Healthy snacks and nutrition education: School feeding in Lebanon’s public schools

Nanor Karagueuzian is School Feeding and Nutrition Project Manager at International Orthodox Christian Charities (IOCC) Lebanon. She has a BSc in Biology and a BSc in Nutrition.

Background

Why school feeding?

From 2001 to 2008, International Orthodox Christian Charities (IOCC) ran school feeding activities in Lebanon, reaching more than 45,000 school children in 243 public schools. The programme offered a school snack consisting of a sandwich or fortified muffin with milk or juice, and nutrition education. IOCC’s experience with school feeding programmes (SFPs) showed that such interventions contribute to ensuring regular attendance and enrolment through parent motivation – particularly important in the context of the Syrian refugee crisis. Well-designed and effectively implemented SFPs can also alleviate short-term hunger, which in turn helps to increase student concentration and school performance. Additionally, SFPs can address specific micronutrient deficiencies, such as iodine and iron deficiency, that directly affect cognition and contribute to improved eating habits through distribution of healthy snacks and education about healthy eating.

Child malnutrition: a double burden in Lebanon

Both Lebanese and Syrian children have a double burden of nutrition problems, including overweight/obesity and undernutrition, with both micronutrient deficiencies and stunting growth. Vulnerable groups including displaced Syrians, Palestinian refugees, and poor Lebanese demographic groups have seen their food security status worsen since 2013 due to the protracted Syrian crisis.

Stunting rates for children under five years old are reported as 23% in Lebanese children from food insecure households (Ghattas et al 2014) and 20% in Syrian children (Hossain et al 2016). Conversely, in a recent study in Akkar, 37% of Lebanese school-age children and 17% of Syrian refugee children were found to be overweight (Daher et al, 2016). In general, child obesity trends are increasing and even doubling among children.

Piloting a new school feeding programme

In 2016, through funding from the World Food Programme (WFP), IOCC began implementing a pilot SFP in 22 intermediate and primary public schools throughout Lebanon to provide daily snacks for 10,000 Syrian refugee and Lebanese students. The project design aimed to improve children’s school access and retention, as well as bolster their nutrition (although the latter has not been measured.)

The SFP provides healthy baked snacks such as baked thyme rolls and almond muffins, fruit, milk and juice, contributing to the intake of essential macro and micronutrients. In addition, nutrition education sessions are conducted in one 40-minute classroom session per month for every grade. These are delivered by IOCC field officers and the school health educator using educational materials developed in collaboration with WFP. Sessions vary based on age groups but follow the same theme, with students introduced to various topics such as food groups, benefits of eating fruits and vegetables, the importance of physical activity and of eating breakfast, etc. The awareness sessions contributed to improving students’ knowledge, as evidenced by pre and post-tests, which in turn contributed to increased consumption of the milk and snacks provided. The programme also included sessions for parents on healthy eating.

Healthy snacks and healthy eating

IOCC staff (nutrition educators) conducted daily and regular monitoring of the distribution and uptake of school snacks, reporting to the WFP and the Ministry of Education. They noted that students are becoming more aware of the importance of eating healthy snacks at school. Despite the fact that many students are still buying unhealthy items from the school shop, some are bringing healthier items from home, such as fruits and vegetables. IOCC nutrition educators had observed that most of the students in the afternoon school shifts (where the project is implemented) do not buy food items from the canteen if their fruit and milk snack is delivered. Focus group meetings with students and parents found that parents had a preference for cash over food, although a considerable number of parents indicated reliance on their child’s distributed snack and that they had stopped sending food with their children to school in order to use that money for other needs.

Programme continuity and sustainability

Given its success, the SFP programme has been continued, delivering milk and fruit to up to 17,000 students in around 40 public schools all over Lebanon during 2017. WFP is handling the procurement of fruit and milk and ensuring delivery of the snacks to the schools, while IOCC educators provide nutrition education sessions to students of all ages in all 40 targeted public schools. The programme will include a summer camp for children to reinforce key healthy eating messages. There is also great interest in integrating nutrition messages within the existing curricula; to this end, IOCC with WFP is reviewing best practices for nutrition education as well as existing material.

The sustainability of the programme is reliant upon the extent to which the distribution of snacks can be sustained, and the capacity of schools to administer nutrition messages. The current cost per child per day to provide school snacks and education is around US$1, and the programme is viewed as highly beneficial by the Ministry of Education.

Due to the shortage in funding and the overall aid environment, there is a need to diversify funding to ensure sustainability of this initiative.

Challenges and lessons learnt

The main challenge lies in measuring the nutrition-related impact of the programme, since indicators such as anaemia are not included, although some anthropometric measurements are being taken by the Ministry of Education. However, indicators such as enrolment and attendance are being captured, despite the attendance dynamics, with numbers continually changing due to lack of deadlines for registration and dropouts.

Another challenge is ensuring the sustainability of the programme, including the provision of meals and nutrition education. Given the experience that IOCC had ten years ago in the same schools, there is a need to ensure institutional memory in what worked well and what challenges remain. To sustain healthy eating in schools, efforts also need to focus on improving the quality of meals and snacks in schools, which are mostly high in sugar and fat. There was a recent attempt to improve the quality of these snacks through legislation, although steps to enforce this law are still lagging.

References

Daher S, Naja F, Hwalla N, Alameddine M & Jomaa L. (2016). Food and Nutrition Security Status of Syrian Refugees and Their Host Communities in Lebanon: The Case of Akkar.

Ghattas H, Sahyoun N, Sassine A, Barbour J, Seyfert K, Hwalla N & Nord M. (2014). Household food insecurity is associated with childhood stunting in vulnerable populations in Lebanon (1014.3). The FASEB Journal, 28(1 Supplement), 1014-3.

Hossain SM, Leidman E, Kingori J, Al Harun A & Bilukha OO. (2016). Nutritional situation among Syrian refugees hosted in Iraq, Jordan, and Lebanon: cross sectional surveys.

Conflict and Health, 10(1), 26.