To our knowledge this is the first study that explored how school representatives and children perceive the implementation and effects of the Chilean Food Labeling and Advertisement Law (FLAL), as well as the factors influencing its effect. Our results indicate that the Law has little influence on the nutrition and activity behavior of primary school children and their families in Magallanes. Children know about healthy and unhealthy food, but this knowledge contrasts with their dietary habits and personal preferences. Although they know the meaning of the new FoPL, they do not adapt their food choices. The parents’ lacking problem awareness regarding childhood obesity, unhealthy nutrition, lacking physical activity and excessive screen time counteract the public health objectives set with the FLAL implementation. Parents’ options appear to be severely limited by unfavorable working conditions, however. Schools on the other hand are overloaded with the different demands placed on them and with the lack of coordination between authorities. The findings of this study confirm that without changes in the family, the community and the working environment, it will be difficult to decrease childhood obesity in peripheral regions in Chile.
School environment
The importance of schools in preventing childhood obesity has been acknowledged by education stakeholders all over the world [30,31,32,33]. School programs have been successful in preventing childhood obesity in different contexts, especially if they include interventions combining diet and physical activity [34,35,36,37]. The FLAL mandates Chilean schools to promote nutrition education and physical activity. The current study found that schools in peripheral regions are making some efforts to improve their students’ dietary and physical activity habits. The focus seems to lie on written nutrition information, a reward system for healthy snacks and the provision of fitness equipment. However, teachers lack adequate pedagogical tools to teach about healthy lifestyle in an effective and sustainable way. Kain et al. found that expert support was crucial for a successful school-based intervention in Chile [38]. The lack of trained staff being able to facilitate fun and engaging physical activities for students with differing fitness levels was also identified as a barrier to physical activity at public schools in Australia [39]. This matches our findings. Nutrition-specific training, on the other hand, was shown to enable classroom teachers to play a key role in preventing overweight in their students [40]. Furthermore, for effective and sustainable school programs, curricula need to be revised thoroughly. In a meta-synthesis of qualitative studies, school stakeholders considered it important to integrate healthy eating messages across the whole curriculum [32]. In their recent research, Correa et al. showed how the FLAL-promoting role of Chilean schools was lost when they were closed during the pandemic, especially in more vulnerable population groups [41]. A systematic review and meta-analysis showed that nutrition education programs being delivered across two or more traditional primary school subjects and using experiential learning approaches proved to have the biggest impact on primary school children’s nutritional knowledge and behavior [42].
Previous studies in the school setting have shown that children expect their teachers and other school staff to be role models for a healthy lifestyle [30, 32, 33, 43]. Interestingly, this was mentioned neither by students nor the school staff in the present study. A possible explanation thereof was that as many of the staff were overweight themselves, they may have been aware of the inconsistent message they would have been sending to their students.
As a further contradiction, the current study found that on the one hand children receive nutritional education, while on the other hand unhealthy food is consumed on special occasions and for celebrations. The latter is consistent with research carried out in California, which reported that a significant amount of unhealthy foods and drinks are brought to schools for classroom rewards, celebrations and fundraising [44]. This practice might create a strong association between special events and unhealthy foods in children. Furthermore, Clarke et al. showed that children tend to associate foods permitted by and provided by schools with healthy nutrition [32], which might exacerbate the contradiction mentioned above.
School representatives also perceived difficulties engaging parents in obesity prevention efforts. Insufficient parental involvement in healthy lifestyle interventions in schools has also been described elsewhere, in Chile [38] and abroad [32]. At the same time, education stakeholders in other studies highlight the importance of educating and empowering parents to make better lifestyle choices [32, 39]. Clarke et al. suggest that a conflict exists between schools and parents about whose responsibility it is to ensure a healthy lifestyle for children [32]. Our findings support this position from the point of view of school directors and staff.
The Chilean FLAL prohibits the sale of products high in critical nutrients in schools. Unhealthy school meals were perceived as a major obstacle to healthy nutrition by education stakeholders in different studies [32, 39]. Our findings indicate, however, that while the involved schools have started to offer healthier school lunches as a response to the Law, the students seem to resist the adaptations. Indeed, in a qualitative systematic review, children’s preference for unhealthy food and their rejection of new, healthier foods at school was identified as a barrier in the prevention of childhood obesity [32].
School kiosks are a further focus of FLAL, as they are not allowed to sell products with warning labels anymore. As a result, there was a substantial reduction in the availability of foods high in calories, sugar and saturated fat in school kiosks in the capital [11]. Our study suggests, however, that the Law may also have undesired side-effects, namely the closing of school kiosks. This affects the livelihoods of kiosk operators, while unhealthy snacks continue to be consumed at schools because the regulation of unhealthy foods does not include foods brought from home and bought elsewhere. In the capital, schools have started to restrict snacks brought from home according to the number of FoPL [13]. Nevertheless, approaches based on restrictions might not promote a true change in awareness and lead to compensatory overconsumption of unhealthy foods outside of school. A study from the UK found that parents had diverging opinions about whether school policies should comprise rules for healthy snacks [32]. In Portuguese schools a healthy snack policy was shown to encourage the consumption of fruits, however [45]. Interestingly, in the present study the only kiosk that still operated was selling healthy foods successfully, showing that a healthy offer may influence students’ snack choice. Further research is necessary to identify promotors for such positive examples, however. Lowering prices for healthy foods and menus could be an approach, as family financial restraints and high prices for healthier options at schools may constitute barriers to healthy eating [32].
While different stakeholders developed FLAL [9], this study calls attention to the lack of coordination between governmental institutions and the lack of stakeholder involvement in its implementation, monitoring and evaluation. This may have lead to a demotivation of school staff. A lack of government coordination of school-based obesity prevention programs has also been reported by stakeholders from other countries [32]. In contrast, a study including primary school headteachers in the UK highlighted their wish to be actively involved in public health decision-making [30].
Finally, in Chile and elsewhere, the critical period for becoming overweight in childhood is before the age of 6 years [2, 46]. In fact, although this study did not assess BMI, most children in the participating primary schools were observed to be overweight or obese. Therefore, further preventive interventions might be necessary during the toddler and preschool years.
In summary, to better implement childhood obesity prevention measures like those established by FLAL in schools, policy makers should ensure the involvement of school stakeholders from the beginning. They should promote better coordination between governmental entities which outlasts changes in the ruling party. To transform children’s lifestyles, curricula will have to be revised to mainstream sound nutrition and healthy lifestyle education. These should lead to active student involvement, the acquisition of new skills and the exposure to new foods. A precondition must be the training of teachers, improving their skills to involve students and parents and empowering them to be role models for their students.
Home environment
The home environment is known to be a key factor in the promotion of a healthy lifestyle, as described in the literature [47]. In qualitative studies, different key stakeholders from the school environment have described the parents’ decisive influence on their child’s lifestyle [30, 32]. The results of the present study revealed a complex interaction between the parents’ lack of problem awareness regarding childhood obesity, lack of time due to high workload and an unhealthy lifestyle within the family. Firstly, most parents were not aware of their children’s unhealthy nutritional status, a phenomenon which has been reported previously for Magallanes and populations in the US and elsewhere (e.g. [47,48,49,50]). It is particularly common among low-income families [51]. Unconscious parents make it hard for governments to succeed with any approach.
Secondly, easy access to junk food at home was identified as a further determinant of childhood obesity in Magallanes. This is in line with the literature, which shows that home availability of healthy and unhealthy foods is positively associated with its intake [52, 53]. In a qualitative study with low-income Latino adolescents in the US, parents were described as a barrier to healthier dietary habits through nutrient-dense family meals and the purchase of high-calorie low-nutrients foods [54]. Parents in Portugal on the other hand used reduced availability of certain sugar-containing foods at home as a strategy to limit their children’s intake of these foods. They expressed difficulties in identifying sugar in foods, however [45]. Our results suggest a high intake of SBBs at home, in line with a study carried out 2016 in Santiago, Chile [7]. Chung et al. found that social norms and expectations regarding SBBs were important factors influencing parents’ and grandparents’ decisions to allow their consumption in pre-school children in Australia [55]. As high levels of SBB are consumed in Chile, it might be difficult even for conscious parents to withstand this social norm.
The results of the present study also reveal that parents are not perceived to be good role models for a healthy lifestyle by children and school staff. Parental role modeling was identified by children, adolescents and other stakeholders in schools as key components leading to healthier student diets and increased physical activity, however [31,32,33, 54]. To what extent our findings are the result of parents’ limited awareness of how their behavior shapes their children’s habits, as Marilia suggests [45], cannot be answered based on our findings.
Our findings further reveal that families consider healthy foods to be too expensive. Since our data were collected, this aspect may have been exacerbated by the pandemic, particularly for mothers with a low socioeconomic status (SES), as FDGs in the capital of Santiago reveal [41]. This underlines the importance for policy makers to also focus on the home environment and on improving the accessibility of nutrient-dense foods.
Thirdly, the present study highlights how parents seem to ignore the impact of high levels of screen time on health or be unable to provide alternatives due to difficult working conditions. Heitzinger et al. [48] showed a correlation between screen time and childhood overweight and obesity in Magallanes, while a systematic review confirmed associations between screen time and greater obesity, higher energy intake, poorer dietary quality and quality of life in children and adolescents [56]. Media consumption further correlates with children’s exposure to commercials [10, 57]. The FLAL, in its first phase, did not restrict TV advertising during all times of the day and only banned ads directed at children based on advertising techniques or the program. Sports-related marketing, shown to lead to unhealthy food consumption patterns in children and youth [58], was therefore still allowed. Moreover, our findings reveal that in the study region, caretakers do not control children’s media access and choice of programs, possibly limiting the effects of the law in this phase to some extent. Alruwaily et al. found, for instance, that child influencers on YouTube mainly promote unhealthy foods [59]. Therefore, limiting screen time in children and having a certain control over the content is a further crucial step in trying to resolve the childhood obesity problematic. In Chile and other countries with strong public health policy measures, this seems not to have been tackled so far. Parental awareness needs to be created, so they serve as role models: By reducing their own screen time, they have a positive influence on their children’s screen-based behavior [60]. At the same time, parents need to have more favorable working conditions, so they have alternatives to leaving their children alone or with inappropriate childcare.
In summary, a higher problem awareness and the importance of setting an example as a parent seem to be key factors that might influence their own behavior regarding nutrition, physical activity and screen-time. Parents themselves are influenced by their community and its environment, however. Interventions aiming at the promotion of a healthy lifestyle should therefore be reframed to involve schools, families and local communities for maximum impact [35, 37]. Healthy foods should be made affordable for all families, especially among vulnerable population groups. Furthermore, in our study region, long working hours present an obstacle to any family or community-based program and need to be considered accordingly.
Children’s awareness and behavior
We found that children knew the black FoP warning labels, which allowed them to differentiate foods high in sugar, saturated fat and sodium. While Arrua et al. showed that warning signs significantly discouraged Uruguayan children’s choice in both product categories in an experimental design [61], our findings do not suggest that labels influenced children’s food choices in everyday life. This is in line with other studies which showed that children understood different food or menu labelling systems, but that the impact on dietary habits seemed to be limited in real-world studies [62, 63]. In our study, desensitization might play a role. In fact, Chilean mothers expressed a certain label fatigue five years after the implementation of the FLAL [41]. The warning labels seem to be especially important for foods formerly perceived to be “healthy” by children and their parents, however [13, 41, 61, 64].
The approach chosen in Chile, which combines FoPL with nutrition education, had some impact on children’s nutrition knowledge. In line with other studies carried out in Chile, it also made them agents of change in some households, by requesting healthier snacks for instance [13]. In contrast, FoP labels without educational strategies did not influence healthfulness perception of children 6–9 years of age [64]. This underlines the importance of the combination of measures. However, as mentioned above, schools’ nutrition education measures in the study region could be improved in quantity and quality.
In line with this study, literature shows that for primary school children, knowledge does not necessarily translate into healthy behaviors. Aspects like social acceptability, eating context, texture, pleasure and versatility influence their food choices [14], while other studies underline the importance of taste on preschooler and adolescent food selection [65].
Our results reveal the narrow range of foods children in the study region are exposed to at home, possibly partially due to environmental factors like high prices of fresh foods in this remote region. This may lead to the reported rejection of all unfamiliar or unpopular foods at school. There is a vast body of literature underlining how import the familiarity of foods is for child acceptance, and how it is shaped in the first years of life (e.g. [51, 66]). Children in our study region are being exposed to a low dietary diversity, especially regarding fruit and vegetables. They are being conditioned to prefer energy-dense and nutrient poor foods. Therefore, dietary interventions at schools may set on too late. Children need to be exposed to new or disliked foods repeatedly at an early age, by tasting them in a supportive environment [51]. One promising way would be to include experiential learning approaches [67] and hands-on experiences like cooking education [68]. That way they may also be repeatedly exposed to new foods and be more likely to accept them, since they are involved in their preparation.
Community environment
Regarding leisure time activities, the results of the present study suggest that children consciously opt for screen-based activities, partially because of scarce alternatives. Neighborhood safety issues were barriers to physical activity for children and adolescents mentioned by headteachers, parents and students in other contexts [30, 31]. Additionally, a higher probability of children being active has been reported in favorable community environments (e.g. lower street connectivity, higher safety from crime, walking/cycling facilities, suitable play areas) [57, 69]. In our findings, a further barrier to physical activity imposed by parents was the cold weather. School staff and parents in other contexts, however, opined that playing outside despite the cold weather helps to build self-confidence in children [33]. All these factors supporting physical activity in children are lacking in our study area. In summary, children in our study region are very much influenced by their families, schools and their environment, as elsewhere. The fact that children are left unsupervised for many hours a week is a big problem. For policy makers, considering the establishment of affordable after-school childcare, where different activities for children are offered, would help limit childrens’ screen-time, while enhancing their possibility to be physically and mentally active. Furthermore, it would create another formal structure in which to promote a healthy lifestyle.
Limitations
We are aware that our research has several limitations. The first is that only schools pertaining to the Health Promoting Educational Establishments participated in the study on a voluntary basis. Their accomplishments had been evaluated very well by the government. Thus, we might have a positive selection bias, not including schools in our sample which face the biggest difficulties in promoting a healthy lifestyle. Moreover, no schools attended by children with a high or a low SES were included in the study, and that the number of formal interviews with school directors is low. A higher number of interviews with representatives from different types of schools might have revealed interesting disparities. The second limitation is that we did not interview the parents of the children, who could have added a “missing piece” regarding the home environment. Moreover, the time span between the implementation of FLAL and data collection may have been too short to identify a notable change in awareness and lifestyle habits. The qualitative design of the study further does not allow for the identification of causal relationships.
This study was carried out in Magallanes, a remote region of the country. Although the results cannot be generalized to other regions in Chile, they may indicate some of the special challenges peripheral regions in Chile face.
