New Regulations for Foods Offered to School Children in Chile : Barriers to Implementation

Objective: To prevent childhood obesity, the Chilean government has recently implemented food regulation laws that apply to schools. This paper reviews the literature regarding the challenges in successfully integrating policies to regulate foods offered in schools. In addition, to understand some of the potential implementation barriers, a survey was conducted to evaluate how well food regulation laws were understood and implemented in Chilean schools. Methodology: A narrative literature review was conducted regarding food regulation policies in Chilean schools and potential barriers to implementation. This informed a subsequent descriptive, qualitative survey which was conducted in the Valparaíso region of Chile to examine knowledge, practices, and potential barriers to implementation of the new regulations. Twelve randomly-selected school food kiosk owners completed a survey and structured interview. Visual observations were also performed at each food kiosk. Content analysis identified trends in food items sold and determined the depth of understanding kiosk owners have of a specific new food law, "La Composición Nutricional de los Alimentos y Su Publicidad (20.606)." Key Results: 7 articles in Spanish and 10 in English were reviewed. The literature review revealed that unhealthful food options are readily available to Chilean students in school kiosks. The results of the survey and interview indicated that the school kiosk owners surveyed have a general understanding of the food law. 10 out of 12, however, were unsure of the law's exact contents. Unhealthful food options, inconsistent with regulation 20.606 were observed in all 12 visited kiosks. Conclusion: Evidence from a literature review and the survey findings confirm that unhealthful foods persist in Chilean schools, despite government food regulations. Although the majority of the school kiosk owners acknowledge law 20.606, most lack an understanding of its exact contents and their role in promoting healthier foods in schools. Further education of vendors and school administrators is needed to enhance compliance with the new Chilean food regulations. DOI : 10.14302/issn.2379-7835.ijn-14-615 Corresponding Author: Katherine Prochownik, Department of Public Health Studies, Johns Hopkins University, kprocho1@jhu.edu Running Title: Chilean Food Regulations for School Children


Introduction
Health conditions in Chile have changed drastically over the last 50 years due to demographic, epidemiologic, and nutritional transitions. The proportion of undernourished children in Chile under the age of 6 decreased from 37% to 2.9% during the period from 1960-2000. 1 Today, excessive childhood weight gain is a grave concern in Chile. According to the World Health Organization (WHO), the prevalence of child obesity among primary school children in Chile increased from 6.5% in 1987 to 17% in 2000 for boys and from 7.8 to 18.6% for girls. 2 The increase in obesity is associated with the developing world. A sedentary lifestyle, changes in diet, and poor eating habits are the three largest causes of obesity in the country. 3 According to the Encuesta Nacional de Salud (ENS), 39% of those older than 15 years are overweight and 300,000 people suffer from morbid obesity in Chile. 3 The Organización para la Cooperación y Desarrollo Economico (OCDE) says that Chile "es el sexto país con más obesidad infantil," 3  For students, available food in kiosks in schools is one of the factors responsible for this problem. In an effort to improve foods available in schools, the Chilean government has implemented regulations to provide healthier food options for students in school settings and prevent childhood obesity. In 2012, the Chilean government approved the law, "La Composición Nutricional de los Alimentos y Su Publicidad (20.606) or "The Nutritional Food Composition Law and Its Publicity," which requires kiosks in schools or near educational facilities to carry food that the Ministry of Health in Chile establishes as safe for consumption. 5 Unhealthy items for consumption include packaged foods, such as chips and candy bars. Healthier foods are those lower in salt, sugar, and fat such as fruit, low fat yogurt, some cereal and granola bars, and low calorie drinks. 6 To assess the impact of this new regulation and potential barriers to its implementation, we conducted a literature review of the challenges in successfully achieving integration of food regulation policies for childhood nutrition. Results of a survey, interview, and structured observations of school food kiosks were used to assess how well food regulation laws were understood and implemented by kiosk owners in schools in Chile.

Narrative Literature Review
Two sequential literature reviews were conducted, one in Spanish and one in English, using Proquest, EbscoHost, Chile's Health Ministry website and PubMed. Search criteria included key words of "Chile," "La Composición Nutricional de los Alimentos y Su Publicidad," "food regulation," "children," "obesity," and "nutrition." These words were used for articles published in English and in Spanish. A total of 3,789 were identified, but only 13 were included as part of this review. These papers represented: 13 studies, 3 policy papers, and a copy of law 20.606 was also retrieved.
Criteria for selection included: 17 articles published after the date of 1988, and articles relevant to the topic of student nutrition. For the purpose of the paper, "students" refers to both school-age children and adolescents (including university students).
Seven articles in Spanish and 10 articles in English were identified for the narrative review. The overarching theme of these articles showed that modernization in Chile has resulted in more unhealthy food options being integrated into children's diet. Results from the literature review shows that unhealthy food options are readily available to children in school kiosks. 6,10 The study concluded that the food products that the students bought with their money were generally packaged products with much sugar, fat, and salt; these foods have a high energetic density and are often more appealing when they are available to students in schools. 10,11 For example, 99% of the children studied said they had money to buy food products at their school, and 90% of them chose to buy unhealthful items (68.1% bought sweet or salty foods, 17.2% sugary soda drinks, and 3.7% fast food). 11 These food options can result in health problems. Rates of children being obese or overweight have increased dramatically over the years. 2,8 Some articles have discussed the importance of the regulation of food marketing to children and how to monitor the enforcement of these foods. 8,9 The study by Bustos advocated for incorporating strategies to promote healthful food options inside educational facilities. One study found an increase in 6 year-old children's rates of overweight and obesity between 1986 and 2000. Boys rates increased by 12% (to 26%) and girls, by 14% (to 27%). 2,8 This article discusses the importance of the regulation of food marketing to children, what and how to regulate food, and how to monitor the enforcement of these food laws. 8,9 Chilean health food law 20.606 addresses regulating certain unhealthy food items, advertising ingredients properly on nutrition labels, bans certain foods high in salt, sugar or fat from being sold in the store, and prohibits food items to be sold with toys, or incentives to purchase these items. 8 Despite this law, previous studies such as these demonstrated that unhealthful food options continue to be readily available for students to purchase in schools. The challenges in successfully integrating food regulation policy are due to a number of factors in Chile. 8 Chile, which is considered a developing country, currently has limited resources to successfully track the law's implementation. Food restrictions in one country could potentially direct advertisers to relocate their marketing elsewhere. 8,12 Previous studies conclude that citizens, particularly the parents of the students, should have a larger role in enforcing healthier foods in schools. One concludes that monitoring of food regulation should be a responsibility of both the government and the people. 13

Experimental Procedure
A narrative literature review of the food regulation policies for childhood nutrition in Chilean schools and barriers to their implementation was conducted, using Pub Med, EbscoHost, and Proquest. A mix-method descriptive, qualitative study was conducted in the Valparaíso Region of Chile to examine knowledge of new school food regulations and barriers to its implementation. Qualitative content analysis techniques were conducted and combined with descriptive analysis.
Visual observations of the food kiosks were also made. that students like to purchase the most." Pattern recognition was employed to detect common themes.

Survey of Schools
Pattern recognition implies seeing something over and over again in one case or across a selection of cases. 7 Results were crosschecked for inter-rater reliability.
Themes were developed for the open-ended questions from the survey and for the 4 interview questions. All completed surveys and interviews were kept in a secured, locked cabinet.
Visual observations were also made of food items sold at each participating school's food kiosk to confirm the owners' self-reported information. Photos were also taken at that time (see Figure 1 for examples).

Study
Results from the close-ended, multiple-choice items of the survey revealed trends among kiosk owners regarding food regulation for students inside of schools.  Results collected from the interviews were organized into common themes ( The results of the survey and interview demonstrate that school kiosk owners have a general understanding of the food law. When asked to explain why they agreed or disagreed with the law, many owners responded that they "did not know" or "did not have a reason." Examples of the visual observations made of the food items sold at the school kiosks can be seen in photographs 1 and 2. Many items would be categorized as "unhealthful foods." Overall, the photos confirmed the kiosk owners' responses.

Discussion
The evidence from the literature review and the study findings illustrate the need to improve outcomes by promoting an understanding of the health food laws and regulation inside of schools, as well as through modifying school children's behavior and eating habits. Only packaged foods 10 We have tea, coffee, sandwiches (cheese/ham), lemon pie, drinks, cereal bars, juice 11 Crackers, cereal bars, sweets, chocolate 12 We have all kinds of products, but everything is packaged. Sweets, chocolates, crackers, drinks, coffee, tea, empanadas, etc.
Our findings suggest that educational campaigns must target kiosk owners as well as the students, their families and school administrators. Composition of Food and its Advertisement, also known as Super8," 10 of the 12 participants indicated they did.
The owners who reported knowing of the law were also familiar with what the law mandated, namely, to regulate the advertising of 'junk' food in school food kiosks, and to promote healthier foods for students in schools. 5 Despite the majority of the kiosk owners demonstrating a general understanding about the law, many continued to sell unhealthful foods. In the interviews, the participants said that the food products "are not healthy because of the high sugar and salt, and they don't help anybody", and that "it is understood that  16 Ecological models consider the connection between the individual (e.g., students) and their environment (e.g., schools). 16 These models propose that behaviors (e.g., eating habits and food selection) are influenced by the intrapersonal, sociocultural, policy, and physical-environmental factors. 16 Regulatory and policy-making actions have the potential to affect health behaviors; policies are sociocultural influences that can alter physical environments (e.g., schools and kiosks). 16