小學飲食模式評估研究2012 Assessment of Dietary Pattern in Primary Schools 2012

小學飲食模式評估研究 2012 調查摘要 Assessment of Dietary Pattern in Primary Schools 2012 Executive Summary 衞生署 Department of Health

目錄 引言 1 第一部分學生 家長和學校問卷調查 3 第二部分學校提供的午膳及小食 10

Contents Introduction 13 Part 1 Questionnaire Survey of Students, Parents and 15 Schools Part 2 Provision of Lunch and Snack in Schools 23

引言 肥胖對生理和心理健康均有顯著的影響 肥胖能導致各種健康問題, 如高血壓 血液中的膽固醇水平上升, 以及增加患上非傳染病 ( 包括心血管病 中風和糖尿病 ) 的風險 肥胖的兒童長大後亦較容易繼續超重 ; 同時亦會較易自卑 不滿自己體型和抑鬱 因此, 處理兒童肥胖率繼續上升這個問題是香港公共衞生的一個優先課題 香港小學學童的過重及肥胖比率由一九九七 / 九八學年的 16.4% 上升至二零零六 / 零七學年的 21.3% 為了應付香港兒童肥胖問題, 衞生署在二零零六 / 零七學年推行 健康飲食在校園 運動, 以提高大眾對兒童健康飲食的認識及關注, 並營造有利健康飲食的校園及社會環境 在二零零八年, 本署進行了全港性的 小學飲食模式評估研究 調查, 評估學生和家長在健康飲食方面的知識 態度和行為, 以及瞭解小學校內的飲食環境 另一方面, 至營學校認證計劃 ( 下稱認證計劃 ) 是一項於二零零九 / 一零學年在 健康飲食在校園 運動中推出的計劃 認證計劃鼓勵學校制定健康飲食政策及措施, 藉著家校通力合作, 切實執行衞生署發出有關校內午膳和小食供應的營養指引, 從而獲得認證的資格 為了進一步優化現時 健康飲食在校園 運動的措施, 並確立未來發展規劃, 衞生署在二零一二年四至六月期間, 委託香港大學社會科學研究中心進行了一項全港性的研究, 以評估現時小學的飲食環境, 以及小學學生及家長對健康飲食的知識 態度及行為, 並與二零零八年時的研究結果作出比較 是項研究目的如下 : ( 甲 ) 評估小學生對健康飲食的知識 態度和行為, 以及認證計劃對學生在這些方面的影響 ( 乙 ) 評估小學生家長對健康飲食的知識 態度和行為, 以及認證計劃對家長在這些方面的影響 ( 丙 ) 了解小學校內的營養環境 ( 包括政策 行為及措施等 ), 以及認證計劃對學校在這些方面的影響 1

( 丁 ) 評估小學校內所供應的小食和午膳的營養質素, 以及認證計劃對小食和午膳供應的影 響 是項研究包括兩部分, 第一部分 ( 學生 家長和學校問卷調查 ) 主要針對首三個項目 ( 甲 ) 至 ( 丙 ) 而進行 ; 第二部分 ( 學校午膳及小食的供應 ) 主要針對第四個項目 ( 丁 ) 而進行 2

第一部分 學生 家長和學校問卷調查 研究方法 是項研究包括兩個部分 : 橫斷性研究和比較研究 首先, 以學校數目及經費來源類別為基礎, 按比例從香港 18 區隨機抽出共 50 間小學 ( 以下簡稱 一般學校 ); 另一方面, 衞生署邀請 了 25 間在二零一一年十一月三十日或以前獲得認證計劃認證資格的學校 ( 以下簡稱 認證 學校 ) 參加, 因此令參與本研究的小學增至 75 間 研究對象包括小四和小五學生及其家長, 以及校長或負責 ( 或監督 ) 膳食 / 小食安排事宜的學校代表 本研究共使用三份自填式問卷, 對象分別為學生 家長及學校代表, 並於二零一二年四至六月進行 各問卷調查的回應率如 下 : 學生問卷 家長問卷 學校問卷 一般學校 認證學校 一般學校 認證學校 一般學校 認證學校 回應的學校數目 50 24 50 24 49 25 回收的問卷數目 7,387 3,285 7,058 3,109 49 25 回應率 73.5% 70.2% 70.2% 66.4% 98.0% 100.0% 註 : 當中一間認證學校拒絕交回學生及家長問卷 ; 另一間一般學校則沒有交回學校問卷 參與者背景 在一般學校中, 小四學生佔 48.3%, 男生佔 49.0% 在回應的家長中, 大部份 (75.8%) 為母親 34.5% 的家長具大學或以上的教育程度,10.6% 的家長表示每月家庭總收入少於 $10,000 在受訪學校中,81.6% 為官立或津貼學校, 而大部分學校為全日制小學 (98.0%) 及男女校 (87.8%) 認證學校學生的背景與一般學校相似, 只是較少家長具有大學或以上的教育程度 3

(19.8% 對 34.5%), 而且較少家庭總收入超過 $60,000(4.7% 對 13.2%) 另一方面, 所有參 與研究的認證學校為全日制小學, 大部分 (96.0%) 為男女校 調查結果 一般學校的學生 知識 態度及行為是次研究結果顯示, 一般學校學生的健康飲食知識水平仍高 大部分學生 (90.9%) 表示他們喜愛吃水果, 而超過三分之二 (68.8%) 則表示他們喜愛吃蔬菜 超過三分之二的學生 (69.8%) 認為自己的飲食習慣是健康的, 另有 17.7% 至 35.7% 的學生表示在調查前一個星期內沒有進食任何煎炸食物 含有高脂肪 / 高糖分 / 高鹽分的食物, 或飲用了含有高糖分的飲品 每天進食水果及蔬菜兩次或以上學生的比例分別為 70.3% 及 83.1% 在調查前一個星期內, 約三分之一的學生 (33.0%) 有從家中帶水果回校進食 飲食行為變化 與二零零八年研究結果相比, 本研究顯示學生進食蔬菜及水果的情況有顯著改善 ( 進食水果 兩次或以上的比例 - 二零一二年 :70.3%; 二零零八年 :57.5%; 進食蔬菜兩次或以上的比 例 - 二零一二年 :83.1%; 二零零八年 :78.7%); 同時, 學生亦減少了進食含有高脂肪 / 高鹽分 / 高糖分的食物或飲用含有高糖分的飲品 ( 見下表 ): 二零零八年 二零一二年 百分比改變 沒有進食含有高脂肪的食物 14.8% 20.7% 5.9% 沒有進食含有高鹽分的食物 27.3% 35.7% 8.4% 沒有進食含有高糖分的食物 12.2% 17.6% 5.4% 沒有飲用含有高糖分的飲品 10.8% 17.7% 6.9% 4

學校舉辦的健康促進活動約七成來自一般學校的學生 (69.2%) 表示有聽過 健康飲食在校園 運動下的 開心果日 活動 ; 當中超過一半 (52.9%) 的學生曾參與 開心果日 的相關活動 另外, 在學校所舉辦的健康飲食推廣活動中, 學生最常參與的是出席講座和收看教育電視 一般學校的家長 知識 態度及行為約七成家長熟悉健康飲食常識, 大部分家長 (80.7% 至 99.2%) 可將食物正確分類為 健康食物 或 不健康食物 約三分之一的家長 (34.5%) 認為其子女的飲食習慣是健康的, 而約三分之二的家長 (64.5%) 則認為自己的飲食習慣是健康的 另外, 約五分之二的家長認為健康飲食習慣是容易維持的 另外, 多於八成的家長 (83.5%) 指出為孩子選擇食物時, 最主要的考慮因素為 營養價值 ; 五分之一的家長 (20.0%) 表示在調查前一星期內曾使用食物獎賞子女的良好表現 就學校食物供應採取的營養規管本調查向家長查詢是否贊成學校對小食部 / 自動售賣機提供的食物或飲品採取某種形式的營養規管 大部分家長贊成規管小食部 / 自動售賣機提供的食物或飲品 (63.8% 至 74.2%), 並對學校提供的午膳 (50.4% 至 93.5%) 採取某種形式的營養規管 與二零零八年的結果相比, 家長對學校小食部 / 自動售賣機採取六項不同的營養規管的支持度均顯著提高, 包括每天售賣新鮮水果及蔬菜, 以及不售賣含高鹽分 高糖分 高脂肪的食物和高糖分飲品 健康飲食在校園的影響 超過三分之二來自一般學校的家長 (67.0%) 在調查前一年內曾聽聞衞生署在小學推廣的健康飲食運動, 而約七分之一的家長則表示在調查前一年內曾參與子女就讀的小學所舉辦的健康飲食推廣活動, 較二零零八年調查的結果為高 (14.2% 比 7.6%) 5

一般學校的飲食環境 所有參與的學校均為學生提供午膳 大部分的一般學校表示已制定學校健康飲食政策, 明顯較二零零八年的比例為高 (85.1% 比 53.0%), 但其中近半數學校 (44.7%) 表示沒有相關政策文件記錄 此外, 大部分學校 (95.9%) 表示有成立膳食專責工作小組, 以安排和監管學生膳食服務, 當中全部 (100%) 都有安排教職員代表出任專責工作小組成員 ; 而大部分學校的專責工作小組成員包括家長代表和校長 / 副校長 對校內供應的食物採取營養規管超過七成的學校 (70.5% 至 76.1%) 支持管制對學生提供含高脂肪 / 高鹽分 / 高糖分的食物或含有高糖分的飲品, 而接近一半的學校 (45.7%) 贊成規定每天售賣新鮮水果和蔬菜 就午膳安排而言, 大部分學校 (87.5% 至 95.9%) 均贊成制定食物營養規定, 包括對五穀類 蔬菜和水果的分量的規定 此外, 幾乎全部學校贊成限制每周選用加工或醃製肉類作午膳食材的次數, 而大部分學校則贊成規定所有午膳不得含有油炸食物和甜品 使用食物作為獎賞 約四分之三的一般學校 (75.5%) 表示學校人員有使用食物獎賞學生, 然而只有 26.5% 學校 表示已制定關於使用食物獎賞的指引 一般學校與認證學校的比較 本研究顯示, 認證學校在學生 家長及學校各層面均比一般學校明顯優勝 舉例來說, 認證學校學生的營養知識較一般學校的學生高 ; 他們亦較少在調查前的一個星期內在家中進食糖果 / 朱古力 曲奇餅 / 夾心餅 薯條 / 蝦條和雪糕 / 雪條 另一方面, 認證學校明顯有較高比例的學生會從家中帶水果回校進食 6

相對於一般學校的家長, 有較多的認證學校家長認識衞生署所舉辦的健康飲食推廣活動 (77.1% 比 67.0%) 此外, 在認證學校中, 表示滿意衞生署在小學推廣健康飲食的工作的家 長比例明顯較一般學校的為高 關於校內小食部售賣小食及午膳的安排方面, 較多認證學校支持實施有關營養規管 至於制定使用食物來獎賞學生指引方面, 認證學校的百分比較一般學校多 (48.0% 比 26.5%), 而認證學校也較少出現學校人員使用食物獎賞學生的情況 (66.7% 比 75.5%), 雖然上述的差異未達到統計學上的顯著水平 總結 根據衞生署學生健康服務的最新數據, 二零一一 / 一二學年的小學生的肥胖率下降至 20.9%, 而二零零九 / 一零學年和二零一零 / 一一學年的肥胖率, 分別為 22.2% 和 21.4% 本研究亦顯示, 學生的飲食習慣也有明顯的改善 肥胖率下降, 很可能是學校 家長 學生和社會上各持份者共同努力的成果 無論是在校園或其他場所, 如只採用單一介入措施, 是不足以逆轉兒童肥胖率上升趨勢的 因此我們需要在學校 家庭 社區 醫護設施和工作間等場所採取多管齊下的策略, 務求使健康體重管理策略可以發揮持久功效 7

建議 綜合調查結果, 我們有以下的建議 : 政府方面 1. 香港政府 ( 特別是教育局及衞生署 ) 應鼓勵所有小學主動參與 健康飲食在校園 運動, 尤其是該運動之中的 至營學校認證計劃 政府持續的支持與倡導, 對營造健康環境, 使學生能實踐健康飲食, 是非常重要的 此外, 政府亦應為學校提供足夠的資源, 包括時間 專門技術和經費, 以推行校本的健康促進活動 2. 政府應鼓勵更多學校制定有關健康飲食的政策, 特別是書面形式的政策, 從而使校 方能營造並維持一個持續性的健康飲食環境 注重營養的學校政策能提供重要的框 架, 為學校在推廣學童健康飲食工作的規劃 實行和評估方面提供指導 3. 政府應向家長和教師傳達有關以食物作為獎賞的不良影響的信息 家長和老師應通 力合作, 共同推廣使用 非食物 作為獎賞的健康環境 學校更可考慮把相關要求 納入學校的健康飲食政策內 4. 政府應定時評估學校的健康飲食政策 活動和措施 為更明白如何為研究工作及行 動策略定出優先次序, 應先評估現行的健康飲食政策和措施, 而評估亦應是 健康 飲食在校園 運動的一個常規工作 5. 政府應多與家長溝通, 以加強他們的參與, 因為家長是一股能帶動學校及孩子行為 改變的強大力量 8

6. 政府應繼續發揮對午膳和小食供應商的影響力, 並推行家校合作, 協助定出校園內 提供更多不同種類的健康食品, 以供學生選擇 7. 政府應考慮向家長提供簡易的健康食譜, 以協助家長為孩子烹調營養豐富的食物 學校方面 8. 健康是從人們的生活 學習 工作和休憩當中創建出來的 學校有責任為學生和教 職員建立一個支援健康飲食的環境 這包括但不僅局限於供應促進健康的午膳和小 食 9. 就家校合作而言, 學校應與家長溝通, 並使家長更積極參與促進健康飲食的工作 適當地徵詢主要持份者的意見及得到他們的參與, 能為學生提供一個穩定 持久, 且一致性的成長環境, 讓他們建立健康生活的習慣 10. 學校應確保食物供應商遵守 學生午膳營養指引 和 學生小食營養指引, 有關 資料可從衞生署 健康飲食在校園 運動專題網站 (http://school.eatsmart.gov.hk) 下載 9

第二部分 學校提供的午膳及小食 研究方法 研究員探訪校園內設有小食部或自動售賣機的學校, 並檢查校內出售的所有小食 ( 包括食物和飲品 ) 研究員根據學校提供的小食資料及實地探訪學校時所取得的記錄, 把小食根據衞生署於二零一零年發布的 學生小食營養指引 分為 適宜選擇 限量選擇 及 少選為佳 三個類別 另一方面, 研究員在取得學校的同意後, 於二零一二年四月至五月期間指定的一個星期內, 收集其中一個上課天的所有午膳樣本進行分析 研究員先檢查所有午膳樣本中的蔬菜分量, 並且確定是否含有衞生署在二零一零年發布的 學生午膳營養指引 中列明的 鼓勵多供應的食品 限制供應的食品 和 強烈不鼓勵的食品 此外, 研究員亦會記錄午膳中五穀類 蔬菜類和肉類的相對比例 調查結果 一般學校內的小食 本研究顯示約六成的小學設有小食部及自動售賣機, 而所提供的食物及飲品都是高糖分 高脂肪和高鹽分的 在一般學校中, 小食部提供健康小食的情況並不普遍 只有 5.9% 的食物和 15.2% 的飲品屬於 學生小食營養指引 中 適宜選擇 的小食類別 另一方面, 約三分之二的食物和飲品屬於 少選為佳 類別 ; 大部分在這個類別的小食均為高熱量和低營養價值的 自動售賣機的情況比小食部更差 : 在一般學校裏, 大部分自動售賣機的食物 (91.9%) 10

及約三分之二的飲品均屬於 少選為佳 的類別 ; 此外, 沒有任何食物及只有 15.6% 的飲品 屬於 適宜選擇 的類別 一般學校內的午膳 本研究發現小學所提供的午膳營養質素仍然有很大的改善空間 在一般學校中, 大約四分之一的樣本提供了不足一份蔬菜 ; 四分之三的午膳樣本的五穀類 蔬菜類和肉類均未能符合 學生午膳營養指引 中 3:2:1 比例的建議 同時,10.9% 的樣本含有至少一種 強烈不鼓勵供應的食品 只有接近兩成的樣本提供全穀麥或添加蔬菜的五穀類, 屬 鼓勵多供應的食品 至營學校認證計劃的影響 調查發現, 從認證學校所收集到的小食和午膳樣本的營養質量均明顯較一般學校的為佳 就以認證學校的自動售賣機為例, 超過四分之三的飲品 (78.0%) 屬於 適宜選擇 類別, 明顯較一般學校的 15.6% 為高 至於午膳方面, 從認證學校收集回來的午膳樣本較一般學校少含有 強烈不鼓勵供應的食品 (2.3% 比 10.9%) 總結 總括而言, 高熱量的食物和高糖分飲品充斥於香港的一般小學環境中 校內的小食部及自動售賣機所提供的小食, 主要是屬於 少選為佳 的類別, 即為低營養價值及高脂肪 高鹽分 高糖分的食物 ; 同時, 能符合午膳營養指引所建議要求的午膳樣本並不多 至於午膳和小食的供應, 認證學校的表現比一般學校優勝, 特別是在小食方面 11

本研究亦證實有需要繼續鼓勵學校提供健康食物 社會可通過以學校為本的健康促進活動, 並針對校內銷售不健康食物的情況制定政策, 可望改善學童的營養狀況 建議 1. 政府應廣泛宣傳本研究所得的結果, 以增加公眾對學校健康飲食的認識 2. 政府應鼓勵所有學校參與 至營學校認證計劃, 以提供更好的飲食環境予小學生 3. 學校應恆常監管供應給學生的小食和午膳, 以確保其質素符合小食和午膳指引中的建議 就小食而言, 學校應考慮從小食部和自動售賣機中除去屬於 少選為佳 類別的食物和飲品 至於午膳方面, 學校應確保午膳包含足夠的蔬菜, 並且不含 強烈不鼓勵供應的食品 4. 小食部營運商與自動售賣機供應商應注意小食指引的要求, 兩者亦應定時與學校溝通, 並提供更多 適宜選擇 的小食 他們應把 少選為佳 類別的食物從售賣予學童的食 物和飲品清單中剔除 5. 午膳供應商應把資源投放於午膳營養質素的改善, 以配合午膳指引的要求 供應商亦應 定時與學校溝通, 以確保所提供的午膳能遵從午膳指引 12

Introduction Obesity has significant impact on both physical and psychosocial health. It can lead to physical health problems such as high blood pressure, raised blood cholesterol levels and an increased risk of developing non-communicable diseases including heart diseases, stroke and diabetes. Obese children are more likely to become obese adults. Moreover, obese children are more prone to low self-esteem, negative body image and depression. Tackling the problem of rising prevalence of childhood obesity in Hong Kong is a public health priority. The obesity rate among primary school students was found to increase from 16.4% in 1997/98 to 21.3% in 2006/07. To tackle the problem of childhood obesity in Hong Kong, the Department of Health (DH) has been running the EatSmart@school.hk (ESS) Campaign since the 2006/07 school year to raise public awareness of and concern about healthy eating in children and to create an environment that is conducive to healthy eating in schools and the community. In 2008, DH conducted a territory-wide survey titled Assessment of Dietary Pattern in Primary Schools to assess the knowledge, attitude and practice among primary school students and parents, and to understand the nutritional environments in primary schools. On the other hand, in school year 2009/10, the EatSmart School Accreditation Scheme (ESAS) was launched under the ESS Campaign. Under ESAS, using accreditation status as an incentive, schools are encouraged to develop policies and implement measures on healthy diets with full cooperation between home and school, with a view to effectively implementing nutritional guidelines issued by DH regarding the supply of lunches and snacks. In order to gauge improvement and inform future programme planning and implementation of the ESS Campaign, DH commissioned the Social Sciences Research Centre of the University of Hong Kong to conduct a territory-wide study between April and June 2012 to examine the current 13

dietary arrangement and to investigate the knowledge, attitude and practice of healthy eating among primary school students and parents. The results of current study were also compared with those of 2008. The objectives of the study included: (a) to assess the knowledge, attitude and practice of healthy eating among primary school students and identify the effects of ESAS on students in these aspects (b) to assess the knowledge, attitude and practice of healthy eating among parents of primary school students and identify the effects of ESAS on parents in these aspects (c) to understand the nutritional environment (covering policy, practice, measures, etc.) in primary schools and identify the effects of ESAS on schools in these aspects (d) to examine the nutritional quality of snacks and lunch provision in primary schools and identify the effects of ESAS on snacks and lunch provision in these aspects This study included two parts. Part 1 (Questionnaire Survey of Students, Parents and Schools) of the study was carried out in accordance with the first 3 objectives ((a) to (c)). Part 2 (Provision of Snacks and Lunch in Schools) of the study was carried out in accordance with the objective (d). 14

Part 1 Questionnaire Survey of Students, Parents and Schools Methodology The study comprised two parts: a cross-sectional study and a comparison study. A total of 50 primary schools (general schools) were randomly selected based on the number of schools and their funding types from 18 districts. In addition, 25 primary schools with ESAS accreditation status attained on or before 30 November 2011 (ESAS schools) were also invited, making a total sample size of 75. Primary 4 and Primary 5 students, their parents and principals or school representatives of primary schools who were responsible for overseeing meal/snack arrangement and supply were invited to participate in the study. Three sets of self-administered questionnaires targeting students, parents and schools were used in the study, which was carried out between April and June 2012. The corresponding response rates for each type of questionnaires were listed below: Student questionnaire Parent questionnaire School questionnaire General schools ESAS schools General schools ESAS schools General schools ESAS schools Number of schools having responded 50 24 50 24 49 25 Number of copies of questionnaire 7,387 3,285 7,058 3,109 49 25 collected Response rate 73.5% 70.2% 70.2% 66.4% 98.0% 100.0% Remarks: One ESAS school refused to return the student and parent questionnaires, whilst one general school did not return the school questionnaire. 15

Demographics For the general schools, 48.3% students were in Primary 4 and 49.0% were male. The majority of parent respondents (75.8%) were mothers. Among the parents, 34.5% attained university level of education or above and 10.6% had a monthly household income of less than $10,000. Among the participating schools, 81.6% were government or aided primary schools. The majority of schools were whole-day schools (98.0%) and most of them (87.8%) were co-educational. The demographic breakdowns of students of the ESAS schools were similar to those from the general schools, except that less parents attained university level of education or above (19.8% vs. 34.5% ) and with monthly household income of $60,000 or more (4.7% vs. 13.2%). Moreover, all the participating ESAS schools were whole-day schools and most of them (96.0%) were co-educational. Key Findings Students from general schools Knowledge, attitude and practice Findings from the study of general schools showed that students knowledge of healthy eating remained at a high level. Most of the students (90.9%) reported that they liked eating fruit and more than two thirds (68.8%) reported they liked eating vegetables. While more than two thirds of the students (69.8%) perceived their eating habits as healthy, 17.7% to 35.7% of the students reported that they did not have any fried/deep fried food, food high in fat, salt or sugar, or drinks high in sugar in the week prior to the survey day. Those who had fruit and vegetables intake twice or more per day was 70.3% and 83.1% respectively. About one third of the students (33.0%) brought fruit from home to eat in schools in the week prior to the survey day. 16

Behavioural change Compared with the similar study in 2008, significant positive changes were noted in the students consumption of fruit (having fruit 2 times or more per day - 2012:70.3%; 2008:57.5%) and vegetables (having vegetables 2 times or more per day - 2012:83.1%; 2008:78.7%), and in their reduced consumption of high fat/salt/sugar food or drinks high in sugar (see the table below). 2008 2012 Change Not having food high in fat 14.8% 20.7% 5.9% Not having food high in salt 27.3% 35.7% 8.4% Not having food high in sugar 12.2% 17.6% 5.4% Not having drinks high in sugar 10.8% 17.7% 6.9% Health promotional activity in school About 70% of the students (69.2%) from the general schools had heard of Joyful Fruit Day under ESS Campaign. Among them, more than half (52.9%) had participated in related activities. The most common healthy eating promotional activities attended by students in schools were seminars and educational TV programmes. Parents from general schools Knowledge, attitude and practice About 70% of the parents were familiar with general knowledge about healthy eating. Besides, the majority (80.7% to 99.2%) of parents classified food items correctly into healthy food or unhealthy food. While one third of the parents (34.5%) perceived their children s eating habits as healthy, about two thirds of the parents (64.5%) perceived their own eating habits as healthy. In addition, about two fifths of the parents thought that healthy eating habits were easy to sustain. When choosing food for their children, more than 80% of parents (83.5%) considered that 17

nutritional value was a major concern. One fifth of the parents (20.0%) reported that they used food as a reward for their children s good behaviour in the week prior to the survey. Imposing measures to restrict food served in schools Parents were asked whether they agreed to imposing some forms of nutritional restrictions on the food and drinks supplied in school tuck shops/vending machines. The majority of parents indicated support for imposing nutritional regulations on the food and drinks supplied in school tuck shops/vending machines (63.8% to 74.2%) and on school lunch (50.4% to 93.5%). A comparison of the results of the current study with those of 2008 found that there were significant increases in the proportion of parents showing support to all six tuck shop/vending machines-related nutritional requirements, including selling fruit and vegetables every day, and not selling food high in salt, sugar or fat content and sugary drinks. Impact of the ESS Campaign Over two thirds of the parents from general schools (67.0%) were aware of the healthy eating promotion campaign launched by DH in primary schools in the year prior to the survey. About one seventh of the parents reported that they had participated in healthy eating promotion activities organised by schools; the percentage saw a significant increase from 2008 (14.2% vs. 7.6%). Eating environment in general schools All participating schools provided school lunch to their students. The majority of schools had developed a healthy eating policy; such figure was significantly higher than that in 2008 (85.1% vs. 53.0%). However, nearly half of them (44.7%) reported not having any related written policy document in place. Besides, most of the schools (95.9%) had a working group which was dedicated to arranging and monitoring the catering service for the students in their schools. All (100%) of these schools had such a working group with membership comprising teaching staff 18

representatives; most of them had parent representatives and their principals/vice principals in such groups. Imposing measures to restrict food served in schools More than 70% of the general schools (70.5% to 76.1%) supported the imposing of restriction on provision of food high in fat/salt/sugar or drinks high in sugar. Furthermore, about half of the schools (45.7%) agreed on the compulsory sale of fresh fruit and vegetables every day. For lunch arrangements, most schools (87.5% to 95.9%) agreed on measures like stipulation of the amounts of grains and cereals, vegetables and fruits. Also, almost all the schools agreed to limit the frequency of using processed or preserved meat in lunch per week. The majority of schools agreed not to provide deep-fried food and desserts to students. Using food as reward Around three quarters of the general schools (75.5%) reported that their school staff used food as a reward for students while only 26.5% of the schools had set up guidelines on using food as a reward. Comparison between general schools and ESAS schools The current study revealed that various aspects of students, parents and schools from the ESAS schools performed significantly better than those from the general schools. For example, students from the ESAS schools generally had better nutritional knowledge than those from the general schools. Besides, they were less likely to eat candies/chocolate, cookies/sandwich biscuits, potato chips/prawn crackers and ice-cream/ice bar at home in the week prior to the survey. A significantly higher proportion of the students from ESAS schools brought fruit from home to eat in schools than the students from general schools. 19

Compared with the general schools, the ESAS schools had more parents who reported they were aware of the healthy eating promotion campaigns launched by DH (77.1% vs. 67.0%). Moreover, a significantly higher proportion of the parents from ESAS schools were satisfied with the healthy eating activities organised for primary schools by DH than the parents from general schools. For the restrictions about tuck shop sales and lunch arrangements in primary schools, the ESAS schools were more likely to support imposing certain nutritional restrictions than the general schools. Furthermore, more proportions of ESAS schools reported that they had set up guidelines on using food as a reward for students (48.0% vs. 26.5%) and their school staff were less likely to use food as a reward for students (66.7% vs. 75.5%), although these differences did not constitute statistical significance. Conclusions According to the latest figures from the Student Health Service of DH, obesity rate among primary school students in the school year 2011/12 dropped to 20.9%. The corresponding rates in the school years 2009/10 and 2010/11 were 22.2% and 21.4% respectively. Together with significant positive changes of the students eating behaviour shown in this study, the achievement of this downward trend is probably a result of the concerted efforts of schools, parents and students, as well as the support of various stakeholders in the community. No single intervention, in schools or other settings, is likely to be sufficient to reverse the childhood obesity trend. Therefore, multiple strategies in schools, homes, communities, healthcare facilities and workplace settings should be adopted to achieve long-lasting effect on healthy weight management. 20

Recommendations Below are some recommendations based on the study findings: For the Government 1. The Government, especially the Education Bureau and DH, should work towards encouraging all primary schools to join the ESS Campaign proactively, in particular the ESAS. Ongoing Government support and advocacy are important for creating a healthy environment in which students can practise healthy eating. Moreover, adequate resources in time, expertise and funding should be provided for carrying out school-based health promotion programmes. 2. The Government should encourage more schools to formulate healthy eating school policies, with documentation, to build and maintain a supportive environment on school campus. Nutrition-friendly school policies provide an essential framework that guides schools in planning, implementing and evaluating effects to promote healthy eating among their students. 3. The Government should convey to parents and teachers the message of negative effects of using food as reward. Parents and teachers should work closely to promote a healthy environment by using non-food rewards. This requirement should be incorporated into the school s healthy eating policy. 4. The Government should regularly evaluate school healthy eating policies, programmes and practices. An assessment of current healthy eating policies and practices is necessary to provide insight into research prioritisation and action strategies for the promotion of healthy eating. Evaluation should be a regular feature of the ESS Campaign. 21

5. Government action to engage parents through effective communication should be enhanced as it is a powerful driving force behind behavioural change in schools and among children. 6. The Government should continue to exert influence on lunch and snack suppliers, as well as schools and parents, to shape the variety and amount of healthy food items available in the school environment for students to choose. 7. The Government should consider providing easy-to-follow healthy cooking recipes to help parents prepare nutritious food for children. For schools 8. Health is pursued where people live, learn, work and play. Schools are responsible for providing their students and staff with environment that promotes healthy eating. This includes, but is not limited to, facilitating the supply of healthy lunch and snacks. 9. In the spirit of home-school cooperation, schools should communicate with parents and engage them more fully in healthy eating promotional efforts. Appropriate consultation and participation of key stakeholders will provide students with a stable and consistent environment for growth and formation of healthy living habits. 10. Schools should ensure that food suppliers comply with the Nutritional Guidelines on School Lunch for Students and Nutritional Guidelines on Snacks for Students, which are readily available at DH s ESS Campaign thematic website (http://school.eatsmart.gov.hk). 22

Part 2 Provision of Lunch and Snack in Schools Methodology For the participating schools which had tuck shops or beverage/food vending machines on campus, researchers conducted field visits to these schools to examine all snacks (food items and beverages). Basing on the information of snacks provided by the schools and field visits, researchers divided all snacks into three categories, namely snacks of choice, snacks to choose in moderation and snacks to choose less in accordance with the Nutritional Guidelines on Snacks for Students issued by DH in 2010. Moreover, fieldworkers visited each participating school to collect samples of all available lunch options of one particular day for further analysis during a mutually agreed period (within a specified week) between April and May 2012. All collected lunch choices were first checked for the quantity of vegetables provided, as well as encouraged food items, limited food items and strongly discouraged food items as defined by the Nutritional Guidelines on Lunch for Students issued by DH in 2010. The proportions of grains, vegetables and meat were also recorded. Key Findings Snacks in general schools The current study showed that 60% of the primary schools had vending machines and tuck shops. Moreover, it revealed that the food and beverages sold in the school tuck shops and vending 23

machines were high in sugar, fat, and salt. For the tuck shops of the general schools, healthy snack choices were not commonly available only 5.9% of food items and 15.2% of beverages belonging to the snacks of choice category as defined in the snack guidelines. On the other hand, around two thirds of the food items and beverages belonged to the snacks to choose less category. Most of the snacks which belonged to this category were energy-dense food of low nutritional value. Situations for vending machines were even worse than those for tuck shops. For the general schools, the majority of food items (91.9%) and about two thirds of beverages sold in vending machines belonged to the snacks to choose less category. Moreover, none of the food items and only 15.6% of the beverages belonged to the snacks of choice category. Lunch in general schools Regarding the nutritional quality of lunch in primary schools, the current study found that there was plenty of room for improvement. For the general schools, about one quarter of samples provided less than one serving of vegetables and three quarters did not provide grains/cereals, vegetables and meat in the ratio of 3:2:1, which failed to achieve the recommendations stated in the lunch guidelines. Moreover, 10.9% of the samples contained at least one strongly discouraged food items. On the other hand, only about 20% of samples provided whole grains or grains and cereals with added vegetables, which belonged to the encouraged food items. Impact of ESAS The snacks and lunch sets collected from the ESAS schools were significantly healthier (in terms of nutrition) than those from the general schools. For example, for vending machines, more than three quarters of the beverages from the ESAS schools (78.0%) belonged to the snacks of choice category, significantly higher than the corresponding value of 15.6% in general schools. For 24

lunch, the samples from the ESAS schools were less likely to contain strongly discouraged food items than those from the general schools (2.3% vs. 10.9%). Conclusions In conclusion, energy-dense food and beverages high in sugar were over-represented in the general school environment of Hong Kong. The snacks provided in tuck shops and vending machines were mainly snacks to choose less, i.e. food with low nutritional value and high in fat, salt and sugar. Besides, not many lunch samples could fulfil the recommendations mentioned in the lunch guidelines. In terms of lunch and snacks provision, the performance of the ESAS schools was far better than the general schools, snacks in particular. This study confirmed the need for continuing work to encourage the provision of healthy food in schools. The community may be able to improve childhood nutrition through school-based health promotion programmes and policies that address the sale of unhealthy food in schools. Recommendations 1. The Government should widely publicise the findings of this study to raise public awareness of the issue of healthy eating in schools. 2. The Government should encourage all schools to participate in ESAS for providing a better nutritional environment to primary school students. 25

3. Schools should regularly monitor the nutritional quality of snacks and lunch to ensure compliance with the recommendations of snack and lunch guidelines. As for snacks, schools should consider eliminating all beverages and food items which belong to the snacks to choose less category from school tuck shops and vending machines. As for lunch, schools should ensure that lunch contains adequate vegetables but not any strongly discouraged food items. 4. Tuck shop operators and vending machine suppliers should be made aware of the requirements stated in the snack guidelines. They should regularly communicate with schools and offer more snacks of choices. They should remove all snacks to choose less from the list of food and beverages for sale to children. 5. Lunch suppliers should invest in improving the nutritional quality of lunch choices to meet the requirements of the lunch guidelines. They should regularly communicate with schools to ensure the lunch could fulfil the lunch guidelines. 26