The Ultra-Processed Food Content of School Meals and Packed Lunches in the United Kingdom

A scoping review of the existing evidence linking school food procurement contract type with school food provision

OBJECTIVE

School food and catering constitutes the largest area of public sector food spend in the UK, with the potential to influence health on a population scale. This review sought to understand and map the existing evidence linking school meals contracts for food procurement with the quality of food provided and health and academic outcomes for school children.

DESIGN

A scoping review of the peer reviewed and grey literature published between 1988 and 2023 was conducted. The strategy searched in Medline, Web of Science, Scopus, ERIC and Google, using key words related to population, exposure and outcomes.

SETTING

UK and International.

PARTICIPANTS

School meal services.

RESULTS

Thirty documents were included representing 16 papers, 3 books and 11 reports. Documents revealed a complex and fragmented school meal provision system and inconsistent evidence relating to the outcomes of interest. Most studies focused on sustainability or nutrition/ guideline compliance and the main types of food providers discussed were commercial contractors, local authorities and in house catering. However, there was a lack of clarity in contract specifications and definitions of quality and concerns over compliance monitoring and financial viability impacting quality. We found no substantial body of peer reviewed research linking school food procurement contract type with food quality or outcomes of interest.

CONCLUSIONS

The lack of research in this area (and conflicting findings) meant that it was impossible to draw robust conclusions on the benefits of using any particular contract provision type over another. Given the magnitude of public sector spending and the need for urgent improvements to the dietary health of the nation, this presents a significant gap in our knowledge.

'Will my fingerprint be enough?': secondary school students struggle to purchase a healthy, tasty and sustainable meal on the UK free school meal allowance

OBJECTIVE

Free school meals (FSM) are a crucial form of support for families. This study aimed to investigate whether the FSM allowance can provide what is perceived to be, healthy, sustainable and satisfying food.

DESIGN

A mixed methods study incorporating co-production, citizen science and participatory approaches was conducted. Citizen scientists were given a daily budget equivalent to the FSM allowance and asked to purchase a 'tasty, healthy and sustainable' school lunch for a week. Alongside keeping records of available and purchased foods, young people engaged in focus groups to capture information on perceptions of food offered and FSM allowance adequacy.

SETTING

Secondary schools in Yorkshire, UK.

PARTICIPANTS

Citizen scientists (n 42) aged 11-15 years across seven schools.

RESULTS

Obstacles were faced in obtaining sustainable and healthful meals when restricted to an FSM allowance. Reasons included restrictions in what could be purchased due to costs, limitations in the use of allowances that restricted breaktime purchases leading to hunger, inadequate portion sizes, systemic barriers like hurried lunch breaks that encourage 'grab and go' options and broken water fountains that led students to purchase bottled drinks. Findings were reinforced by descriptive food record data.

CONCLUSIONS

Our findings suggest that schools would benefit from national policies to address the lack of funding, infrastructure issues and capacity to support optimal provision of food to those on FSM as well as provide greater flexibility in how pupils use their allowance. Young people verified these findings, which they presented to policymakers at a parliamentary event.

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.

School food policy in secondary schools in England and its impact on adolescents' diets and dental health: the FUEL multiple-methods study

Background

School food standards are a legal requirement for state-funded schools in England and are designed to promote healthy eating in pupils. However, state-funded academies/free schools established between 2010 and 2014 are exempt from this legislation. To complement the school food standards, the government launched the School Food Plan in 2013, which outlines voluntary actions that schools can take to support healthy eating and increase school meal uptake. There has been little evaluation of the school food standards and School Food Plan in secondary schools.

Objectives

To compare implementation and costs of the school food standards and School Food Plan, and pupil dietary and dental outcomes in two groups of secondary schools: those mandated and those not mandated to comply with the school food standards legislation.

Methods

An observational, multiple-methods study. We sampled state-funded secondary school academies/free schools, pupils aged 11-15 years, and school staff/governors with a role in food provision/education from the Midlands. We collected qualitative data in four schools. The primary outcome was pupil free sugar intake at lunch; across the school day; and during 24-hours. Secondary outcomes were additional nutritional outcomes and dental caries measures. We assessed school food standards/School Food Plan implementation and costs using researcher observation, document analysis, and surveys with staff/governors, schools and pupils. Dietary intake and dental outcomes were measured online using 24-hour dietary recall and surveys, respectively. In the qualitative study we conducted staff/governor interviews and pupil focus groups in a subsample of schools. We used multilevel analyses to explore variation in pupil outcomes across the school food standards-mandated and school food standards-non-mandated school groups. Data were analysed using the Framework approach.

Results

Thirty-six schools (13 school food standards-mandated, 23 school food standards-non-mandated), 2453 pupils and 151 staff/governors participated. On average, schools were compliant with 64% of school food standards and implemented 41% of School Food Plan actions, with no differences across school food standards-mandated/non-mandated schools. There was a wide variation in annual costs of the school food standards and School Food Plan reported by schools (mean of £195 per pupil). Pupils in school food standards-mandated schools had lower lunch intakes of free sugar than those in school food standards-non-mandated schools (adjusted mean difference = -2.78 g, 95% confidence interval -4.66 to -0.90 g). After further adjustment for total energy intake, there was no significant difference in free sugar intake, but the school food standards-mandated group had lower fruit and vegetable intake at all time points, and higher consumption of confectionery during the school day and sugar-sweetened beverages over 24 hours. There were no differences in dental outcomes between the two groups. Twenty-one staff/governors and 137 pupils participated in the qualitative study. Staff described balancing school food standards compliance with conflicting priorities related to financial viability. Some pupils felt that school food did not meet their needs for convenience, speed, value for money and taste, and disliked the lunchtime experience. Little time was afforded to healthy-eating education within the curriculum.

Limitations

There were large numbers of missing data for some study elements, including assessment of some School Food Plan actions and cost data.

Conclusions

In the secondary school context, the current school food standards are difficult to comply with and the School Food Plan has not achieved the desired outcomes. We found no evidence to show that school food standards legislation has positively influenced nutritional intake.

Future research

We need to develop healthy secondary-school food provision models that meet pupils' preferences, and better understand how to situate the food and healthy-eating agenda in secondary schools.

Trial registration

This trial is registered as ISRCTN68757496.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: 17/92/39) and is published in full in Public Health Research; Vol. 12, No. 12. See the NIHR Funding and Awards website for further award information.

National school food standards in England: a cross-sectional study to explore compliance in secondary schools and impact on pupil nutritional intake

BACKGROUND

Many countries have introduced school food standards to improve the dietary intakes of school-aged children. England has school food standards (SFS) legislation in place but little is known about how well secondary schools comply with this. We aimed to assess compliance with the SFS legislation in English secondary schools and explore the impact of the SFS on pupils' nutritional intake.

METHODS

We conducted a cross-sectional study with English secondary schools from 2019 to 2022. We compared SFS compliance and pupil nutritional intake in schools mandated or not mandated to comply with the SFS legislation, and explored the association between school compliance and pupil nutritional intake. We assessed the percentage of SFS (%SFS) complied with by reviewing school food menus and observing food served in school canteens. We assessed pupil nutritional intake using a 24-hour dietary recall measure (Intake24) and estimated intakes of free sugar (primary outcome) and other nutrients/foods. We used adjusted multilevel models to compare pupil intakes in the SFS-mandated and SFS-non-mandated schools, and to explore the association between school SFS compliance and pupil intakes.

RESULTS

36 schools (23 not mandated and 13 mandated to comply with the SFS) and 2,273 pupils participated. The median %SFS complied with was 63.9% (interquartile range 60.0-70.0%). This was similar for SFS-non-mandated (64.5%) and SFS-mandated schools (63.3%). Compliance was highest for standards applying to lunchtime (median = 81.3%) and lowest for those applying across the whole school day (median = 41.7%). It was also lower for standards restricting high fat, sugar and energy-dense items (median = 26.1%) than for standards aiming to increase dietary variety (median = 92.3%). Pupils from SFS-mandated schools had a lower mean lunchtime intake of free sugar (g) (adjusted mean difference: -2.78g; 95% CI: -4.66g to -0.90g). There were few significant associations between %SFS complied with and pupil nutritional intake.

CONCLUSIONS

English secondary schools do not fully comply with SFS legislation regardless of whether they are mandated to comply. Schools and caterers may require monitoring and support to fully comply. There is little evidence that SFS compliance is associated with better pupil nutritional intake. Food environments outside of school also need to be considered.

STUDY REGISTRATION

ISRCTN68757496 (17-10-2019).

Ultra-processed food consumption in UK adolescents: distribution, trends, and sociodemographic correlates using the National Diet and Nutrition Survey 2008/09 to 2018/19

PURPOSE

We quantified levels of ultra-processed food (UPF) consumption and investigated consumption patterns in a representative sample of UK adolescents.

METHODS

We used data from 4-day food diaries from adolescents in the UK National Diet and Nutrition Survey (NDNS) (2008/09-2018/19). UPF were identified using the NOVA classification. We estimated the percentage of Total Energy Intake (%TEI) and the absolute weight (grams). Linear regression models quantified differences in UPF consumption across survey years and its association with participant's individual characteristics. This was an analysis of the repeated cross-sectional data from the UK NDNS Rolling Programme waves 1-11 (2008/09-2018/19). A total of 2991 adolescents (11-18y) with complete information on dietary intake were included.

RESULTS

Mean UPF consumption was 861 (SD 442) g/d and this accounted for 65.9% (SD 13.4%) of TEI. Between 2008 and 2019, mean UPF consumption decreased from 996 to 776 g/d [ - 211 (95%CI  - 302;  - 120)] and from 67.7% to 62.8% of TEI [ - 4.8% (95%CI  - 8.1;  - 1.5)]. Higher %TEI was consumed by adolescents with lower socioeconomic status; white ethnicity and living in England North. A higher weight of UPF consumption (g/d) was associated with being male, white, age 18y, having parents with routine or manual occupation, living in England North, and living with obesity.

CONCLUSION

Average energy intake from UPF has decreased over a decade in UK adolescents. We observed a social and regional patterning of UPF consumption, with higher consumption among adolescents from lower socioeconomic backgrounds, from a white ethnicity and living in England North. Our findings suggest inequalities associated with UPF intake and factors that might lie beyond individual choice.

The impact of the cost of living crisis and food insecurity on food purchasing behaviours and food preparation practices in people living with obesity

Lower income households are at greater risk of food insecurity and poor diet quality than higher income households. In high-income countries, food insecurity is associated with high levels of obesity, and in the UK specifically, the cost of living crisis (i.e., where the cost of everyday essentials has increased quicker than wages) is likely to have exacerbated existing dietary inequalities. There is currently a lack of understanding of the impact of the current UK cost of living crisis on food purchasing and food preparation practices of people living with obesity (PLWO) and food insecurity, however this knowledge is critical in order to develop effective prevention and treatment approaches to reducing dietary inequalities. Using an online survey (N = 583) of adults residing in England or Scotland with a body mass index (BMI) of ≥30 kg/m2, participants self-reported on food insecurity, diet quality, perceived impact of the cost of living crisis, and their responses to this in terms of food purchasing behaviours and food preparation practices. Regression analyses found that participants adversely impacted by the cost of living crisis reported experiencing food insecurity. Additionally, food insecurity was associated with use of specific purchasing behaviours (i.e., use of budgeting, use of supermarket offers) and food preparation practices (i.e., use of energy-saving appliances, use of resourcefulness). Exploratory analyses indicated that participants adversely impacted by the cost of living crisis and who used budgeting had low diet quality, whereas use of meal planning was associated with high diet quality. These findings highlight the fragility of food budgets and the coping strategies used by PLWO and food insecurity during the cost of living crisis. Policy measures and interventions are urgently needed that address the underlying economic factors contributing to food insecurity, to improve access to and affordability of healthier foods for all.

Ultra-processed food and non-communicable diseases in the United Kingdom: A narrative review and thematic synthesis of literature

The social and economic constructs of the United Kingdom (UK) provide a fertile food environment for the dramatic expansion in the ultra-processed food (UPF) market, driving increased UPF consumption. This has coincided with the significant increase in the incidence and prevalence of non-communicable diseases (NCDs) such as obesity, type 2 diabetes, cardiovascular disease, and cancer, with an inherent impact on morbidity and mortality. Our review aims to assess the current epidemiological and public health trends in the United Kingdom, specifically examining consumption of UPFs and subsequent development of NCDs, summarizing existing meta-analytical and experimental approaches. First, we address important socioeconomic and psychosocial domains that may contribute to increased availability and consumption of UPF. Additionally, we explore the putative mechanistic basis for the association between UPFs and NCDs: partly attributable to their energy density, the macro- and micronutrient composition (including high refined carbohydrate, saturated, and trans fats composition, in addition to low fiber and protein content), and artificially engineered additives and other compounds that adversely affect health in inadequately researched pathophysiological pathways. This review highlights the importance of promoting minimally processed diets to both clinical and political decision makers.

School food hero and the battle of the food foes: A story of public health policy, power imbalance and potential

This paper explores the impact of school food policy from the perspective of school food workers to offer an alternative account of why school food may not be having the desired impact on child health or food choices. Drawing upon the findings from an institutional ethnography carried out in three UK primary schools, we argue that school food is being asked to perform an unrealistic task of luring children and families away from more unhealthy food options, without being given adequate resources or powers to do this job effectively. We theorise that the narrative depicting school food as a hero, combatting the harms of poor dietary choices and poor health outcomes, is inappropriate as a countermeasure to mitigate the effects of wider food industry forces. We revisit the narrative to consider the power imbalances within society that structure dietary choices, presenting our findings and the wider policy review in the form of a story about the evolution of school food set against a shifting food environment. We conclude with recommendations for policy makers who want to see school food have a greater impact in improving child health.

Factors that influence food choices in secondary school canteens: a qualitative study of pupil and staff perspectives

Background

Adolescence is recognised as a period of nutritional vulnerability, with evidence indicating that United Kingdom adolescents have suboptimal dietary intakes with many failing to meet dietary recommendations. Additionally, adolescence is a time of transition when they become more independent in their dietary choices and begin to develop their own sense of autonomy and are less reliant on their parent's guidance, which is reported to lead to less favourable dietary behaviours. Reducing the prevalence of poor dietary intakes and the associated negative health consequences among this population is a public health priority and schools represent an important setting to promote positive dietary behaviours. The aim of this school-based study was to explore the factors and barriers which influence food choices within the school canteen and to identify feasible strategies to promote positive dietary behaviours within this setting.

Methods

Thirteen focus groups with 86 pupils in Year 8 (n = 37; aged 11-12 years) and Year 9 (n = 49; aged 12-13 years) in six secondary schools across Northern Ireland, United Kingdom were conducted. Additionally, one-to-one virtual interviews were conducted with 29 school staff [principals/vice-principals (n = 4); teachers (n = 17); and caterers (n = 7)] across 17 secondary schools and an Education Authority (EA) senior staff member (n = 1). Focus groups and interviews were audio-recorded, transcribed, and analysed following an inductive thematic approach.

Results

Using the ecological framework, multiple factors were identified which influenced pupils' selection of food in the school canteen at the individual (e.g., time/convenience), social (e.g., peer influence), physical (e.g., food/beverage placement), and macro environment (e.g., food provision) level. Suggestions for improvement of food choices were also identified at each ecological level: individual (e.g., rewards), social (e.g., pupil-led initiatives), physical (e.g., labelling), and macro environment (e.g., whole-school approaches).

Conclusion

Low-cost and non-labour intensive practical strategies could be employed, including menu and labelling strategies, placement of foods, reviewing pricing policies and whole-school initiatives in developing future dietary interventions to positively enhance adolescents' food choices in secondary schools.

The Nutritional Quality of Food Provision at UK Government-Funded Holiday Clubs: A Cross-Sectional Analysis of Energy and Nutrient Content

A large proportion of children are at risk of food insecurity during school holidays in the UK. The government-funded Holiday Activities and Food (HAF) programme provides free holiday clubs offering at least one healthy meal/day to eligible children and adolescents. This study aims at evaluating the nutritional quality of food provision at HAF holiday clubs, particularly hot/cold and vegetarian/non-vegetarian meals. Menu variants (n = 2759) from 49 HAF holiday clubs were assessed for adherence to School Food Standards (SFS) and their notional compositional quality, which was scored utilising a novel nutrient-based meal quality index. The median adherence to SFS across all available menus was 70% (IQR 59-79%). Overall, hot variants scored statistically higher menu quality scores than cold variants for both 5-11y (92.3 (80.7-102.7) vs. 80.4 (69.3-90.6)) and 11-18y (73.5 (62.5-85.8) vs. 58.9 (50.0-70.7)) criteria. Cold and hot menu variants tended to score differentially for quality sub-components. These findings highlight areas for potential future improvement in HAF holiday club provision with a tendency for food provision to appear less ideal for attendees for those aged 11-18. Ensuring that children from low-income households have access to a healthy diet is crucial to reduce UK health inequalities.

A Mixed Methods, Quasi-Experimental Evaluation Exploring the Impact of a Secondary School Universal Free School Meals Intervention Pilot

Food insecurity amongst households with children is a growing concern globally. The impacts in children include poor mental health and reduced educational attainment. Providing universal free school meals is one potential way of addressing these impacts. This paper reports findings on the impact of a universal free school meals pilot in two English secondary schools. We adopted a mixed-methods, quasi-experimental design. The intervention schools were one mainstream school (n = 414) and one school for students with special educational needs (n = 105). Two other schools were used as comparators (n = 619; n = 117). The data collection comprised a cross sectional student survey during the pilot (n = 404); qualitative interviews with students (n = 28), parents (n = 20) and school staff (n = 12); and student observations of lunchtimes (n = 57). Qualitative data were analysed using thematic analysis, and descriptive analyses and logistic regressions were conducted on the quantitative data. Self-reports of food insecurity were high at both intervention (26.6%) and comparator schools (25.8%). No effects of the intervention were seen in the quantitative findings on either hunger or food insecurity. Qualitative findings indicated that students, families and staff perceived positive impact on a range of outcomes including food insecurity, hunger, school performance, family stress and a reduction in stigma associated with means-tested free school meals. Our research provides promising evidence in support of universal free school meals in secondary schools as a strategy for addressing growing food insecurity. Future research should robustly test the impact of universal free school meals in a larger sample of secondary schools, using before and after measures as well as a comparator group.

Improving adolescents' dietary behaviours in the school-setting: challenges and opportunities

Adolescence is a critical time of physical, psychological and social development, and thus, optimal nutritional intakes are required during this life stage. Despite this, adolescence is recognised as a period of nutritional vulnerability, with many reportedly failing to meet current dietary guidelines. The school-setting presents a favourable environment to intervene and promote positive dietary behaviours and is also inclusive regardless of socio-economic status. However, a lack of consensus exists on how best to utilise schools to facilitate improvements in dietary behaviours among this age group. Whilst previous research has focused on identifying the factors motivating dietary choices within the school-setting, less is known on the optimum strategies to enhance these dietary choices which could positively contribute to the design of future interventions. It is reported that adolescents have good nutritional knowledge, although this does not appear to be a central consideration when making their dietary choices. Alternative factors at the individual (taste, visual appeal, familiarity, food quality, price, portion size, value for money, time/ convenience), social (peer influence), physical (product placement) and macro environment (food availability) levels have been frequently cited as important influences on adolescents' dietary choices in school. Although school-based interventions have shown potential in achieving positive dietary change among adolescents, more research is needed to determine the most effective methods in improving dietary behaviours in schools. This review summarises the key factors which influence adolescents' school-based dietary choices and the effectiveness of previously conducted interventions, identifying promising components for consideration when developing future dietary interventions within the school-setting.

A qualitative process evaluation of universal free school meal provision in two London secondary schools

BACKGROUND

In the UK, one in five households with children experienced food insecurity in 2022, defined as a household-level economic and social condition of limited or uncertain access to adequate food. Free school meals are a public health intervention aimed at reducing food insecurity amongst children. The provision of universal free school meals (UFSM) to secondary school-aged children is a novel and untested intervention in the UK. This study is a process evaluation of a pilot of UFSM in two secondary schools in England. The aim was to understand the feasibility, acceptability, cost implications and lessons for the implementation of UFSM.

METHODS

20 parents, 28 students and 8 school staff from two intervention schools participated in online qualitative interviews, as well as 4 staff from non-intervention schools. The Framework Method of thematic analysis was applied. These data were supplemented with student-led observations of school meal times, and school lunch uptake-data and cost information provided by the local authority delivering the pilot.

RESULTS

UFSM in secondary schools is a feasible and acceptable intervention, with coherent goals of increased access to a healthy meal, reduced food insecurity and better nutrition. All participants perceived these goals were met. Acceptability was further enhanced by the perception that UFSM were supporting a greater proportion of low-income families than the national, targeted Free School Meal scheme, as well as being easier to implement. Potential barriers to implementation include limited school kitchen and dining infrastructure, meal quality and choice, and increased queuing times. Participants' concerns that UFSM may benefit middle- and high- income families not in need were not as prevalent as the perception that UFSM was an effective way to support all families with secondary-aged children experiencing food insecurity.

CONCLUSION

This small-scale pilot study suggests that UFSM in secondary schools is feasible and acceptable, but more evidence is required from larger studies on the impact on long-term health, psychosocial and educational outcomes. Future, larger studies should also include detailed economic evaluations so this approach can be compared with other possible interventions.