How to cite this article: Muñoz-Dávila C, Rangel-Peniche DB. Dietary training for school food service providers in support of the Acuerdo Nacional para la Salud Alimentaria. Rev Med Inst Mex Seguro Soc. 2015 Nov-Dec;53(6):704-9.
Received: September 4th 2014
Accepted: October 14th 2014
Carolina Muñoz-Dávila,a Diana Beatriz Rangel-Penicheb
aUniversidad Autónoma de San Luis Potosí, San Luis Potosí, México
bUniversidad Autónoma de Querétaro, Querétaro, México
Communication with: Carolina Muñoz-Dávila
Telephone: (44) 4140 9238
Background: To address the problem of overweight and obesity in Mexico, in 2010 the Acuerdo Nacional para la Salud Alimentaria was published. At school level, food service providers were considered essential to comply with certain commitments. The goal of this intervention was to train school food service providers in school eating establishments (SEE) as to the criteria in the general guidelines for the sale and distribution of food in schools of basic education.
Methods: 13 SEE in San Luis Potosi participated. Based on an initial diagnosis, a class-workshop of 5 sessions was designed. Knowledge regarding food was evaluated at the beginning and end of the sessions. The percentage of adherence regarding general hygiene and food preparation and distribution was obtained at the beginning, one month, and two months post-intervention.
Results: School food service providers had little knowledge on the objectives of the Acuerdo in food groups and combination, as well as reading labels; there were significant changes in the last two after intervention. The initial percentage of overall hygiene compliance was 60 %, with an increase of almost 20 % post-training. The preparation and distribution of food did not show significant changes.
Conclusions: School food service providers acquired knowledge about the guidelines that a SEE comply with, without putting them into practice, given the economic impact that it implies.
Keywords: Feeding, Food habits, Health education, Mexico.
In the past 20 years, overweight and obesity have increased dramatically in our country. According to the Encuesta Nacional de Salud y Nutrición of 2012, the combined prevalence of overweight and obesity in schoolchildren was 34.4%, slightly lower than the 34.8% reported in the 2006 survey.1
Excess weight has allowed non-communicable diseases such as type 2 diabetes and cardiovascular disease, once specific to adults, to now manifest in children. Thus, the World Health Organization (WHO) in 2004 invited governments around the world to promote healthy eating on school campuses and address basic health issues. It was also suggested that supplies of foods high in salt, sugar, and fat be limited, and that the consumption of fruits, vegetables, whole grains, and potable water be increased.2
Given the prevalence of obesity in Mexico, a national policy on this issue was necessary, recognizing the problem as multifactorial. Thus, in January 2010 the Secretaría de Salud, the Secretaría de Educación Pública, and other representatives of the public, social, and private sectors, published the "National Agreement for Dietary Health: strategy against overweight and obesity" (“Acuerdo Nacional para la Salud Alimentaria: estrategia contra el sobrepeso y la obesidad”) (ANSA).3 On August 19th of the same year the "Agreement establishing general guidelines for the sale and distribution of food and beverages in school eating establishments (SEE) of elementary school campuses" was signed.4 These guidelines established criteria that would regulate food and drink to be dispensed in SEEs.
Given that children spend between 4 and 5 hours a day in federal or state elementary schools,5 educational institutions are appropriate places to carry out the practice of dietary health. It is held that SEEs, shops, cooperatives, and retail spaces or centers are key points for the development of proper eating habits; they should offer healthy food and drinks as well as snacks with adequate nutritional balance, as stipulated in the guidelines.4 Since 80% of elementary students bring money for food, school can be a window of opportunity to achieve impact with intervention programs.6
To help comply with ANSA, the intervention for this study aimed to train school food service providers in the knowledge and application of nutritional criteria corresponding to stage III of the guidelines. They were trained in the proper selection of foods, the application of suitable methods for preparing them, and the implementation of hygiene and sanitation in food handling, thus complying with Titles IV and V and their respective chapters of the guidelines.4,7
The Secretaría de Educación del Gobierno del Estado of San Luis Potosi assigned 13 public elementary schools to implement this program. Permission was arranged with the directors, and the school food service providers responsible for the operation of the various SEEs were invited to attend courses and workshops on food preparation. The schools selected for this study were in sectors 001, 002, 003, 005, 018, and 023, which concentrate all of the public elementary schools of the capital.
3 instruments were designed to obtain general information about the school and the SEE in relation to hygiene and food preparation, the facilities, and packaged products for sale. The following briefly describes its content.
For the evaluation of the points above, dichotomous variables were used (complies = 1, does not comply = 0), the total score was obtained and divided by the total number of items. The percentage of adherence or compliance was obtained for each of the institutions as well as an average by category.
Initial and final diagnosis
With the instruments designed for this study, the evaluation was conducted and the initial diagnosis obtained. For the 3 areas, the degree of compliance with the various established items was obtained. The initial assessment forms were applied again at one month and 2 months after the intervention.
Courses and workshops
Based on the results of the initial diagnosis, workshops were designed as an educational technique for this program. In these workshops, participants did activities that favored learning of theoretical knowledge as well as skills, abilities, techniques, and procedures.8 The topics covered included: general hygiene measures, selection, food preparation, and sale of processed products in compliance with the guidelines. The workshops were taught by a college graduate in gastronomy, with content supervision by a registered dietitian. The workshops lasted two hours each, and were given once a week for 5 weeks. Knowledge was assessed prior to each workshop and immediately after it ended.
After applying the assessment instruments, values were obtained for each item evaluated (hygiene, technical standards in food preparation, and distribution of processed foods). ANOVA was used to determine differences between each category, and repeated measures ANOVA to evaluate changes at baseline, one month, and 2 months after intervention. Repeated measures t-test was used for initial and final evaluation of the knowledge imparted in the courses and workshops.
Of the 13 SEEs evaluated, only 2 were permanent establishments, so the school food service providers of the remaining 11 prepared foods at home and brought it to the school and arranged tables to sell products. None of the SEEs had potable water or drainage, although 3 of them stored water in drums. One establishment had gas and 6 had electricity. It should be noted that all SEE were operated by parents of students of the same school, where 40% of them supplement their income with other work. In order to have the concession of the SEE, those running the stands had to pay a share to the school, leaving a very low profit margin.
Figure 1 shows the items evaluated, showing that the general hygiene of the premises obtained the highest degree of adherence (just 60%), compared with the categories of food preparation and distribution. Specifically in the category of hygiene, deficiencies were reflected in items such as cleaning and maintenance measures of the establishment, personal hygiene, and vending area. In the other two categories evaluated, failures were found in food preparation due to the selection of prohibited foods and inappropriate portion sizes used. Establishments were also found with adherence to the guidelines regarding the permitted sale of processed products, and others with high sales of these products, mostly sweets and fried foods.
Figure 1 Initial evaluation of School Eating Establishments. *Significant difference compared to the other two categories (p ≤ 0.01). *Significant difference compared to criteria
Based on these results, the themes to offer in training workshops were developed.
Table I presents the initial and final results in terms of theoretical knowledge that school food service providers had, before and after the workshops. As regards initial knowledge about general hygiene and food to be included in a healthy lunchbox, these were acceptable, with scores above 80. However, school food service providers had no information on the objectives pursued by ANSA or how to know if a processed product may be sold or not (reading labels), nor about food groups or their combination to make suitable preparations. The final evaluation of the workshops showed that, except for the ANSA objectives, scores above 75 were found in all other subjects, although the changes were not significant in several points addressed.
|Table I Evaluation of knowledge of school food service providers. Comparative knowledge before and after receiving workshops|
|Knowledge about||Pre-intervention score||Post-intervention score||p|
|ANSA objectives||66.6 ± 21.2||66.7 ± 15.81||0.90|
|General hygiene of the
|83.3 ± 25.8||75.0 ± 12.2||0.58|
|Reading labels||68.7 ± 15.5||85.0 ± 16.0||0.048|
|Food groups||66.7 ± 25.0||76.7 ± 13.2||0.28|
|Combination of foods||50.0 ± 00.0||100.0 ± 0.00||0.00|
|Foods to include in a healthy lunchbox||95.4 ± 15.0||89.0 ±15. 1||0.22|
|partially paired t-test|
Figure 2 shows the results of the assessment of SEEs after the training workshops received by the school food service providers. Hygiene, and food preparation and distribution were evaluated before the intervention, and one month and two months after it; the same instruments were applied on all 3 occasions. Compared with the percentages of pre-intervention adherence, positive and significant changes were found in what corresponded to the general hygiene of the establishment. Importantly, actions evaluated at this point do not depend on the school food service provider, including the structure of the stand, regular fumigation, and water service, conditions that a SEE must cover.4,7 It should be noted that the recommendations made in the workshops allowed the school food service providers to make changes that did not incur higher costs, such as hairnet use, cutting nails, handwashing, collecting trash in closed containers, etc.
Figure 2 Percentage of compliance with the guidelines. Initial evaluation and post-intervention evaluations of School Eating Establishments. *Initial values versus second evaluation (p ≤ 0.04); ** Second evaluation versus final evaluation (p ≤ 0.022); *** Initial values vs final evaluation (p ≤ 0.01). * Initial values vs. Second evaluation (p ≤ 0.04).
** Second evaluation vs. Final evaluation (p ≤ 0.022).
*** Initial values vs. fianl evaluation (p ≤ 0.01).
As for the preparation of dishes and food for sale, a slight improvement was found (5%), not significant, in which school food service providers offered more fruit and vegetables for sale; they increased the degree of compliance with the guidelines as to not using fat in preparations or no longer frying foods, using whole wheat bread, and more. Sales of processed products had little compliance with respect to the guidelines, with no significant changes despite the workshops. The children preferred to buy lower-cost processed products to prepared dishes.
It has been observed that food education processes involving food preparation workshops are a useful tool to modify food selection and preparation and to generate changes in eating habits in some communities.9
This intervention brought the school food service provider closer to federal and state regulations on dietary health and issues of nutrition, hygiene, and food preparation, since the degree of knowledge was increased in most of the areas evaluated. Note that the implementation of the knowledge and recommendations offered in the workshops was put into practice for a very short time, since children were not used to buying fruit, vegetables, or non-fried foods, the cost of which was slightly higher than packaged products, so school food service providers resumed their usual practices. Such practices have been reported in previous studies, in which there is a gap between knowledge and behavior.10
Food preparation entails some risk to the school food service provider, since perishable food, if not sold in time, must be thrown away. Food preparation involves more work for them and, given the conditions of the SEE, preparations are made at home because they do not have places equipped for the preparation and sale of food. Ceasing to sell processed products was not appealing either for the child or the person running the establishment, as the products are easy to transport without contamination risk, cost less, and are preferred by students.
The actions required to achieve compliance with ANSA’s primary objectives and the criteria established by the guidelines, clearly go beyond the SEE, as numerous external constraints were identified that hinder the opportunity to create positive changes in the operation of the establishment.
In 2010, some inconveniences were presented at the time the SEEs in San Luis Potosi received the state food list. The school food service providers had not received prior explanation about the changes they needed to make in the sale of food, so the information was confusing and meaningless. In some cases, the state list was in the school director’s office, while it should be held by the food service provider.
Of great importance are the high fees exacted daily from SEEs by the Departamento de Cooperativas Escolares of the Secretaría de Educación del Gobierno Estatal (SEGE), whose destination is a fund used for the restoration and improvement of schools. Fees range from $100 to $300 pesos a day depending on the size and enrollment. It is worth noting that the proceeds from the sale of food has to cover the costs of raw materials, processed products, daily fees, and even material for improving the establishment; the rest is profit for the provider, representing an average of $100 pesos a day, or in some cases nothing. The school food service providers also reported unfair unregulated competition, with the sale of prohibited food outside of schools.
In 2011 when this project began, the Comité de Establecimiento de Consumo Escolar had not yet been integrated into the schools evaluated as stipulated in the guidelines, the entity that would monitor the operation of the facility and report to the Consejo Escolar de Participación Social. It was not until 2012 that the structuring of the Comité began with its supervisory function in half of the schools evaluated. In some other schools there was supervision by the SEGE, by area and sector supervisors, teachers, licensees, and college nutrition interns.
Given the structure of the agreement, the supervision urged them to comply, without the ability to sanction, so compliance was therefore voluntary. On May 9th of this year, the 2010 agreement was repealed, and on May 15th the Diario Oficial de la Federación published the new agreement corresponding to 2014 to 2015 for elementary schools, medium-superior and superior levels, which began in the second half of 2014. It is important to note that this new agreement presents changes in the guidelines, so Title V, Chapter One includes prohibitions and sanctions for schools that violate what is stated in the guidelines, with which greater compliance is expected.11 For its part, the government of San Luis Potosi in its "State Strategy for the Prevention and Control of Overweight, Obesity, and Diabetes" aims to carry out health promotion activities, implementing actions in school cooperatives and full-time schools that include dissemination of recommendations on nutritional counseling and hygiene practices in food handling, so synergy is expected from these actions.12
While training in the operation of a school cooperative is essential to comply with the guidelines set by ANSA, the participation of parents, teachers, principals, and education and health authorities is needed so that efforts are not siloed in one sector.
The school food service providers were able to acquire knowledge and practice in the preparation of dishes that meet the guidelines, however they were not implemented due to lack of response from the children.
The training offered in the workshops impacted the area of hygiene with statistically significant improvements.
Training did not achieve significant results in the preparation of dishes or the sale of processed products.
The objectives pursued by ANSA are not of importance to school food service providers, their concern is more in relation to selling products.
Training based on food preparation workshops aimed at school food service providers can be a support strategy that contributes to the fulfillment of ANSA objectives, as long as the factors impeding compliance are taken into account.
Conflict of interest statement: The authors have completed and submitted the form translated into Spanish for the declaration of potential conflicts of interest of the International Committee of Medical Journal Editors, and none were reported in relation to this article.