Condition category
Nutritional, Metabolic, Endocrine
Date applied
31/07/2019
Date assigned
17/10/2019
Last edited
03/06/2020
Prospective/Retrospective
Retrospectively registered
Overall trial status
Ongoing
Recruitment status
Suspended

Plain English Summary

Background
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 was introduced means that all academies and free schools set up between 2010 and 2014 are not legally 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 required by law to meet them with those that are not. 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.

Aims
We will make comparisons between secondary schools required to meet the standards and those that are not required to meet the standards. We will compare: the food provided and sold in schools; the school food environment and culture; 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.

Who can participate?
Secondary schools in the West Midlands and pupils from years 7, 9 and 10 in those schools.

What does the study involve?
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 how well the School Food Plan is implemented. 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 assess 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 will ask pupils from years 7, 9 and 10, in school time, to complete an online survey including a 24-hour dietary 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.

What are the possible benefits and risks of participating?
The results will help us to assess the impact of the national School Food Standards. This information will be used to inform the Department for Education and Department of Health to enable further development of national policy relating to school food. In turn, this may help to shape the health of future secondary school pupils. Additionally, pupil and parent participants will be given a £5 shopping voucher as a thank you for their time spent participating in our study.

Schools will be provided with a summary of the data collected from their school, which may support any internal evaluation of school food. The process of collecting the views of pupils, parents, staff and Governors will also provide an additional method for the school to ensure their voices on school food provision and education are heard. All schools who take part in the study will be given £300 to cover the costs of their involvement.

There are no anticipated risks to those taking part in this study.

Where is the study run from?
The University of Birmingham, UK

When is the study starting and how long is it expected to run for?
September 2019 to February 2021

Who is funding the study?
National Institute for Health Research (NIHR), UK

Who is the main contact?
Dr Miranda Pallan (scientific)
m.j.pallan@bham.ac.uk
Dr Emma Lancashire (public)
e.r.lancashire@bham.ac.uk

Trial website

http://www.birmingham.ac.uk/FUEL-study

Contact information

Type

Scientific

Primary contact

Dr Miranda Pallan

ORCID ID

http://orcid.org/0000-0002-2868-4892

Contact details

Murray Learning Centre
University of Birmingham
Edgbaston
Birmingham
B15 2TT
United Kingdom
0121 414 7990
m.j.pallan@bham.ac.uk

Type

Public

Additional contact

Dr Emma Lancashire

ORCID ID

Contact details

Institute of Applied Health Research
University of Birmingham
Edgbaston
Birmingham
B15 2TT
United Kingdom
+44 (0)121 414 3999
e.r.lancashire@bham.ac.uk

Additional identifiers

EudraCT number

Nil known

ClinicalTrials.gov number

Nil known

Protocol/serial number

17/92/39; CPMS 43416

Study information

Scientific 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

Acronym

FUEL

Study hypothesis

Evidence from dietary surveys indicates that dietary intake of free sugars and sugar sweetened beverages (SSBs) among UK children and adolescents regularly exceeds recommended levels. These high intake patterns are of public health concern given the association between sugar consumption and obesity. Patterns of school food consumption are an important determinant of total dietary profile, with up to a third of children’s energy and micronutrient intake provided by lunch on school days. Adolescence is a key period for the establishment of dietary patterns, and in school adolescents have more choice and greater autonomy regarding the food they eat compared with younger children. Therefore a healthy school food environment may have a significant influence on the dietary intake of adolescents.

National School Food Standards (SFS) have been in place in England since 2006 and were updated in 2015. They are a legal requirement for most state schools. The Standards are a set of requirements for school food to help children develop healthy eating habits and ensure that they get the energy and nutrition they need across the whole school day. In addition to the national SFS, the School Food Plan (SFP) was launched in 2013. This provides a wider set of non-statutory recommendations for schools which aim to address the overall ethos of the school in relation to food, promoting adoption of a ‘whole school’ approach. There has been little evaluation of the impact of the SFS on the diets of pupils in secondary schools, and to date, there has been no evaluation of the implementation of the SFS within secondary schools, or the influence of the wider SFP recommendations on the overall ethos of the schools in relation to food.

The way in which the SFS legislation has been introduced in England means that there are a group of academies and free schools that are exempt from the legal requirement to meet the Standards. This gives an opportunity to examine the influence of the SFS legislation by comparing these exempt schools with those that are mandated to meet the Standards.

We aim to assess whether the mandatory SFS and additional SFP recommendations influence the food provided and sold in secondary schools; the school food environment and ethos; and the healthy eating and cooking skills curriculum. We also aim to assess the impact of the SFS and SFP on sugar and other dietary intake, and the dental health of secondary school pupils. In addition, we will explore the extent to which schools vary in how the SFS and SFP recommendations are implemented; the cost to schools and families of measures to improve healthy eating and food provision; and the economic impact of the SFS and SFP.

Ethics approval

Approved 20/08/2019, University of Birmingham Ethics Committee (Research Support Group,
C Block Dome, Aston Webb Building, University of Birmingham, Edgbaston, B15 2TT, UK; +44 (0)121 414 8825; s.l.cottam@bham.ac.uk), ref: ERN_18-1738

Study design

Observational mixed methods study

Primary study design

Observational

Secondary study design

Cross sectional study

Trial setting

Schools

Trial type

Prevention

Patient information sheet

http://www.birmingham.ac.uk/FUEL-study

Condition

Dietary intake and dental health

Intervention

Current interventions as of 31/12/2019:

This research consists of two stages. In the first stage, a variety of data on SFS and SFP implementation and school and pupil outcomes will be collected at the school and individual pupil level. We will aim to recruit an equal number of schools mandated and not mandated to comply with the SFS, with pupil recruitment occurring from one selected class (form groups or class groupings where there is no streaming and all pupils have to attend) from each of three different year groups for every school. We will compare outcomes at the school level (food provision and sales, school meal uptake, eating environment, food curriculum, school food culture, and costs related to these factors) and at the individual level (sugar and other dietary intake, dental caries experience) in the two school groups. We will also capture data to explore the implementation and embedding of the SFS, SFP and the influence of the school context on this. We aim to develop a typology of schools relating to school food: provision; environment; culture; curriculum, and the wider school context, which will reflect the degree of implementation of the SFS, SFP and other local initiatives to improve the diets of pupils. In the second stage, a smaller number of case study schools (4-8) will be identified for in-depth qualitative evaluation with school staff (interviews) and pupils (focus groups). Schools will be sampled to ensure inclusion of a range of schools in terms of level of SFS/SFP implementation and institutional characteristics such as school size.

Data will be collected through the following methods/tools:
• Key information survey to head teachers
• Costings survey for completion by senior management
• Survey to key staff and Governors identified by the school to have roles relating to food provision, eating environment, food curriculum, or SFS/SFP implementation (including head teachers, lead catering staff, PHSE leads, teachers with responsibility for the food/cooking curriculum, relevant representatives from the governing body)
• Pupil survey, including a Paediatric Quality of Life measure (CHU-9D) and dental health measures
• Pupil 24 hour recall dietary assessment tool
• Parent survey to parents of pupils participating in the study
• Observation checklist for auditing the school food environment and ethos (food outlets; dining and communal facilities; food consumption behaviours; wider environment within and surrounding the school)
• School food compliance checklist for auditing school food provision (using menus, price lists and observation)
• Canteen sales data (aggregated data on food sales for two (non-continuous) months in the academic year)
• Analysis of key documents from schools e.g. policies; minutes of Governors meetings; catering contract; menus
• Collection of key data from schools e.g. school meal take-up
Data collection tools to measure compliance with the SFS are based on the national SFS checklists for school lunches and school food other than lunch.
Data collection tools to measure implementation of the SFP are based on the national School Food Plan checklist for head teachers, guidance for Governors and the creating a culture and ethos of healthy eating document aimed at school Senior Leadership Teams.
Normalization Process Theory has underpinned the design of staff survey questions relating to the implementation and sustained embedding of the SFS and SFP recommendations

_____
Previous interventions:

This research consists of two stages. In the first stage, a variety of data on SFS and SFP implementation and school and pupil outcomes will be collected at the school and individual pupil level. We will aim to recruit an equal number of schools mandated and not mandated to comply with the SFS, with pupil recruitment occurring from one randomly selected class from each of three different year groups for every school. We will compare outcomes at the school level (food provision and sales, school meal uptake, eating environment, food curriculum, school food culture, and costs related to these factors) and at the individual level (sugar and other dietary intake, dental caries experience) in the two school groups. We will also capture data to explore the implementation and embedding of the SFS, SFP and the influence of the school context on this. We aim to develop a typology of schools relating to school food: provision; environment; culture; curriculum, and the wider school context, which will reflect the degree of implementation of the SFS, SFP and other local initiatives to improve the diets of pupils. In the second stage, a smaller number of case study schools (4-8) will be identified for in-depth qualitative evaluation with school staff (interviews) and pupils (focus groups). Schools will be sampled to ensure inclusion of a range of schools in terms of level of SFS/SFP implementation and institutional characteristics such as school size.

Data will be collected through the following methods/tools:
• Key information survey to head teachers
• Costings survey for completion by senior management
• Survey to key staff and Governors identified by the school to have roles relating to food provision, eating environment, food curriculum, or SFS/SFP implementation (including head teachers, lead catering staff, PHSE leads, teachers with responsibility for the food/cooking curriculum, relevant representatives from the governing body)
• Pupil survey, including a Paediatric Quality of Life measure (CHU-9D) and dental health measures
• Pupil 24 hour recall dietary assessment tool
• Parent survey to parents of pupils participating in the study
• Observation checklist for auditing the school food environment and ethos (food outlets; dining and communal facilities; food consumption behaviours; wider environment within and surrounding the school)
• School food compliance checklist for auditing school food provision (using menus, price lists and observation)
• Canteen sales data (aggregated data on food sales for each school day for the previous 3 months)
• Analysis of key documents from schools e.g. policies; minutes of Governors meetings; catering contract; menus
• Collection of key data from schools e.g. school meal take-up
Data collection tools to measure compliance with the SFS are based on the national SFS checklists for school lunches and school food other than lunch.
Data collection tools to measure implementation of the SFP are based on the national School Food Plan checklist for head teachers, guidance for Governors and the creating a culture and ethos of healthy eating document aimed at school Senior Leadership Teams.
Normalization Process Theory has underpinned the design of staff survey questions relating to the implementation and sustained embedding of the SFS and SFP recommendations.

Intervention type

Other

Phase

Drug names

Primary outcome measure

Intake of free sugars (g) during:
1. School day lunch
2. The full school day
3. A full 24 hour period on a school day
This will be measured cross-sectionally using Intake24, an online self-completion 24-hour dietary recall tool that is based on the multiple pass method. A minimum of one and a maximum of two (non-consecutive) dietary recalls on school days will be undertaken for each pupil participant, with a mean value taken when two recalls are completed.
We will replicate the methods for calculation of free sugars provided by Public Health England with values derived from the UK Nutrient Databank composition codes.

Secondary outcome measures

Dental caries experience. This will be measured cross-sectionally using an online self-completion survey with validated self-report measures taken from the national Child Dental Health Survey.
A range of other dietary measures (in addition to the primary outcome) will also be assessed through the Intake24 tool, administered as described above. Nutrient information will again be retrieved from the UK Nutrient Databank using standardised composition codes. The outcomes are listed below.
1. Percentage of total dietary energy intake from free sugars, and the proportion of participants with free sugar intake providing greater than 5% of total energy intake
2. Number of eating/drinking occasions (excluding plain water)
3. Total energy intake
4. Total fat intake
5. Frequency of consumption of sugar-sweetened beverages
6. Frequency of consumption of sugar and chocolate confectionary
7. Fruit and vegetable consumption and the proportion of participants consuming 5 or more portions of fruit and vegetables per day
8. Fibre intake

Overall trial start date

01/03/2019

Overall trial end date

31/05/2021

Reason abandoned (if study stopped)

Eligibility

Participant inclusion criteria

School inclusion criteria:
1. Secondary phase academies and free schools
2. Located within 14 Local Authority areas in the West Midlands (Birmingham, Coventry, Dudley, Herefordshire, Sandwell, Shropshire, Solihull, Staffordshire, Stoke-on-Trent, Telford and Wrekin, Walsall, Warwickshire, Wolverhampton, Worcestershire)

Pupil inclusion criteria:
1. Pupils from classes in Years 7, 9 and 10

Participant type

Healthy volunteer

Age group

Mixed

Gender

Both

Target number of participants

Total number of participants = 1980; total number of clusters = 44 (45 participants per cluster)

Participant exclusion criteria

Schools:
1. Community schools, voluntary schools, foundation schools, secure and pupil referral units and special or alternative provision schools

Recruitment start date

02/09/2019

Recruitment end date

26/02/2021

Locations

Countries of recruitment

United Kingdom

Trial participating centre

University of Birmingham
Edgbaston
Birmingham
B15 2TT
United Kingdom

Sponsor information

Organisation

University of Birmingham

Sponsor details

Edgbaston
Birmingham
B15 2TT
United Kingdom
0121 414 3344
researchgovernance@contacts.bham.ac.uk

Sponsor type

University/education

Website

https://www.birmingham.ac.uk

Funders

Funder type

Government

Funder name

NIHR Evaluation, Trials and Studies Co-ordinating Centre (NETSCC); Grant Codes: 17/92/39

Alternative name(s)

Funding Body Type

Funding Body Subtype

Location

Results and Publications

Publication and dissemination plan

Findings will be of value at: national level (to inform government school food policy); school level (to enable effective implementation); the public (to support wider understanding of school food policy).
We will produce the following outputs:
1. An updated online dietary assessment tool (Intake24), adapted for use in a culturally diverse population. This will be of future use in nutritional epidemiological or intervention studies in culturally diverse communities.
2. Full study report published in the National Institute for Health Research Journals Library (https://www.journalslibrary.nihr.ac.uk/#/)
3. Open access publications and conference presentations on:
a. The implementation of the school food standards and school food plan in secondary educational settings, including the variation in practice and the barriers and facilitators to implementing such policy
b. The costs associated with implementing school food standards and related policy in secondary educational settings
c. The impact of statutory school food standards on pupils’ dietary intake and dental health
d. The association between the level of implementation and embedding of school food standards and wider school food policy/initiatives, and pupils’ dietary intake and dental health
We will present findings at national and international conferences, and targeted journals will include both general medical journals and specialist journals
4. A short brief for policy audiences.
We will disseminate findings to key national agencies (Department of Health, Department for Education, Public Health England, School Food Alliance, National Association for Headteachers etc.), and to local level organisations (Regional School Commissioners, Local Governors’ Association etc.)
The information gained from the study will also be disseminated at a local level through Local Authorities.
In addition to preparing reports for different agencies, we will engage in the following dissemination activities:
• Communicating study findings through the educational and general press;
• Presenting at meetings held by key networks and organisations
• Producing a summary report for participating schools, pupils and parents, and for the non-participating schools who have expressed an interest

IPD sharing statement:
The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request. After publication of the main findings of the study, the Chief Investigators will consider external requests to gain access to anonymised data. The dataset will be preserved and available for this purpose for a minimum of 10 years following the end of the study. Those requesting data will be asked to provide a brief research proposal including the objectives, timelines, intellectual property rights, and expected outputs, and a Data Sharing Agreement between the University of Birmingham and the requestor will be drawn up. Requestors will be required to acknowledge the research team and funders as a minimum and consider co-authorship of any publications arising from the data. Permission for anonymised data to be shared for the purpose of future academic research will be sought from all participants via the informed consent form.

Intention to publish date

01/07/2021

Participant level data

Available on request

Basic results (scientific)

Publication list

Publication citations

Additional files

Editorial Notes

03/06/2020: The public contact has been updated and the plain English summary has been updated accordingly. 24/04/2020: Due to current public health guidance, recruitment for this study has been paused. 31/12/2019: The interventions were changed. 07/10/2019: Trial’s existence confirmed by National Institute for Health Research (NIHR)