Hyska J. Improving Nutrition and Health Among Albanian School Children (Policy brief). SEEJPH 2022, posted: 06 July 2022. DOI: 10.11576/seejph-5709 P a g e 1 | 9 POLICY BRIEF Improving nutrition and health among Albanian schoolchildren Jolanda Hyska1,2 1 Department of Public Health, Faculty of Medicine, University of Medicine, Tirana, Albania; 2 Department of Food and Nutrition, Institute of Public Health, Tirana, Albania. Corresponding author: Jolanda Hyska; Address: Rr. Aleksander Moisiu, No. 88, Tirana, Albania; Telephone: +355672052972; Email: lhyska@yahoo.it Hyska J. Improving Nutrition and Health Among Albanian School Children (Policy brief). SEEJPH 2022, posted: 06 July 2022. DOI: 10.11576/seejph-5709 P a g e 2 | 9 Abstract Nutrition is a critical part of health and development. Better nutrition is related to improved infant, child and maternal health, stronger immune systems, safer pregnancy and childbirth, lower risk of non-communicable diseases and longevity. Prevention of malnutrition among adolescents and improvement of the nutritional status of children are considered important targets in Albanian health system efforts to achieve benefits in the population’s health. Key approaches for improving nutritional status and nutrition-related knowledge, attitude and practices among school-children in Albania (based on the main findings from the in-depth analysis of three nationwide surveys conducted in Albania between 2015 and 2018 on nutritional status and nutrition-related knowledge, attitudes and practices among school- children in Albania and other findings) consist ofprevention and promotion from an early age, focus on knowledge, attitudes and practices, limit exposure to less healthy foods and increase parental awareness and involvement. These studies findings and respective recommendations can support the development of a National School Food and Nutrition Education programme in Albania. While there is evidence for the need to intervene at the national level, the stratified analysis at regional and district levels points to the need for the design and implementation of specific interventions at the local level. It is also very crucial to strengthen and improve anthropometric nutrition and surveillance systems for nutritional risk factors for children and adolescents, and use the data obtained by these systems effectively and appropriately. Keywords: Albania, attitude, nutrition, nutritional status, school-age children. Conflicts of interest: None declared. Acknowledgment: This document is based on the In-depth analysis of three nationwide surveys conducted recently in Albania regarding ‘Nutritional Status and Nutrition-Related Knowledge, Attitude and Practices Among School-Children in Albania”carried out by Ass. Prof Jolanda Hyska in the framework of the Project "Improving the nutritional status of children in schools in Albania", a project developed by the Albanian Center for Economic Research (ACER), funded by UNICEF Albania. The views and opinions expressed in this publication are those of the author and do not necessarily represent the official opinion of ACER nor of UNICEF. Hyska J. Improving Nutrition and Health Among Albanian School Children (Policy brief). SEEJPH 2022, posted: 06 July 2022. DOI: 10.11576/seejph-5709 P a g e 3 | 9 The Impact of nutrition on health Nutrition is a critical part of health and development. Better nutrition is related to improved infant, child and maternal health, stronger immune systems, safer pregnancy and childbirth, lower risk of non- communicable diseases (such as diabetes and cardiovascular disease), and longevity (1). Two of the major challenges of our times are malnutrition in all its forms and the degradation of environmental and natural resources. Both are happening at an accelerated pace (2). The State of Food Security and Nutrition in the World Report (SOFI 2019) shows that the number of the undernourished has been slowly increasing for several years in a row, and at the same time the number of overweight and obese people all over the world is increasing at an alarming rate. Poor diets are a major contributory factor to the rising prevalence of malnutrition in all its forms. Moreover, unhealthy diets and malnutrition are among the top ten risk factors contributing to the global burden of disease. In addition, the way we produce and consume food is taking a toll on the environment and natural resource base. Food production accounts for the use of 48 percent and 70 percent of land and fresh water resources respectively at the global level (2). The health effects of poor nutritional practices and habits are manifested from early childhood and have implications for health status in adulthood (WHO, 2018). It is well established that poor nutrition for children has negative effects for their health, growth and development, school performance and, consequently, for their productivity in adulthood (3). Both under- nutrition and overweight and obesity among children reflect poor nutritional practices. Adequate and healthy nutrition is essential for children to reach their full potential at every stage of their development. What children eat today and their understanding of how food affects their health are crucial for tackling the problem of obesity (4) and other health problems resulting from poor dietary practices. Prevention of malnutrition among adolescents and improvement of the nutritional status of children are considered important targets in Albanian health system efforts to achieve benefits in the population’s health by increasing the proportion of people who have access to adequate, safe and nutrient-rich food, eat a balanced diet and maintain a healthy body weight (5). As the linkages between childhood nutrition and health, and development and productivity in adulthood have become increasingly evident, it is clear that addressing malnutrition is central to improving individual development and well-being, improving the overall economic and social development of families and communities and supporting societal development (6). Given the high human and economic returns that investments in child and adolescent nutrition bring and the growing recognition of the right to adequate food, the global commitment to addressing malnutrition has intensified. It now features prominently on the international agenda, including the Sustainable Development Goals (SDGs), the Rome Declaration and Framework for Action adopted by the Second International Conference on Nutrition (ICN2), and the UN Decade of Action on Nutrition 2016–2025, among others (7,8). The role of school-based food and nutrition education More and more, schools have become a focus for policies and programmes that aim to address malnutrition and other health problems related to poor nutrition and unhealthy diets. Schools reach the majority of school-age children (9) in non-crisis contexts over a prolonged period of time, and can extend benefits to families, the Hyska J. Improving Nutrition and Health Among Albanian School Children (Policy brief). SEEJPH 2022, posted: 06 July 2022. DOI: 10.11576/seejph-5709 P a g e 4 | 9 whole school community and to the surrounding community. School-based food and nutrition education (SFNE) consists of coherent and mutually- reinforcing educational strategies and learning activities which, supported by a healthy food environment, help schoolchildren, adolescents and their communities improve their food choices and diets. When implemented successfully, SFNE helps schoolchildren, along with school staff and parents, achieve lasting improvements in their diets, food practices, outlooks and knowledge, build their capacity to change and adapt to external change, and to pass on their learning to others. Essential elements of SFNE are: 1) a healthy food environment and safe and nutritious school food; 2) food and nutrition education; 3) inclusive food procurement (including local production) and nutrition- sensitive value chains; and 4) enabling policy, legal and institutional environments. Successful SFNE involves a holistic approach with explicit linkages, interactions and coherence between each of these elements. School food and nutrition approach is a direct response to the international call for improved nutrition and food systems, and supports SDGs 2 (Zero Hunger), 3 (Good Health and Well-being), 4 (Quality Education), 5 (Gender Equality) and 12 (Responsible Consumption and Production) (10). SFNE also plays an important role in complementing global efforts to improve food environments, and in empowering children and adolescents to become active participants and future leaders in shaping food systems that are better able to deliver healthy and sustainable diets. KEY APPROACHES FOR IMPROVING NUTRITIONAL STATUS AND NUTRITION- RELATED KNOWLEDGE, ATTITUDE AND PRACTICES AMONG SCHOOL-CHILDREN IN ALBANIA (Based on the main findings from the in- depth analysis of three nationwide surveys conducted in Albania between 2015 and 2018 on nutritional status and nutrition- related knowledge, attitudes and practices among school-children in Albania and other findings) (11,12) 1. Prevention and promotion from an early age Prevention is the best cost–benefit method to control overweight and obesity in children and thus future adults. Children are considered a priority population for prevention strategies because weight loss is difficult for adults and there are more interventions available for children than for adults. Some of these potential strategies for intervention in children can be implemented by targeting schools as a natural development zone for nutrition education (13).  Prevention can be achieved through various interventions that target the school environment, physical activity and diet, such as: high importance of physical activity; healthy foods in cafeteria, ban on sweetened beverages and energy- dense junk food; training of teachers regarding health education; incorporation of more knowledge about nutrition and physical activity and nutrition-related diseases in school curriculum, etc. (14).  As eating patterns and dietary habits are established early in life, and behaviour change later in life is more difficult, it is most effective to help children form good habits at an early age by improving their everyday skills in making good food choices, planning and preparing healthful meals, protecting the quality and safety of the foods they eat and in establishing healthful Hyska J. Improving Nutrition and Health Among Albanian School Children (Policy brief). SEEJPH 2022, posted: 06 July 2022. DOI: 10.11576/seejph-5709 P a g e 5 | 9 personal habits and lifestyles, based on activity-approaches with less emphasis on reading and more on learning by doing, with a variety of activities, exercises, investigations and analysis that can be done in groups or individually (12). Data showed that: - Two-thirds of children say they know only an average amount or less about food, health and nutrition. - Two out of five children (40%) are more concerned about how much they eat than what kind of food they eat. - Only one-third (36.7%) of children believe it is important for their growth and health for them to have three main meals and in between snacks. - Only one in three children believes that without breakfast they “can’t learn as much”. - Only about half of children indicate meat and chicken as very good foods and one-third are uncertain about fat intake and health. - About half of the children (47%), believe also that skipping breakfast can result in being less able to follow the lessons.  In Albania a holistic and integrated approach is imperative to develop health promotion programs for children in the fight against childhood obesity, which aim to change behaviour rather than simply providing information alone (which often has little impact on what people do) as: - the prevalence of overweight and obesity is still a public health problem in the country, with a rising trend among children 6-15 years old (from 21.7% in 2016 to 27.9% in 2018); - overweight/obesity level is about 30% lower among children with good knowledge compared with children who exhibited poor knowledge about food, health and nutrition, the likelihood of consuming breakfast was 30% higher among normal weight children compared to their overweight/obese counterparts; - this prevalence is higher in children from urban areas compared with rural areas, and among boys compared to the girls; - moreover, obesity is a multifactorial disease where preventive interventions should address all causal factors. 2. Focus on knowledge, attitudes and practices Good nutrition education helps children to become “nutritionally literate”. Children educated in this way will come to know how to make good food- and lifestyle- choices and develop good eating habits for themselves and for others. Nutritionally literate adults will know where to get answers to questions about food, diet and health. The value of nutrition education to the long-term development of a society is plain to see (15). Nutrition education has the best chance of making a real impact if it involves action, direct experience and participation by the children; stimulates all their faculties; takes learning outside the classroom into real-life situations (15).  There is a need to promote healthy nutrition in school-aged children by focusing on behaviour, in addition to knowledge, especially regarding the consumption of those foods most important for children’s growth and development. - While virtually all children recognize the importance of breakfast, on the measurement day only three out of five of Hyska J. Improving Nutrition and Health Among Albanian School Children (Policy brief). SEEJPH 2022, posted: 06 July 2022. DOI: 10.11576/seejph-5709 P a g e 6 | 9 children reported they had eaten breakfast. Breakfast consumption in children (self- reported) is lower than the other main meals (71%, compared with 89% for lunch and 87% for dinner). - There is a considerable proportion of children who do not consume milk on a daily basis, with a range 47%-65% (11). - Children’s positive attitudes toward healthy foods, healthy nutritional habits and health benefits do not often correlate with their nutritional practices (behaviours); They seem to know the benefits of eating fresh fruits and vegetables, with almost all of them saying that fruit is very good for their health (92%), actually less than three in five children consume fruits on a daily basis whereas vegetable consumption is far too lower (with a range: 20%- 30% in all three surveys). - The TV is switched on during meals every day in 43% of the families. One third of children eats their dinner while watching TV, using a mobile phone, or tablet (37%) every day, or almost every day. 3. Limit exposure to less healthy foods Food marketing has a huge effect on children’s health. Limiting the advertising of unhealthy foods to the maximum possible has been assessed as a very effective intervention to improve the food environment, promote good eating habits and reduce the problems caused by malnutrition.  It is important to assess the need for specific arrangements related to the advertising of unhealthy foods and to make recommendations that adequately address the prohibition of advertising of unhealthy food in the premises of basic education educational institutions, as: - Children in Albania are a target group from unhealthy food advertisements (12). Even some public schools (both urban and rural) allow some form of food and beverage advertisements in the school building or on the school grounds. - Although the legal framework in force has widely regulated the issue of food marketing, the standard regulation lacks regulations dedicated to food and nutrition of children (12).  It is crucial that schools provide food for children at school and control foods that are being bought by children to eat at school, limit exposure to less healthy food options, improve the nutritional quality of any foods sold in schools’ environments, and ensure that the healthy option is always available and the easier option, as: - Only one in three children (33%) takes food from home to eat at school every day or almost every day, much more frequent among children in the 4th grade and in those with a better family income. - More than half of the children (58%) carry money to school for buying food, beverages, or lunch every day or almost every day, and one-fifth (22%) sometimes do; - Most schools have some kind of food shop, cafeteria or vending machine in the school vicinity or on the premises, from which adults and children can purchase foods. However, the quality of the foods offered is poor, consisting primarily of candies, Hyska J. Improving Nutrition and Health Among Albanian School Children (Policy brief). SEEJPH 2022, posted: 06 July 2022. DOI: 10.11576/seejph-5709 P a g e 7 | 9 chips, chocolates, or peanuts (81%), pies, pizza, or sandwiches (78%), and sweetened or fizzy beverages (73%). Very few of these vendors offer fresh fruit, vegetables, milk or yoghurt. - About half of schools do not provide children with access to drinking water, either free or for purchase. - Very few schools provide some form of meal or snack. Only about 5% of parents confirm that their children eat food provided by the school. 4. Increase parental awareness and involvement  It will be important to increase parental awareness and involvement that enables sustainable changes in support of healthy lifestyles, which could make poor nutrition prevention interventions more effective as: - There were a significant association between breakfast consumption and the relationship with caregiver’s education: children of highly educated caregivers reported a higher prevalence of breakfast consumption compared with children with low-educated caregivers (16). - The parental perception of the body image of their children was different from the actual nutritional status for all three conditions namely children who were thin, overweight, or obese in both studies. The parental perception gets marginalized for those who have overweight and especially obese children. - Consumption of fresh fruit and vegetables was significantly higher among children with highly educated parents. Conclusions Prevention policies focused on key factors such as healthy diet and regular physical activity are among the best investments in the personal well-being of a young European generation in good health (17).  These studies findings and respective recommendations can support the development of a national school food and nutrition education (SFNE) programme in Albania,  While there is evidence for the need to intervene at the national level, the stratified analysis at regional and district levels points to the need for the design and implementation of specific interventions at the local level.  It is also very crucial to strengthen and improve anthropometric nutrition and surveillance systems for nutritional risk factors for children and adolescents, and use the data obtained by these systems in effectively and appropriately. References 1. World Health Organization. Nutrition. Available from: https://www.who.int/health- topics/nutrition (accessed: April 12, 2022). 2. 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