Zdrav Var 2007; 46: 85-90 85 QUALITY OF MENUS IN SECONDARY SCHOOLS WITH REGARD TO RECOMMENDATIONS OF WORLD HEALTH ORGANIZATION (WHO) KAKOVOST JEDILNIKOV V SREDNJIH ŠOLAH GLEDE NA PRIPOROČILA SVETOVNE ZDRAVSTVENE ORGANIZACIJE (SZO) Anita Jamšek1 Prispelo: 5. 9. 2006 - Sprejeto: 14. 8. 2007 Original scientific article UDC 613.22(497.4-16) Abstract Background: Meals provided at school constitue an important part of the students’ daily diet. The World Health Organisation (WHO) has issued nutrition recommendations for children and adolescents aged 7 to 18 years. The aim of this study was to test the hypothesis that the quality of meals served in Slovene secondan/ schools does not meet the criteria recommended by WHO. Methods: In 2003, a survey on the quality of school meals, based on food diaries kept during one week, was conducted by the Ministry of Education, Science and Sports in ali Slovene secondary school. Fifty-eight menus (230 meals) sen/ed in eight (5.6 %) Slovene secondan/schools were analysed. A computer programme devised for evaluating the patient catering service in the University Medical Center Ljubljana was used in the survey Results: Energy and nutritional values (carbohydrate, protein and fat content) were calculated for each mid-morning school meal. Energy requirements recommended by WHO for boys and for girls were met by only 10.3 % and 13.8% of the one-week menus analysed. The proportion of meals providing the recommended dietary carbohydrate intake was 6.9% for boys and 17.3% for girls. The most striking finding was that none of the mid-morning meals complied with the WHO recommendations for dietary protein intake. Only 1.7% and 3.5 % of school meals, respectively were found to provide adequate fat content recommended for boys and girls. Conclusion: Our hypothesis has been fully confirmed given that mid-morning meals are considered to provide 30 % of the estimated average energy and nutritional values. School meals provided in Slovene secondan/ schools do not meet the WHO criteria for energy and nutritional values. Strategies to improve the quality of school food should aim to balance energy intake and energy expenditure through physical activity to increase carbohydrate intake and cut down on protein. Also, schools should employ professionals in school nutrition to manage school food services. Key words: secondan/ school pupils, organization of school nutrition service, meals, energv value, nutritional value Izvirni znanstveni ~lanek UDK 613.22(497.4-16) Izvle~ek Izhodi{~a: [olska prehrana oz. obrok v ~asu pouka je pomemben del celodnevne prehrane dijakov. Svetovna zdravstvena organizacija (SZO) je izdala prehranska priporo~ila za otroke in mladostnike, stare od 7 do 18 let. Na 1Biotehni{ka fakulteta, Oddelek za ‘ivilstvo, Jamnikarjeva 101, 1000 Ljubljana Correspondence to: e-mail: anita.jamsek@gmail.com 86 Zdrav Var 2007; 46 podlagi teh priporo~il smo postavili raziskovalno hipotezo: Kakovost jedilnikov v srednjih {olah ne ustreza priporo~ilom SZO oz. WHO. Metode: Ministrstvo za {olstvo, znanost in {port (M[Z[) je junija 2003 na vse slovenske srednje {ole poslalo anketo o organiziranosti prehrane v srednjih {olah. V obdelavo smo dobili tedenske jedilnike. Prejeti jedilniki (N=36) so bili pregledani in za vsako {olo je bil pripravljen dopis in preglednica, v katero je bilo potrebno dopisati ‘ivila, ki sestavljajo posamezne jedi na jedilniku, proizvajalca posameznih ‘ivil in koli~ino ‘ivila v jedi oziroma obroku. [ole smo zaprosili, da preglednice izpolnijo in vrnejo. Na koncu smo analizirali 58 jedilnikov (230 malic) 8 (5,6 %) srednjih {ol v Sloveniji. Jedilnike smo analizirali z ra~unalni{kim programom Priprava hrane za bolnike v Klini~nem centru v Ljubljani. Rezultati: Vsaki malici smo dolo~ili energijsko in hranilno vrednost (vsebnost ogljikovih hidratov, ma{~ob in beljakovin). Dobljene povpre~ne vrednosti tedenskih jedilnikov smo primerjali s priporo~ili SZO. Ugotovili smo, da imajo {ole energijsko in hranilno zelo razli~ne malice. Energijskim priporo~ilom SZO za fante ustreza samo 10,3 % povpre~nih tedenskih jedilnikov, za dekleta pa 13,8 % jedilnikov. Dele‘ malic, ki ustrezajo priporo~ilom potreb po ogljikovih hidratih, je pri fantih 6,9 % in dekletih 17,3 %. Najbolj presenetljiv in zaskrbljujo~ podatek je, da med analiziranimi malicami niti ena ne ustreza priporo~ilom SZO za beljakovine. Pri priporo~enih vrednostih za ma{~obe priporo~ilom ustreza 1,7 % malic za fante in 3,5 % malic za dekleta. Zaklju~ki: Raziskovalno hipotezo, da kakovost jedilnikov v srednjih {olah ne ustreza priporo~ilom SZO oz. WHO, lahko popolnoma potrdimo. V primeru, ko analizirano malico, to upo{tevamo kot {olski obrok, ki po priporo~ilih pokrije 30 % dnevnega energijskega vnosa. V tem primeru jedilniki na slovenskih srednjih {olah niti po energijskih vrednostih niti koli~ini hranil ne ustrezajo priporo~ilom SZO. Cilji za izbolj{anje {olske prehrane in njeno vzdr‘evanje med mladostniki so uravnovesiti energijski vnos in telesno dejavnost, pove~ati vnos ogljikovih hidratov, zmanj{ati vnos beljakovin in ne nazadnje zaposliti strokovno usposobljene vodje prehrane. Klju~ne besede: srednje{olci, organizacija {olske prehrane, obroki, energijska vrednost, prehranska vrednost Introduction The term »school nutrition service« refers to organised provision of mid-morning meals, and ex-ceptionally of other daily meals, for pupils attending secondary schools (1). Regular and healthy eating during adolescence is very important and plays a crucial role in the young person’s physical, mental and social well-being. Economically speaking, qual-ity school food has an immediate social impact, but also represents a necessary long-term investment. Ensuring that young people eat healthy food is one of the main factors leading to one of the most trea-sured goals - good health of the individual and soci-ety (2). WHO states that adolescents who had adopted healthy dietary habits in their youth are more likely to main-tain them in adult life. This means there is less chance they will develop chronic disorders, heart disease, can-cer, diabetes and osteoporosis (3). WHO therefore decided to endorse European recommendations for healthy nutrition of children and adolescents aged 7 to 18 years (4). The table below indicates energy and nutritional requirements of pupils to be met by school meals. Adolescents need a greater amount of quality food than primary school pupils. For normal activity they require normal blood sugar levels, which can only be ensured by a mid-morning school meal. Their productivity and motivation decrease after approximately four hours of work, or after four hours elapsed after the last meal (5). School meals must therefore be designed to fully meet the adolescenfs energy and nutrient requirements. In Slovenia 22.1 % of schools have a central kitchen, 5.6 % have only a meal distribution kitchen, 50 % have a refreshment room and 20 % have no food service facility (6). As many as half of schools, i.e. those with refreshment rooms, are therefore not equipped for pre-paring technologically and nutritionally adequate meals on site. The hypothesis we vvanted to test in the study is that the quality of secondan/ school meals fails to meet the criteria recommended by the WHO. Methods In June 2003, the Ministn/ of Education, Science and Sports launched a survey investigating the organisation of school food services in Slovenia. AN secondan/ schools in the country were asked to ansvver 25 sur- Jamšek A. Quality of menus in secondary schools with regard to recommendations of VVorld Health Organization (WHO)__________87 Table 1. Summary of nutritional guidelines for school meals (4). Tabela 1. Povzetek smernic {olske prehrane (4). Nutrient / Hranilo Recommendations for school meal/ Priporočila za šolsko prehrano Age 15-18year/ Starost 15-18 let Boys/ Dečki Girls/ Deklice Energy / Energija 30 % Estimated Average Requirement (EAR) / 30 % dnevne energijske potrebe 3450 kJ (825 kcal) 2635 kJ (630 kcal) Proteins / Beljakovine > 30 % Recommended Nutrient Intake (RNI) / > 30 % priporočen hranilni vnos > 14.5 g > 15.4 g Carbohvdrates / Oglj.hidrati > 50 % of food energv / > 50 % dnevnih energijskih potreb > 103.1 g > 78.7 g Fats/ Maščobe < 35 % of food energv / < 35 % dnevnih energijskih potreb <32g < 24.5 g Note: Energy in kJ (cal.) and the amount of nutrients in grams are calculated for 11500 kJ and 8780 kJ of daily energy requirements in boys and girls, respectively. Calculations vvere done by the authors RNI - recommended nutrient intake EAR - estimated average requirement vey questions and to record their mid-morning meal menus for the follovving periods: • 1st week: 7 - 11 October 2002 • 2nd week: 14 - 18 October 2002 • 3rd week: 6 - 10 January 2003 • 4th week: 13 - 17 Januan/2003 • 5th week: 7 - 11 April 2003 • 6th week: 14 - 18 April 2003 We received and checked menus from 36 (25.3 %) of 142 secondary schools and school centers. The respon-dents vvere sent a letter asking them to complete a table specifying vvhich foodstuffs vvere used in each particular dish, and to give their amount and the produce^s name. The schools vvere asked to return com-pleted tables to our address. We received completed tables from only eight (5.6 %) schools. We analvsed 58 menus served over one vveek, i.e. a total of 230 mid-morning meals, using the University Medical Centre Ljubljana computer programme for patient catering service evaluation, vvhich is part of the VVINPIS busi-ness information svstem. Results There are considerable inter-and intra-school differ-ences concerning the mid-morning meals offered. The participating schools vvere therefore divided into three groups: • Schools providing only one cold mid-morning meal (six schools). • Schools providing a choice of three mid-morning meals, tvvo cold and one cooked menu (one school). • Schools offering a cooked mid-morning meal (one school). The average energy and nutritional values of mid-morning meals served in the schools over a vveek vvere com-pared vvith those recommended by WHO. A mid-morn- 88 Zdrav Var 2007; 46 ing meal with an energy value vvithin ± 5% of ne energy requirements recommended for secondan/ school stu-dents (132 kJ i.e. 31.5 cal for girls andl 71 kJ i.e. 41 cal for boys), was considered to provide adequate energy intake (Table 1). School meals with carbohydrate and protein content that was 5% higher than the lower limit of the recommended value were considered nutrition-ally suitable for secondary school students (Table 1), and so were the mid-morning snacks containing 5 % less fat than the upper recommended value of this nutrient (Table 1). Average energy values of mid-morning meals served over a week differed largely from one school to an-other. Energy value of the meals surveved ranged from 685.9 kJ (164 cal) to 4,131.2 kJ (988.3 cal). VVe found that three mid-morning meals provided by the same school had very different energy and nutritional levels, the highest energy value being 4,011.7 kJ (960 cal) and the lovvest 685.9 kJ (164 cal). Our analysis of 58 one-week mid-morning meal menus shovved the follovving: • boys: 12.1 % of mid-morning menus exceeded the recommended energy level, 77.6 % were belovvthe recommended energy value and 10.3 % were meet-ing the recommended energy levels. • girls: 41.4 % of the mid-morning menus analysed provided more energy than recommended, 44.8 % supplied less energy than recommended and 13.8 % were meeting the recommended values. The analysis of mid-morning meals served over a week shovved that the meals did not meet standards for school meals set in the WHO guidelines. As many as 86.2 % of boys and 89.7 % of girls eat school meals that are either too abundant or too frugal, to large or too small, too calorie rich or too calorie lovv; Carbohydrate content in an average mid-morning meal ranged from 32 g to 134.1 g (Table 1). We found that 75.9 % of one week’s menus failed to meet the recommended carbohydrate requirements for boys, and that only 6.9 % complied vvith the WHO recommendations. The proportion of meals vvith adequate carbohydrate content for girls vvas slightly higher (17.2 %), yet half of one-vveek menus contained more carbohydrates than the recommended value. Average school meals contained 6.7 g to 45.7 g of pro-teins (Table 1). Figure 2 indicates that the protein content recommended for boys and girls vvas too high in 87.9 % of one-vveek menus and too lovv in 12.1 %, vvhich means that 0 % of meals served over one vveek met the recommended protein requirements. The amount of fat in average school meals ranged betvveen 0.3 g and 57.8 g (Table 1). The fat content recommended for boys and girls vvas too lovv in 79.3 % and in 55.2 % of one week’s menus, respectively. It should be pointed out that 41.2 % of one-vveek menus contained more fat than the recommeded amount of fat for girls. Compliance of energy value of school meals vvith energv levels recommended by WHO Boys Girls Gender too low in carbohydrates adequate carbohydrate content premalo oglj. hidratov ustrezna količina oglj. hidratov too rich in carbohydrates preveč oglj. hidratov Figure 1. The proportion of one-vveek mid-morning meal menus vvith carbohydrate content meeting/not meeting carbohydrate requirements recommended by WHO. Slika 1. Odstotek tedenskih jedilnikov dopoldanskih šolskih malic z ustrezno/neustrezno vsebnostjo oglj. hidratov glede na smernice SZO. Jamšek A. Quality of menus in secondary schools with regard to recommendations of VVorld Health Organization (WHO)__________89 Compliance of school meals with the WHO recommendations relating to protein content 100 ~ 80 ¦a 60 40 20 87^ 87^ 12,1 12,1 0 0 | | | | Boys Girls Gender too low in proteins premalo beljakovin adequate protein content ustrezna količina beljakovin too rich in proteins preveč beljakovin Figure 2. The proportion of one-week school menus meeting/ not meeting protein requirements recom- mended by WHO. Slika 2. Odstotek tedenskih jedilnikov dopoldanskih malic z ustrezno/ neustrezno vsebnostjo beljakovin glede na priporočila SZO. Compliance of school meals with the WHO recommendations relating to fat content too low in fat premalo maščob adequate fat content ustrezna količina maščob too rich in fat preveč maščob Figure 3. The proportion of one week’s menus meeting/not meeting fat requirements recommended by WHO. Slika 3. Odstotek tedenskih jednilnikov dopoldanskih malic z ustrezno/neustrezno vsebnostjo maščob glede na priporočila SZO. Discussion Nutritional requirements vary with age. Proper nutri-tion is much more important in the young than in adults. Even a short period of inadequate dietary intake of essential nutrients and/or energy may lead to delay in grovvth and development, as well as to poor health, tiredness and lovvered resistance to infection. Intense grovvth and development, as vvell as increased physi-cal strain due to participation in sports, increase en-ergy and nutritional requirements in children, as vvell as their need for essential nutrients (7). The main goal of nutrition planning for children should therefore be to offer balanced, safe and protective meals meeting en-ergy and nutritional demands that vary depending on gender, age, vveight, height, physical activity and nutri- 90 Zdrav Var 2007; 46 tional status. Our study shovved significant differences betvveen the school meals served (e.g. energy values ranged from 685,9 kJ to 4,131.2 kJ). Energy and nutri-tional values of ali mid-morning meals should comply with current WHO dietary recommendations. Energy and nutrient requirements of every pupil should be ad-equately met, irrespective of which mid-morning meal he/she choses. The main problem encountered was that three fourths of school meals failed to meet the energy reference values for boys, and that the menus served either failed to meet or exceeded energy values rec-ommended for girls. Carbohydrates are primary nutrients supplying energy (8). They are very important in the diet because they slowly increase glucose in blood and thereby impact the pupils’ performance at school (8). We found that 75.9 % of menus failed to meet carbohydrate requirements for boys. For girls, who need less dietary carbohydrates, 51.7 % of the menus were too rich in carbohydrates. The need for protein increases during adolescence because of increasing lean body mass, red celi mass and myoglobin, and due to hormonal changes. It is therefore of primary importance for pupils to get enough proteins. Their protein intake, hovvever, should not exceed the recommended value because immoderate protein intake is connected with high intake of fats (8). Eating food rich in proteins, phvtanic and oxalic acids, phosphates and fibrins, and consuming alcoholic beverages, caf-feine and some medicines hinders absorption of dietary calcium from the intestine (9). The amount of proteins supplied by the food analysed failed to meet protein re-quirements recommended by WHO. As many as 87.9 % of the menus analysed were too rich in proteins, which is likely to result in ill health and increase the risk of osteoporosis in later life. Adolescents have increased need for energy to support physical grovvth and development. Yet, to avoid the risk of cardiovascular disease, diabetes type II and obesity in this population group, the amount of fat in adolescents’ diet must not exceed the recommended require-ments. We expected that the recommended fat content would be exceeded in most menus, but the exact oppo-site was true: the one-week menus analysed supplied inadequate amounts of fats. School meals should pro-vide 32 g of fat for boys and 24.5 g of fats for girls, but the amount of fat was inadequate for boys in 79.3% of the menus and for girls in 55.2 % of the menus analysed. Schools urgently need clear guidelines and nutrition stan-dards to be able to plan healthy mid-morning meals that would meet the recommended energy and nutritional requirements. In addition, schools should employ nutritional professionals to manage school food service, and make arrangements for the cooking personnel to attend courses on healthy nutrition on a yearly basis. Conclusions The results of the survey of one-week school menus have confirmed our hypothesis that the quality of food served in Slovene secondary schools does not comply with the WHO recommendations. School meals were found to be either too calorie rich or too calorie low for 86.2 % of boys and for 89.7 % of girls. Meals provided by secondan/ schools need to be improved to supply more carbohy-drates and fats and less protein. Schools should provide for balance betvveen dietary energy intake and energy expenditure through physical activity, and employ a school foodservice professional. Moreover, aH secondan/schools in Slovenia should use standardised recepies to ensure that their menus meet specific standards of healthy school nutrition. A clear set of rules and instructions regulating the vvork of school kitchen personnel should be adopted. Caterers delivering food to secondan/ schools should be selected according to strict criteria. References 1. Pravilnik o subvencioniranju šolske prehrane dijakov in vajencev v srednjih šolah. Ur. I. RS št. 34/2004; 3966-9. 2. Škof I. Organizacija in kakovost prehrane študentov Univerze v Ljubljani. Diplomsko delo. Ljubljana: Univerza v Ljubljani, Biotehniška fakulteta, Oddelek za živilstvo, 2001. 3. Health behaviour in school-aged children (HBSC) studv. International report from the 2001/2002 survev. Copenhagen: VVorld Health Organization, 2004. Dosegljivo na: http://www.euro.who.int/Document/e82923.pdf. 4. Food and nutrition policy for schools. Copenhagen: VVorld Health Organization, 2004. 5. Pokorn D. S prehrano do zdravja. Hrana čudežno zdravilo II -Recepti in diete. Ljubljana: EWO, 1996. 6. Lubej M. Nadzor zdravstvene inšpekcije v kuhinjah in gostinskih obratih srednjih šol. Prehrana mladostnikov srednješolcev-strokovni seminar. 27. januar 2004. Zbornik. Maribor: Živilska šola Maribor, 2004; 47-51. 7. Pokorn D, Arko U. Prehrana adolescenta. Zdrav Var 1995; 34: 113-6. 8. Standardi zdravega prehranjevanja v vzgojo izobraževalnih ustanovah (interno gradivo). Ljubljana: Inštitut za varovanje zdravja Republike Slovenije, 2004. 9. Pokorn D. Higiena prehrane. Ljubljana: Medicinska fakulteta 1996, 76-7. Legend: g - gram kJ - kilo Joule MŠZŠ - Ministry of Education, Science and Sports VVINPIS - business information system WHO -VVorld Health Organisation