follow-up. No intervention effects were found on survey variables. Parent comments revealed that materials were either received positively (as they reinforced existing behaviours) or negatively (as they were not perceived to be helpful or appropriate). The results of this study suggest that providing educational materials and resources to parents of primary school children in Derby was not sufficient to increase provision of healthier packed lunches. Future research should investigate how behavioural science can support families to improve the nutritional content of primary school children's lunchboxes.