The role of Public Health in School Fruit Scheme Slovene experience

Transcription

1 The role of Public Health in School Fruit Scheme Slovene experience Mojca Gabrijelčič Blenkuš National Institute of Public Health of the R of Slovenia With the contribution of: Ministry of Agriculture, Forestry and Food of the R of Slovenia Ministry of Education and Sport of the R of Slovenia Ministry of Health of the R of Slovenia DG AGRI, Management Committee, 'SFS' Brussels, 11 December 2007

2 Presentation outline I. Role of Public Health II. Working together III. National school meal program and Apple project - Slovenia IV. Conclusions

3 I. Role of Public Health

4 Food and health Diets determine nutritional status Nutritional status determines health Balanced diets are essential to good health Unsafe foods generate disease Source: FAO presentation to WHO meeting, Paris, June 2007

5 Lost years of healthy life in Europe 2000 Other diseases 21% Diseases with major nutritional determinants (F/V play major role) 41% Diabetes mellitus 5% Diseases in which nutrition plays a role 38% Malignant neoplasms 32% Nutrition deficiencies 2% Source: Food and health in Europe 2004, The world health report 2000 Sec. source: WHO presentation, 2006 CVD 61%

6 Agriculture policies and practices Agriculture policies and agriculture production practices Influence what farmers choose to grow Could influence what consumers choose to eat Source: FAO presentation to WHO meeting, Paris, June 2007

7 Common agriculture policy (CAP) budget Dietary targets Fruit, vegetables 4% Wine, tobacco, olive oil, sugar 18% Fruit, vegetables 35% Other 5% Cereals (for food) 20% Meat, fish, dairy 25% Meat, dairy, animal food 58% Source: European Commission, Directorate- General for Agriculture Cereals 35% Source: WHO/FAO TSR 916 Source: Food and Health in Europe, WHO, 2004 Sec. source: WHO presentation, 2004

8 Fruit and Vegetable, at least 400 g/day The group fruit and vegetable represents one of the key groups in human diet. Sufficient intake of fruit and vegetable provides the body with: - essential nutrients that increase the body s antioxidative potential - dietary fibre and micronutrients; The inclusion of fruit and vegetables into the diet effectively reduces the energetic density of our meals.

9 WHO. World Health Report 2002

10 WHO. World Health Report 2002

11 Low FV intake leads to poor health and premature death Increasing FV consumption in EU could decrease burden of: heart disease by 17-24% selected cancers by up to 17 % reduce total deaths by over 1 million people/year Source: Pomerleau, Lock, McKee 2006

12 Approximately 5m school children in Europe are obese 22% of obese schoolchildren have significantly raised blood pressure (1.1m in EU) 34% of have significantly raised levels of insulin (1.7m in Europe) 25,000 children have type 2 diabetes 28% have early stage fatty liver disease (1.4m in Europe) Increasing burden of disease in present children and adolescent and in futur adult population. Source: IOTF

13 Proportion of boys with normal body weight Source: Strel et all, Faculty of Sport, University of Ljubljana, 2004

14 Proportion of girls with normal body weight Source: Strel et all, Faculty of Sport, University of Ljubljana, 2004

15 Nutritional habits in children and adolescents in Slovenia - To low intake of fruits and vegetables - Boys consume fruit and vegetables statisticaly significant less regularly - The intake of fruit and vegetables decreases with age - To often meals consist of energy-dense and nutrient-poor foods - Number of daily meals is to low, with irregular periodicity - No risk of not being cool if you decide for healthy nutrition choices - Sedentary lifestyle is high and increasing Source: National Institute of public health - reports 2000, HBSC 2006

16 Summary of strenght of evidence on factors that might promote or protect against weight gain and obesity, WHO TRS 916 Evidence Decreased risk No relationship Increased risk Concincing Regular physical activity High dietary intake of dietary fibre Sedentary lifestyles High intake of energy dense, micronutrient poor foods Probable Home and school environments that support healthy food choices for children Breastfeeding Heavy marketing of energy dense foods and fast-food outlets High intake of sugarssweetened soft drinks and fruit juices Adverse socioeconomic conditions Possible Low glycaemic index foods Protein content of the diet Large portion sizes High proportion of food prepared outside the home Insufficient Incresased eating frequency Alcohol

17 Limited evidence of cost-effectiveness One economic modelling study from Norwegian Directorate of Health: providing a free school fruit programme to all pupils grade 1-10 would be cost-effective if it resulted in a lifelong increase in mean fruit and vegetable consumption of only 2.5 g/day Source: Sælensminde, K. Frukt og grønnsaker i skolen Beregning av samfunnsøkonomisk lønnsomhet. Oslo: Sosial-og helsedirektoratet; 2006 Sec. source: LSHTM 2007

18 II. Working together

19 Most of determinants of ill-health or positive health are not under control of health sector Health is created and lived by people within the settings of their everyday life; where they learn, work, play and love. (Ottawa charter, 1986).

20 Amsterdam Treaty, Article 152: a high level of human health protection shall be ensured both in the definition and implementation of all Community policies and activities Lisbon strategy (economic goals, for the first time supported by social cohesion goals) Nutrition and physical activity policy documents (EC, WHO, FAO) WHO Nutrition Friendly School Initiative (NFSI)

21 Diet is influenced by features of supply and demand SUPPLY DEMAND Food production, processing and retail Agricultural policies distribution Trade and fiscal policies Social policies Price Urban planning policies Availability Consumer protection policies Quality Educational policies Safety Individual choices Knowledge, attitudes, practices Income Source: WHO, 2007

22 HIA Report to Ministry of Health Recommendations can be summarized in four main policy areas: - fruit and vegetables, - wine, - diary produce and - rural development. Source: Lock K, Gabrijelčič Blenkuš M, Maučec Zakotnik J, Poličnik R. HIA on Food and Agricultural Policies in Slovenia. Report to Ministry of Health, 2003

23 Perception of HIA on food and agriculture policies by different stakeholders Medical expert: broader socio-economic determinants of health were included Agricultural expert: assessment was based on a relatively narrow medical concept expressed by agriculture expert: Thus one should be well-versed and technically competent when dealing with inter-sector communication and work. Expert multidisciplinary competency is the key and we do not have enough of it. The fixation on medicine is very disturbing. Medical experts think that everything derives from it... This disrupts normal work. The agricultural experts believe that they are untouchable because of the large portion of the budget and the money they possess. Qualitative evaluation conclusion: lack of multidisciplinary competence, more cooperation and discussion is needed! Source: HIA effectivenes DG SANCO project, Who Observatory with Memberstates, research data 2006

24 Ministers of health, education and family/social affairs are signing official obligation to take care for children and adoloescent health together, with harmonized activities (2007) Intersectoral working body for school nutrition was established in May Leading sector is education, agriculture and health participating. Source: Slovene NIPH, 2007

25 III. National school nutrition program and Apple project Slovene experience

26 National school nutrition programme 1. All kindergartens in Slovenia offer breakfast, midmorning snacks, lunches and afternoon snacks. Financing: Ministry of Education, local comunity, parents 2. Most primary schools offer breakfast, midmorning snacks, lunches and afternoon snacks. All primary schools offer at least two meals (midmorning snacks and lunches) every school day. Financing: Ministry of Education and Sport, local comunity (regular expenses), parents 3. Regretfully the situation in secondary schools is not as good, although is foreseen that the adopted guidelines could improve the current situation. Financing: Ministry of Education and Sport, parents Source: Ministry of Education and Sport, 2007

27 Contents 1. Recommended energy and nutrient daily intake for different age groups (2 18 years), with calculations for different of meals 2. Periodicity of meals 3. Recommended frequency of intake for different food groups, fruit and/or vegetables part of every meal 4. List of food items/groups with limited inclusion in daily meal 5. Demo seasonal menues Guidelines for healthy nutrition in kindergartens, primary and secondary schools, 2005 Vending machines for sweetened soft drinks in school buildings are not recommended.

28 National school nutrition programme The main objectives are: - to provide a supportive environment for healthy choice in schools, supporting better health status of school children - to support regular curricula with the elements of hiden curricula - to support families and working mothers, - to reduce social inequalities and inequalities in health

29 NUTRITION IN SCHOOLS - PROVISIONS Legal basis: All schools must provide at least one meal a day Provision of school meals in primary schools: - 1 job assignment of school nutrition organizer for every 4,200 children - 1 job assignment of chef for the preparation of snacks for every 400 children (approx. 410 kitchen employes) - all primary schools in Slovenia have central or dispensing school kitchens Participation of primary school pupils in individual meals: breakfast: 3,5 % morning snack: 97 % lunch: 46 % afternoon snack: 6,5 % Source: Ministry of Education and Sport, 2007

30 Morning meal/snack is part of the National programme, for which partial financing is provided by the Ministry of Education and Sport. All schoolchildren pay solely for the price of food, composing the meal. Other meals such as lunch or breakfast are placed into the so called economic, but non profit programme. Subsidising of school meal, for children and adolescents from families with lower socioeconomic status, subsidies for school meals for pupils/students in 2006/07: EUR 0.55 daily per pupil for 36,4% of pupils EUR 0.85 daily per pupil for 32,8% of secondary school students Source: Ministry of Education and Sport, 2007

31 PROJECT APPLE IN SCHOOL started primary chools 25 secondary schools selection criteria participation in Slovenian network of Health Promotion Schools regional distribution of schools Supported by Ministry of Education and Sport in cooperation with: Ministry of Health and Institute of Public Health of the Republic of Slovenia and Ministry of Agriculture, Forestry and Food Source: Ministry of Education and Sport, 2007

32 PROJECT APPLE IN SCHOOL means of support funds for schools to buy apples (3 times a week) list of certain local producers (4 varieties of apples) setting conditions that must be met by the producers obligations of each school a contract with the selected provider plan of activities - set specific goals - adequate supply of apples - adequate offer of apples to pupils - set cooperation of pupils, teachers and parents - promotion and cooperation with local community Source: Ministry of Education and Sport, 2007

33 PLANING proces is described (for schools) - concrete, measurable goals - description of pupils/students participation - description of the distribution of apples - additional activities (link with regular curicula, taste education, link with environmental education - cooperation with parents, local comunity, local producers Source: NIPH

34 EVALUATION protocol is described (for schools) - observed changes - measurement of the observed changes - realization of the plan - satisfaction with the outcomes (children, teachers, management, parents) - cooperation with the fruit providers - most successful approaches - recommendations Source: NIPH

35 Main changes/outcomes proved by evaluation: - increased consumption of apples among pupils - popularity of apples grew higher - apples occasionally replaced unhealthy foodd - increased awareness of the importance of healthy food among pupils - inter-subject links and links with other projects and various promotional activities - high motivation of pupils, parents and teachers - offered non-coercive way for: - environmental education - learning about sustainable development - recognising the importance of biodiversity and environment protection, - waste management (separate collection and composting) - importance of the inclusion and cohesion of all actors Source: Ministry of Education and Sport, 2007

36 Administrative details Primary schools Total budget (in ) Budget /month /person in * Secondary schools Total budget (in ) Budget /month /person in * 2005/ , , / , ,65 * Apples have exclusively been purchased locally Source: Ministry of Education and Sport, 2007

37 IV. Conclusion

38 Conclusions SFS may help curbing presently increasing trends of excessive body weight and obesity in children and adolescents and ensure a long-term protection of children and adolescents against obesity. MS should involve the Ministry of Agriculture as well as the Ministry of Education and the Ministry of Health (intersectoral collaboration). Flexibility and sustainability of SFS shall be assured. Education shall be part of the programes. It is essential to involve local comunity, specially local producers, parents ant others.

39 Conclusions SFS is an effective tool for ensuring equity in health. The investment into SFS would be justified when compared with the disease burden, i.e. - direct and - indirect disease-related costs and - the costs of lost opportunities as well as - all the consequences of a lower quality of life already in childhood and particularly in later life. Comprehensive approach to these issues would call for additional measures to counteract the adverse influences on children and adolescents dietary choices, such as e.g. measures to ban marketing of unhealthy food to children.

40 Intersectoral collaboration in partnerships is a way forward