Title: An evaluation of the implementation of national school food standards in secondary schools and their impact on the school food environment and pupil intake of free sugars: a mixed methods study
Funder: Department of Health and Social Care

Abstract: RESEARCH QUESTION: How are national School Food Standards implemented in secondary schools and what is their impact on the sugar and other dietary intake, and dental health of school pupils?_x000D_ _x000D_ BACKGROUND: Excess sugar consumption is a major contributor to increased energy intake, obesity, and poor dental health. Adolescents consume three times the recommended amount of their total energy intake from free sugars. Since 2006 statutory national School Food Standards (SFS) have been in place, and in 2013 a wider set of recommendations for schools were published (School Food Plan (SFP)). The SFS were updated in 2015. The impact of the statutory 2006 SFS has been evaluated in primary schools but there is limited research in secondary schools, and no evaluation has taken place since the introduction of the SFP and updated SFS. Academies and free schools founded between 2010 and 2014 are exempt from the statutory standards, providing opportunity to compare school contexts and pupil outcomes in two school groups: secondary academies and free schools which are mandated to implement the SFS vs. those which are not mandated to do so._x000D_ _x000D_ AIMS AND OBJECTIVES: In the two secondary school groups we will compare: school food provision and sales, the school environment, culture and curriculum relating to food, and the costs of implementing the SFS and related policy/initiatives. In pupils in the two school groups we will compare sugar and other dietary intake, and dental caries experience. We will also explore the variation in implementation of the SFS and SFP, the influence of school context on this, and how this variation relates to pupil outcomes._x000D_ _x000D_ METHODS: We will undertake an observational mixed-methods study, and sample schools in the West Midlands (n=22 in each group) using propensity score stratification to obtain comparability between groups. In all schools we will collect school-level data on food provision and sales, school meal uptake, eating environment, food curriculum, school food culture, and costs related to these factors through analysis of a variety of school documents, direct observation, questionnaires to school staff and governors, and questionnaires to parents. These data will inform the development of a school typology which will indicate the level of implementation of the SFS and related policy. In the participating schools we will recruit pupils from years 7, 9 and 10 (n=990 in each school group), and collect dietary intake data through a 24 hour recall method, and self-reported data on dental symptoms and treatment. We will compare the primary outcomes of sugar intake at school lunchtime and over 24 hours in pupils from the two school groups. We will also compare a variety of other dietary outcomes and dental outcomes. Using the developed school typology, we will select different school types for case studies (n=4-8). In case-study schools we will collect in-depth data through interviews with school staff and focus groups with pupils to further inform understanding of the process and determinants of implementation of school food policy. We will conduct exploratory analyses to examine the association between school types and pupil outcomes._x000D_ _x000D_ TIMELINE: The planned study is 27 months, commencing in March 2019._x000D_ _x000D_ DISSEMINATION AND IMPACT: We will disseminate findings to national and local health and educational organisations. The findings will directly inform national school food policy and provide information on the way in which schools require support to effectively implement this.

Lay abstract: BACKGROUND_x000D_ National School Food Standards were introduced in 2006 and are a legal requirement for most state schools. In 2013, the School Food Plan, a wider set of voluntary recommendations for schools, was developed, and subsequently updated standards were introduced in 2015. There is little information on the impact of School Food Standards on school food provision and pupil food intake in secondary schools, and the impact of the updated standards and the School Food Plan recommendations has not been explored. The way in which the School Food Standards legislation has been introduced means that all academies and free schools set up between 2010 and 2014 are not obliged to meet the standards. This gives an opportunity to examine the influence of a legal requirement to meet the standards by comparing schools which are, versus those that are not required by law to meet them. Specifically, we want to assess whether the standards influence pupils' sugar intake, as adolescents have high levels of sugar consumption, which can lead to obesity and poor dental health._x000D_ _x000D_ AIMS_x000D_ We aim to make comparisons between secondary schools required to meet the standards and those who are not required to meet the standards. We will compare: the food provided and sold in schools; the school eating environment and ethos; the healthy eating and cooking skills curriculum; the cost to schools of measures to improve healthy eating and food provision; the consumption of foods high in sugar, other elements of the diet and dental health in pupils. We will also explore the extent to which schools vary in how the School Food Standards and School Food Plan are implemented. _x000D_ _x000D_ DESIGN_x000D_ We will recruit 44 secondary schools in the West Midlands to take part (22 who are required to adhere, and 22 that do not have to adhere to the standards). We will examine whether a requirement to adhere to the standards policy is associated with the provision, sale and consumption of healthier foods (focusing on sugar intake) in schools, and whether and how requirement to adhere relates to the implementation of the School Food Plan. This will be done through collation of data from a variety of school documents (including relevant school policies, food and catering contracts, relevant curricular teaching), researcher observations (to ascertain the school environment and culture including the food on offer and the eating spaces in schools) and questionnaires to key staff members, governors and parents to gain their views and experiences of the food standards, the school eating environment, culture and curriculum. We also aim to recruit around 1980 pupils from years 7, 9 and 10 from the 44 participating schools. In school time we will ask them to complete an online survey including a 24-hour recall tool, and questions about the food they eat and the health of their teeth. We will compare the average sugar intake, tooth decay symptoms and treatment, and intake of other food types among pupils in the two school groups. We will compare information on school food sales across the two school groups. We will use the above information to identify 4-8 schools with varying levels of provision and sale of healthy foods, in which we will collect more in-depth information through interviews with key staff members and small discussion groups with pupils. We will explore whether consumption of sugar and other foods is influenced by how well the School Food Standards and School Food Plan are implemented._x000D_ _x000D_ PUBLIC INVOLVEMENT_x000D_ Secondary school pupils, parents and teachers in senior management positions have contributed to the study design. We have convened a panel of parents, governors, and teachers to consult with at key points during the project. We will also regularly consult with a secondary school council of pupils. _x000D_ _x000D_ DISSEMINATION_x000D_ We will communicate the findings to key health and educational organisations nationally and locally. Findings will help shape future school food policy.

Research activity codes: 3.2 INTERVENTIONS TO ALTER PHYSICAL AND BIOLOGICAL ENVIRONMENTAL RISKS
Health categories: CANCER AND NEOPLASMS;CARDIOVASCULAR;METABOLIC AND ENDOCRINE;ORAL AND GASTROINTESTINAL;STROKE