Impact of fat reduction on micronutrient density of children's diets: the CATCH Study

Strategies for enhancing the implementation of school-based policies or practices targeting diet, physical activity, obesity, tobacco or alcohol use

BACKGROUND

Several school-based interventions are effective in improving child diet and physical activity, and preventing excessive weight gain, and tobacco or harmful alcohol use. However, schools are frequently unsuccessful in implementing such evidence-based interventions.

OBJECTIVES

1. To evaluate the benefits and harms of strategies aiming to improve school implementation of interventions to address student diet, physical activity, tobacco or alcohol use, and obesity. 2. To evaluate the benefits and harms of strategies to improve intervention implementation on measures of student diet, physical activity, obesity, tobacco use or alcohol use; describe their cost or cost-effectiveness; and any harms of strategies on schools, school staff or students.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search was between 1 September 2016 and 30 April 2021 to identify any relevant trials published since the last published review.

SELECTION CRITERIA

We defined 'Implementation' as the use of strategies to adopt and integrate evidence-based health interventions and to change practice patterns within specific settings. We included any trial (randomised controlled trial (RCT) or non-randomised controlled trial (non-RCT)) conducted at any scale, with a parallel control group that compared a strategy to implement policies or practices to address diet, physical activity, overweight or obesity, tobacco or alcohol use by students to 'no intervention', 'usual' practice or a different implementation strategy.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Given the large number of outcomes reported, we selected and included the effects of a single outcome measure for each trial for the primary (implementation) and secondary (student health behaviour and obesity) outcomes using a decision hierarchy. Where possible, we calculated standardised mean differences (SMDs) to account for variable outcome measures with 95% confidence intervals (CI). For RCTs, we conducted meta-analyses of primary and secondary outcomes using a random-effects model, or in instances where there were between two and five studies, a fixed-effect model. The synthesis of the effects for non-randomised studies followed the 'Synthesis without meta-analysis' (SWiM) guidelines.

MAIN RESULTS

We included an additional 11 trials in this update bringing the total number of included studies in the review to 38. Of these, 22 were conducted in the USA. Twenty-six studies used RCT designs. Seventeen trials tested strategies to implement healthy eating, 12 physical activity and six a combination of risk factors. Just one trial sought to increase the implementation of interventions to delay initiation or reduce the consumption of alcohol. All trials used multiple implementation strategies, the most common being educational materials, educational outreach and educational meetings. The overall certainty of evidence was low and ranged from very low to moderate for secondary review outcomes. Pooled analyses of RCTs found, relative to a control, the use of implementation strategies may result in a large increase in the implementation of interventions in schools (SMD 1.04, 95% CI 0.74 to 1.34; 22 RCTs, 1917 participants; low-certainty evidence). For secondary outcomes we found, relative to control, the use of implementation strategies to support intervention implementation may result in a slight improvement on measures of student diet (SMD 0.08, 95% CI 0.02 to 0.15; 11 RCTs, 16,649 participants; low-certainty evidence) and physical activity (SMD 0.09, 95% CI -0.02 to 0.19; 9 RCTs, 16,389 participants; low-certainty evidence). The effects on obesity probably suggest little to no difference (SMD -0.02, 95% CI -0.05 to 0.02; 8 RCTs, 18,618 participants; moderate-certainty evidence). The effects on tobacco use are very uncertain (SMD -0.03, 95% CIs -0.23 to 0.18; 3 RCTs, 3635 participants; very low-certainty evidence). One RCT assessed measures of student alcohol use and found strategies to support implementation may result in a slight increase in use (odds ratio 1.10, 95% CI 0.77 to 1.56; P = 0.60; 2105 participants). Few trials reported the economic evaluations of implementation strategies, the methods of which were heterogeneous and evidence graded as very uncertain. A lack of consistent terminology describing implementation strategies was an important limitation of the review.

AUTHORS' CONCLUSIONS

The use of implementation strategies may result in large increases in implementation of interventions, and slight improvements in measures of student diet, and physical activity. Further research is required to assess the impact of implementation strategies on such behavioural- and obesity-related outcomes, including on measures of alcohol use, where the findings of one trial suggest it may slightly increase student risk. Given the low certainty of the available evidence for most measures further research is required to guide efforts to facilitate the translation of evidence into practice in this setting.

Individual-, family-, and school-level interventions targeting multiple risk behaviours in young people

BACKGROUND

Engagement in multiple risk behaviours can have adverse consequences for health during childhood, during adolescence, and later in life, yet little is known about the impact of different types of interventions that target multiple risk behaviours in children and young people, or the differential impact of universal versus targeted approaches. Findings from systematic reviews have been mixed, and effects of these interventions have not been quantitatively estimated.

OBJECTIVES

To examine the effects of interventions implemented up to 18 years of age for the primary or secondary prevention of multiple risk behaviours among young people.

SEARCH METHODS

We searched 11 databases (Australian Education Index; British Education Index; Campbell Library; Cumulative Index to Nursing and Allied Health Literature (CINAHL); Cochrane Central Register of Controlled Trials (CENTRAL), in the Cochrane Library; Embase; Education Resource Information Center (ERIC); International Bibliography of the Social Sciences; MEDLINE; PsycINFO; and Sociological Abstracts) on three occasions (2012, 2015, and 14 November 2016)). We conducted handsearches of reference lists, contacted experts in the field, conducted citation searches, and searched websites of relevant organisations.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), including cluster RCTs, which aimed to address at least two risk behaviours. Participants were children and young people up to 18 years of age and/or parents, guardians, or carers, as long as the intervention aimed to address involvement in multiple risk behaviours among children and young people up to 18 years of age. However, studies could include outcome data on children > 18 years of age at the time of follow-up. Specifically,we included studies with outcomes collected from those eight to 25 years of age. Further, we included only studies with a combined intervention and follow-up period of six months or longer. We excluded interventions aimed at individuals with clinically diagnosed disorders along with clinical interventions. We categorised interventions according to whether they were conducted at the individual level; the family level; or the school level.

DATA COLLECTION AND ANALYSIS

We identified a total of 34,680 titles, screened 27,691 articles and assessed 424 full-text articles for eligibility. Two or more review authors independently assessed studies for inclusion in the review, extracted data, and assessed risk of bias.We pooled data in meta-analyses using a random-effects (DerSimonian and Laird) model in RevMan 5.3. For each outcome, we included subgroups related to study type (individual, family, or school level, and universal or targeted approach) and examined effectiveness at up to 12 months' follow-up and over the longer term (> 12 months). We assessed the quality and certainty of evidence using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

We included in the review a total of 70 eligible studies, of which a substantial proportion were universal school-based studies (n = 28; 40%). Most studies were conducted in the USA (n = 55; 79%). On average, studies aimed to prevent four of the primary behaviours. Behaviours that were most frequently addressed included alcohol use (n = 55), drug use (n = 53), and/or antisocial behaviour (n = 53), followed by tobacco use (n = 42). No studies aimed to prevent self-harm or gambling alongside other behaviours.Evidence suggests that for multiple risk behaviours, universal school-based interventions were beneficial in relation to tobacco use (odds ratio (OR) 0.77, 95% confidence interval (CI) 0.60 to 0.97; n = 9 studies; 15,354 participants) and alcohol use (OR 0.72, 95% CI 0.56 to 0.92; n = 8 studies; 8751 participants; both moderate-quality evidence) compared to a comparator, and that such interventions may be effective in preventing illicit drug use (OR 0.74, 95% CI 0.55 to 1.00; n = 5 studies; 11,058 participants; low-quality evidence) and engagement in any antisocial behaviour (OR 0.81, 95% CI 0.66 to 0.98; n = 13 studies; 20,756 participants; very low-quality evidence) at up to 12 months' follow-up, although there was evidence of moderate to substantial heterogeneity (I² = 49% to 69%). Moderate-quality evidence also showed that multiple risk behaviour universal school-based interventions improved the odds of physical activity (OR 1.32, 95% CI 1.16 to 1.50; I² = 0%; n = 4 studies; 6441 participants). We considered observed effects to be of public health importance when applied at the population level. Evidence was less certain for the effects of such multiple risk behaviour interventions for cannabis use (OR 0.79, 95% CI 0.62 to 1.01; P = 0.06; n = 5 studies; 4140 participants; I² = 0%; moderate-quality evidence), sexual risk behaviours (OR 0.83, 95% CI 0.61 to 1.12; P = 0.22; n = 6 studies; 12,633 participants; I² = 77%; low-quality evidence), and unhealthy diet (OR 0.82, 95% CI 0.64 to 1.06; P = 0.13; n = 3 studies; 6441 participants; I² = 49%; moderate-quality evidence). It is important to note that some evidence supported the positive effects of universal school-level interventions on three or more risk behaviours.For most outcomes of individual- and family-level targeted and universal interventions, moderate- or low-quality evidence suggests little or no effect, although caution is warranted in interpretation because few of these studies were available for comparison (n ≤ 4 studies for each outcome).Seven studies reported adverse effects, which involved evidence suggestive of increased involvement in a risk behaviour among participants receiving the intervention compared to participants given control interventions.We judged the quality of evidence to be moderate or low for most outcomes, primarily owing to concerns around selection, performance, and detection bias and heterogeneity between studies.

AUTHORS' CONCLUSIONS

Available evidence is strongest for universal school-based interventions that target multiple- risk behaviours, demonstrating that they may be effective in preventing engagement in tobacco use, alcohol use, illicit drug use, and antisocial behaviour, and in improving physical activity among young people, but not in preventing other risk behaviours. Results of this review do not provide strong evidence of benefit for family- or individual-level interventions across the risk behaviours studied. However, poor reporting and concerns around the quality of evidence highlight the need for high-quality multiple- risk behaviour intervention studies to further strengthen the evidence base in this field.

Strategies for enhancing the implementation of school-based policies or practices targeting risk factors for chronic disease

BACKGROUND

A number of school-based policies or practices have been found to be effective in improving child diet and physical activity, and preventing excessive weight gain, tobacco or harmful alcohol use. Schools, however, frequently fail to implement such evidence-based interventions.

OBJECTIVES

The primary aims of the review are to examine the effectiveness of strategies aiming to improve the implementation of school-based policies, programs or practices to address child diet, physical activity, obesity, tobacco or alcohol use.Secondary objectives of the review are to: Examine the effectiveness of implementation strategies on health behaviour (e.g. fruit and vegetable consumption) and anthropometric outcomes (e.g. BMI, weight); describe the impact of such strategies on the knowledge, skills or attitudes of school staff involved in implementing health-promoting policies, programs or practices; describe the cost or cost-effectiveness of such strategies; and describe any unintended adverse effects of strategies on schools, school staff or children.

SEARCH METHODS

All electronic databases were searched on 16 July 2017 for studies published up to 31 August 2016. We searched the following electronic databases: Cochrane Library including the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; MEDLINE In-Process & Other Non-Indexed Citations; Embase Classic and Embase; PsycINFO; Education Resource Information Center (ERIC); Cumulative Index to Nursing and Allied Health Literature (CINAHL); Dissertations and Theses; and SCOPUS. We screened reference lists of all included trials for citations of other potentially relevant trials. We handsearched all publications between 2011 and 2016 in two specialty journals (Implementation Science and Journal of Translational Behavioral Medicine) and conducted searches of the WHO International Clinical Trials Registry Platform (ICTRP) (http://apps.who.int/trialsearch/) as well as the US National Institutes of Health registry (https://clinicaltrials.gov). We consulted with experts in the field to identify other relevant research.

SELECTION CRITERIA

'Implementation' was defined as the use of strategies to adopt and integrate evidence-based health interventions and to change practice patterns within specific settings. We included any trial (randomised or non-randomised) conducted at any scale, with a parallel control group that compared a strategy to implement policies or practices to address diet, physical activity, overweight or obesity, tobacco or alcohol use by school staff to 'no intervention', 'usual' practice or a different implementation strategy.

DATA COLLECTION AND ANALYSIS

Citation screening, data extraction and assessment of risk of bias was performed by review authors in pairs. Disagreements between review authors were resolved via consensus, or if required, by a third author. Considerable trial heterogeneity precluded meta-analysis. We narratively synthesised trial findings by describing the effect size of the primary outcome measure for policy or practice implementation (or the median of such measures where a single primary outcome was not stated).

MAIN RESULTS

We included 27 trials, 18 of which were conducted in the USA. Nineteen studies employed randomised controlled trial (RCT) designs. Fifteen trials tested strategies to implement healthy eating policies, practice or programs; six trials tested strategies targeting physical activity policies or practices; and three trials targeted tobacco policies or practices. Three trials targeted a combination of risk factors. None of the included trials sought to increase the implementation of interventions to delay initiation or reduce the consumption of alcohol. All trials examined multi-strategic implementation strategies and no two trials examined the same combinations of implementation strategies. The most common implementation strategies included educational materials, educational outreach and educational meetings. For all outcomes, the overall quality of evidence was very low and the risk of bias was high for the majority of trials for detection and performance bias.Among 13 trials reporting dichotomous implementation outcomes-the proportion of schools or school staff (e.g. classes) implementing a targeted policy or practice-the median unadjusted (improvement) effect sizes ranged from 8.5% to 66.6%. Of seven trials reporting the percentage of a practice, program or policy that had been implemented, the median unadjusted effect (improvement), relative to the control ranged from -8% to 43%. The effect, relative to control, reported in two trials assessing the impact of implementation strategies on the time per week teachers spent delivering targeted policies or practices ranged from 26.6 to 54.9 minutes per week. Among trials reporting other continuous implementation outcomes, findings were mixed. Four trials were conducted of strategies that sought to achieve implementation 'at scale', that is, across samples of at least 50 schools, of which improvements in implementation were reported in three trials.The impact of interventions on student health behaviour or weight status were mixed. Three of the eight trials with physical activity outcomes reported no significant improvements. Two trials reported reductions in tobacco use among intervention relative to control. Seven of nine trials reported no between-group differences on student overweight, obesity or adiposity. Positive improvements in child dietary intake were generally reported among trials reporting these outcomes. Three trials assessed the impact of implementation strategies on the attitudes of school staff and found mixed effects. Two trials specified in the study methods an assessment of potential unintended adverse effects, of which, they reported none. One trial reported implementation support did not significantly increase school revenue or expenses and another, conducted a formal economic evaluation, reporting the intervention to be cost-effective. Trial heterogeneity, and the lack of consistent terminology describing implementation strategies, were important limitations of the review.

AUTHORS' CONCLUSIONS

Given the very low quality of the available evidence, it is uncertain whether the strategies tested improve implementation of the targeted school-based policies or practices, student health behaviours, or the knowledge or attitudes of school staff. It is also uncertain if strategies to improve implementation are cost-effective or if they result in unintended adverse consequences. Further research is required to guide efforts to facilitate the translation of evidence into practice in this setting.

The WHO Health Promoting School framework for improving the health and well-being of students and their academic achievement

BACKGROUND

The World Health Organization's (WHO's) Health Promoting Schools (HPS) framework is an holistic, settings-based approach to promoting health and educational attainment in school. The effectiveness of this approach has not been previously rigorously reviewed.

OBJECTIVES

To assess the effectiveness of the Health Promoting Schools (HPS) framework in improving the health and well-being of students and their academic achievement.

SEARCH METHODS

We searched the following electronic databases in January 2011 and again in March and April 2013: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL, Campbell Library, ASSIA, BiblioMap, CAB Abstracts, IBSS, Social Science Citation Index, Sociological Abstracts, TRoPHI, Global Health Database, SIGLE, Australian Education Index, British Education Index, Education Resources Information Centre, Database of Education Research, Dissertation Express, Index to Theses in Great Britain and Ireland, ClinicalTrials.gov, Current controlled trials, and WHO International Clinical Trials Registry Platform. We also searched relevant websites, handsearched reference lists, and used citation tracking to identify other relevant articles.

SELECTION CRITERIA

We included cluster-randomised controlled trials where randomisation took place at the level of school, district or other geographical area. Participants were children and young people aged four to 18 years, attending schools or colleges. In this review, we define HPS interventions as comprising the following three elements: input to the curriculum; changes to the school's ethos or environment or both; and engagement with families or communities, or both. We compared this intervention against schools that implemented either no intervention or continued with their usual practice, or any programme that included just one or two of the above mentioned HPS elements.

DATA COLLECTION AND ANALYSIS

At least two review authors identified relevant trials, extracted data, and assessed risk of bias in the trials. We grouped different types of interventions according to the health topic targeted or the approach used, or both. Where data permitted, we performed random-effects meta-analyses to provide a summary of results across studies.

MAIN RESULTS

We included 67 eligible cluster trials, randomising 1443 schools or districts. This is made up of 1345 schools and 98 districts. The studies tackled a range of health issues: physical activity (4), nutrition (12), physical activity and nutrition combined (18), bullying (7), tobacco (5), alcohol (2), sexual health (2), violence (2), mental health (2), hand-washing (2), multiple risk behaviours (7), cycle-helmet use (1), eating disorders (1), sun protection (1), and oral health (1). The quality of evidence overall was low to moderate as determined by the GRADE approach. 'Risk of bias' assessments identified methodological limitations, including heavy reliance on self-reported data and high attrition rates for some studies. In addition, there was a lack of long-term follow-up data for most studies.We found positive effects for some interventions for: body mass index (BMI), physical activity, physical fitness, fruit and vegetable intake, tobacco use, and being bullied. Intervention effects were generally small but have the potential to produce public health benefits at the population level. We found little evidence of effectiveness for standardised body mass index (zBMI) and no evidence of effectiveness for fat intake, alcohol use, drug use, mental health, violence and bullying others; however, only a small number of studies focused on these latter outcomes. It was not possible to meta-analyse data on other health outcomes due to lack of data. Few studies provided details on adverse events or outcomes related to the interventions. In addition, few studies included any academic, attendance or school-related outcomes. We therefore cannot draw any clear conclusions as to the effectiveness of this approach for improving academic achievement.

AUTHORS' CONCLUSIONS

The results of this review provide evidence for the effectiveness of some interventions based on the HPS framework for improving certain health outcomes but not others. More well-designed research is required to establish the effectiveness of this approach for other health topics and academic achievement.

Community-based interventions for enhancing access to or consumption of fruit and vegetables among five to 18-year olds: a scoping review

BACKGROUND

Low fruit and vegetable ( FV) consumption is a key risk factor for morbidity and mortality. Consumption of FV is limited by a lack of access to FV. Enhanced understanding of interventions and their impact on both access to and consumption of FV can provide guidance to public health decision-makers. The purpose of this scoping review is to identify and map literature that has evaluated effects of community-based interventions designed to increase FV access or consumption among five to 18-year olds.

METHODS

The search included 21 electronic bibliographic databases, grey literature, targeted organization websites, and 15 key journals for relevant studies published up to May 2011. Retrieved citations were screened in duplicate for relevance. Data extracted from included studies covered: year, country, study design, target audience, intervention setting, intervention strategies, interventionists, and reported outcomes.

RESULTS

The search located 19,607 unique citations. Full text relevance screening was conducted on 1,908 studies. The final 289 unique studies included 30 knowledge syntheses, 27 randomized controlled trials, 55 quasi-experimental studies, 113 cluster controlled studies, 60 before-after studies, one mixed method study, and three controlled time series studies. Of these studies, 46 included access outcomes and 278 included consumption outcomes. In terms of target population, 110 studies focused on five to seven year olds, 175 targeted eight to 10 year olds, 192 targeted 11 to 14 year olds, 73 targeted 15 to 18 year olds, 55 targeted parents, and 30 targeted teachers, other service providers, or the general public. The most common intervention locations included schools, communities or community centres, and homes. Most studies implemented multi-faceted intervention strategies to increase FV access or consumption.

CONCLUSIONS

While consumption measures were commonly reported, this review identified a small yet important subset of literature examining access to FV. This is a critically important issue since consumption is contingent upon access. Future research should examine the impact of interventions on direct outcome measures of FV access and a focused systematic review that examines these interventions is also needed. In addition, research on interventions in low- and middle-income countries is warranted based on a limited existing knowledge base.

Are energy dense diets also nutrient dense?

OBJECTIVE

Some beverages are nutrient dense, but they are often excluded from nutrient density calculations. The purpose of this study was to assess whether the energy-nutrient association changed when beverages were included in these calculations.

DESIGN

Applying a cross-sectional design, a 24-hour dietary recall was collected on each participant. Subjects/

SETTING

440 young adults (ages 19-28 years) in Bogalusa, Louisiana participated in this study.

STATISTICAL ANALYSIS

Mean nutrient intakes and food group consumption were examined across the energy density (ED) tertiles using two calculation methods: one with food and all beverages (excluding water) (ED1) and one including food and only energy containing beverages (ED2). Regression models were used and multiple comparisons were performed using the Tukey-Kramer procedure. A p-value < 0.05 was considered to be significant.

RESULTS

With increasing ED, there was a significant increase in the consumption of total meats (ED1 p < 0.05; ED2 p < 0.01). In contrast, there was a significant decrease in consumption of fruits/juices (ED1 p < 0.01; ED2 p < 0.0001), vegetables (ED1 p < 0.01; ED2 p < 0.05), beverages (both p < 0.0001) and total sweets with increasing ED (both p < 0.0001). There was a significantly higher mean intake of total protein (grams) (ED2 p < 0.0001), amino acids (ED1 histidine/leucine p < 0.05; ED2 p < 0.0001), and total fat (grams) (ED1 p < 0.0001; ED2 p < 0.0001) with higher ED compared to lower ED. The percent energy from protein (ED1 p < 0.05; ED2 p < 0.0001), total fat (both p < 0.001) and saturated fatty acids (both p < 0.0001) significantly increased and the percent energy from carbohydrate (both p < 0.0001) and sucrose (both p < 0.0001) significantly decreased with increasing ED.

CONCLUSION

This study suggests that ED may influence the ND of the diet depending on whether energy containing beverages are included or excluded in the analysis.

Health and nutrition education program in primary schools of Crete: changes in blood pressure over 10 years

OBJECTIVE

To examine the long-term effects of the 'Cretan Health and Nutrition Education Program' on blood pressure.

SUBJECTS

A representative population of 176 pupils (85 from the intervention schools and 91 from the control schools).

DESIGN

Blood pressure, dietary, anthropometrical and physical activity data were obtained at baseline (academic year 1992-1993) and at follow-up examination (academic year 2001-2002).

RESULTS

The findings of the current study revealed that the increase over the 10-year period in systolic (SBP) and diastolic blood pressure (DBP) was higher in the control group (CG) than in the intervention group (IG) (P=0.003 and P<0.001 respectively). Regarding dietary indices, the IG were found to have a significantly higher intake of potassium (P=0.018) and magnesium (P=0.011) compared to the CG. Furthermore, the decrease in body mass index (BMI) z-score observed in the IG was found to differentiate significantly from the increase observed in the CG (P=0.042). On the contrary, the increase in leisure time, moderate to vigorous physical activities (MVPA) observed in the IG, was found to differentiate significantly from the decrease observed in the CG (P=0.032). Intervention's effect on SBP was mediated by changes in MVPA (beta=-0.20, P=0.030) and BMI (beta=0.19, P=0.048). Similarly, intervention's effect on DBP was mediated by changes in MVPA (beta=-0.18, P=0.048), BMI (beta=0.26, P=0.007) and magnesium intake (beta=-0.20, P=0.048).

CONCLUSION

The findings of the current study are encouraging, indicating favorable changes in blood pressure, micronutrients intake, BMI and physical activity over the 10 years of follow-up and 4 years after program's cessation, thus providing some support for the effectiveness of school-based health education programs in successfully tackling certain chronic disease risk factors early in life.

Position of the American Dietetic Association: individual-, family-, school-, and community-based interventions for pediatric overweight

The American Dietetic Association (ADA), recognizing that overweight is a significant problem for children and adolescents in the United States, takes the position that pediatric overweight intervention requires a combination of family-based and school-based multi-component programs that include the promotion of physical activity, parent training/modeling, behavioral counseling, and nutrition education. Furthermore, although not yet evidence-based, community-based and environmental interventions are recommended as among the most feasible ways to support healthful lifestyles for the greatest numbers of children and their families. ADA supports the commitment of resources for programs, policy development, and research for the efficacious promotion of healthful eating habits and increased physical activity in all children and adolescents, regardless of weight status. This is the first position paper of ADA to be based on a rigorous systematic evidence-based analysis of the pediatric overweight literature on intervention programs. The research showed positive effects of two specific kinds of overweight interventions: a) multicomponent, family-based programs for children between the ages of 5 and 12 years, and b) multicomponent, school-based programs for adolescents. Multicomponent programs include behavioral counseling, promotion of physical activity, parent training/modeling, dietary counseling, and nutrition education. Analysis of the literature to date points to the need for further investigation of promising strategies not yet adequately evaluated. Furthermore, this review highlights the need for research to develop effective and innovative overweight prevention programs for various sectors of the population, including those of varying ethnicities, young children, and adolescents. To support and enhance the efficacy of family- and school-based weight interventions, community-wide interventions should be undertaken; few such interventions have been conducted and even fewer evaluated.

Position of the American Dietetic Association: Dietary guidance for healthy children ages 2 to 11 years

It is the position of the American Dietetic Association that children ages 2 to 11 years should achieve optimal physical and cognitive development, attain a healthy weight, enjoy food, and reduce the risk of chronic disease through appropriate eating habits and participation in regular physical activity. The health status of American children has generally improved over the past three decades. However, the number of children who are overweight has more than doubled among 2- to 5-year-old children and more than tripled among 6- to 11-year-old children, which has major health consequences. This increase in childhood overweight has broadened the focus of dietary guidance to address children's over consumption of energy-dense, nutrient-poor foods and beverages and physical activity patterns. Health promotion will help reduce diet-related risks of chronic degenerative diseases, such as cardiovascular disease, type 2 diabetes, cancer, obesity, and osteoporosis. This position paper reviews what US children are eating and explores trends in food and nutrient intakes as well as the impact of school meals on children's diets. Dietary recommendations and guidelines and the benefits of physical activity are also discussed. The roles of parents and caregivers in influencing the development of healthy eating behaviors are highlighted. The American Dietetic Association works with other allied health and food industry professionals to translate dietary recommendations and guidelines into achievable, healthful messages. Specific recommendations to improve the nutritional well-being of children are provided for dietetics professionals, parents, and caregivers.

Calcium intake trends and health consequences from childhood through adulthood

Issues involving low calcium intake and dairy product consumption are currently the focus of much debate and discussion at both the scientific and lay community levels. In this review, we examine the following major areas of interest: (1). the role of calcium intake and dairy product consumption in chronic diseases, (2). nutritional qualities of milk and other dairy products, (3). trends in calcium intake and dairy product consumption, (4). current status of calcium intakes and dairy product consumption in children, (5). tracking of calcium intake and diary product consumption, (6). the impact of school meal participation on calcium intake and dairy product consumption, (7). concerns related to calcium-fortified foods and beverages and (8). factors influencing children's milk consumption. To date, the findings indicate that calcium intake and dairy product consumption have beneficial roles in a variety of chronic diseases; dairy products provide an abundant source of vitamins and minerals; calcium intakes of children have increased over time, yet intakes are not meeting the current adequate intake (AI) calcium recommendations; dairy consumption has decreased, and soft drink consumption and, possibly, consumption of calcium-fortified products have increased; consumption of dairy products have a positive nutritional impact on diets of children, particularly from school meals, and there are many factors which influence children's milk consumption, all of which need to be considered in our efforts to promote adequate calcium intakes by children. Based on this review, areas that need immediate attention and future research imperatives are summarized in an effort to further our understanding on what we already know and what we need to know to promote healthier eating habits early in life.

What are the key food groups to target for preventing obesity and improving nutrition in schools?

OBJECTIVE

To determine differences in the contribution of foods and beverages to energy consumed in and out of school, and to compare consumption patterns between school canteen users and noncanteen users.

DESIGN

Cross-sectional National Nutrition Survey, 1995.

SETTING

Australia. SUBJECTS ON SCHOOL DAYS: A total of 1656 children aged 5-15 y who had weekday 24-h dietary recall data.

RESULTS

An average of 37% of total energy intake was consumed at school. Energy-dense foods and beverages such as fat spreads, packaged snacks, biscuits and fruit/cordial drinks made a greater contribution to energy intake at school compared to out of school (P< or =0.01). Fast foods and soft drinks contributed 11 and 3% of total energy intake; however, these food groups were mostly consumed out of school. Fruit intake was low and consumption was greater in school. In all, 14% of children purchased food from the canteen and they obtained more energy from fast food, packaged snacks, desserts, milk and confectionary (P< or =0.05) than noncanteen users.

CONCLUSIONS

: Energy-dense foods and beverages are over-represented in the Australian school environment. To help prevent obesity and improve nutrition in schools, biscuits, snack bars and fruit/cordial drinks brought from home and fast food, packaged snacks, and confectionary sold at canteens should be replaced with fruit and water.

Nutrient intake over time in a multi-ethnic sample of youth

OBJECTIVES

The purpose of this paper is to present longitudinal data on nutrient intakes of youth with emphases on differences by sex and race/ethnicity. Nutrients selected for examination are those implicated in chronic disease.

DESIGN

24-hour dietary recalls were collected from a cohort of third, fifth and eighth graders (n = 1874).

SETTING AND SUBJECTS

The sample is drawn from the Child and Adolescent Trial for Cardiovascular Health and includes students from California, Louisiana, Minnesota and Texas.

RESULTS

Across the total sample, nutrient intakes met recommended levels except that total fat, saturated fat and sodium consistently exceeded recommendations and calcium and iron intake of girls consistently fell short of recommended levels. Nutrient consumption between third and eighth grade differed by sex and race/ethnicity for a number of nutrients. In particular, females' intake of energy from total fat, calcium, iron, folic acid, vitamin A and vitamin D decreased over time relative to males' intakes, controlling for overall energy intake. Compared with the other ethnic/racial groups, African-American students increased their intake of energy from total fat and saturated fat over time.

CONCLUSIONS

Our results suggest that the diets of youth change over time, and negative trends are more common in females than in males and in African-American and Hispanics compared with Caucasian students. Nutrition education and intervention are needed throughout childhood and adolescence with an emphasis on choosing healthful foods. In addition, greater attention to differential opportunities and reinforcements for females and males, and Caucasian, Hispanic and African-American students is warranted.

"Healthy-start": outcome of an intervention to promote a heart healthy diet in preschool children

OBJECTIVE

We evaluated the effects of a preschool nutrition education and food service intervention "Healthy Start," on two-to-five-year-old children in nine Head Start Centers in upstate NY. The primary objective was to reduce the saturated fat (sat-fat) content of preschool meals to <10% daily energy (E) and to reduce consumption of sat-fat by preschoolers to <10% E.

METHODS

Six centers were assigned to the food service intervention and three to control condition. Food service intervention included training workshops for cooks and monthly site visits to review progress towards goals. Child dietary intake at preschool was assessed by direct observation and plate waste measurement. Dietary intake at home was assessed by parental food record and telephone interviews. Dietary data were collected each Fall/Spring over two years, including five days of menus and recipes from each center. Dietary data were analyzed with the Minnesota NDS software.

RESULTS

Consumption of saturated fat from school meals decreased significantly from 1.0%E to 10.4%E after one year of intervention and to 8.0%E after the second year, compared with an increase of 10.2% to 13.0% to 11.4%E, respectively, for control schools (p < 0.001). Total caloric intake was adequately maintained for both groups. Analysis of preschool menus and recipes over the two-year period of intervention showed a significant decrease in sat-fat content in intervention preschools (from 12.5 at baseline to 8.0%E compared with a change of 12.1%E to >11.6%E in control preschools (p < 0.001)). Total fat content of menus also decreased significantly in intervention schools (31.0% to >25.0%E) compared with controls (29.9% to >28.4%E).

CONCLUSIONS

The Healthy Start food service intervention was effective in reducing the fat and saturated fat content of preschool meals and reducing children's consumption of saturated fat at preschool without compromising energy intake or intake of essential nutrients. These goals are consistent with current U.S Dietary Guidelines for children older than two years of age.

Self-reported calcium intake and bone mineral content in children and adolescents

OBJECTIVE

We examined the relationship between self-reported calcium (Ca) intake and bone mineral content (BMC) in children and adolescents. We hypothesized that an expression of Ca adjusted for energy intake (EI), i.e., Ca density, would be a better predictor of BMC than unadjusted Ca because of underreporting of EI.

METHODS

Data were obtained on dietary intakes (repeated 24-hour recalls) and BMC (by DEXA) in a cross-section of 227 children aged 8 to 17 years. Bivariate and multivariate analyses were used to examine the relationship between Ca. Ca density, and the dependent variables total body BMC and lumbar spine BMC. Covariates included were height, weight, bone area. maturity age, activity score and EI.

RESULTS

Reported EI compared to estimated basal metabolic rate suggested underreporting of EI. Total body and lumbar spine BMC were significantly associated with EI, but not Ca or Ca density, in bivariate analyses. After controlling for size and maturity, multiple linear regression analysis revealed unadjusted Ca to be a predictor of BMC in males in the total body (p = 0.08) and lumbar spine (p = 0.01)). Unadjusted Ca was not a predictor of BMC at either site in females. Ca density was not a better predictor of BMC at either site in males or females.

CONCLUSIONS

The relationship observed in male adolescents in this study between Ca intake and BMC is similar to that seen in clinical trials. Ca density did not enable us to see a relationship between Ca intake and BMC in females, which may reflect systematic reporting errors or that diet is not a limiting factor in this group of healthy adolescents.

Diet quality, nutrient intake, weight status, and feeding environments of girls meeting or exceeding recommendations for total dietary fat of the American Academy of Pediatrics

OBJECTIVES

To compare the diet quality and weight status of girls consuming diets meeting the recommendation of the American Academy of Pediatrics for dietary fat with those of girls consuming >30% of energy from fat and to examine relationships between girls' dietary fat intake, mothers' nutrient intakes, and mothers' child-feeding practices.

DESIGN

Participants were 192 white girls and their mothers, who were divided into 2 groups: >30% of energy from fat (high fat [HF]) or </=30% of energy from fat (low fat [LF]), based on girls' 3-day dietary recalls. Girls' food group and nutrient intakes, Healthy Eating Index, body mass index, and mothers' nutrient intakes and child-feeding practices were compared.

RESULTS

Girls with HF diets consumed fewer fruits, more meat, and more fats and sweets and had lower Healthy Eating Index scores than did the girls in the LF group. Mothers of girls in the HF group had higher fat intakes than did those in the LF group. Girls and mothers in the HF group had lower intakes of fiber and vitamins A, C, B6, folate, and riboflavin. Mothers in the HF group reported using more restriction and pressure to eat in feeding their daughters. Girls in the HF group showed greater increase in body mass index and skinfold thickness from age 5 to 7 years.

CONCLUSION

These findings provide additional support for the recommendation of the American Academy of Pediatrics to limit total dietary fat. Findings reveal that mothers' use of controlling feeding practices are not effective in fostering healthier diets among girls and that mothers' own eating may be more influential than their attempts to control the intake of their daughters. dietary fat, dietary quality, nutrient intake, overweight, feeding practices, children.

Nutrient intakes and dietary patterns of young children by dietary fat intakes

OBJECTIVE

To determine whether low fat intake is associated with increased risk of nutritional inadequacy in children 2 to 8 years old and to identify eating patterns associated with differences in fat intake.

STUDY DESIGN

Using 2 days of recall from the Continuing Survey of Food Intake by Individuals (CSFII), 1994 to 1996, we classified 2802 children into quartiles of energy intake from fat (<29%, 29% to 31.9% [defined as moderate fat], 32% to 34.9%, and > or =35%) and compared nutrient intakes, the proportion of children at risk for inadequate intakes, Food Pyramid servings, and fat content per serving across quartiles.

RESULTS

More children in quartile 2 were at risk for inadequate intakes of vitamin E, calcium, and zinc than children in higher quartiles (P <.0001); more children in quartiles 3 and 4 were at risk for inadequate intakes of vitamins A and C and folate (P <.001). Fruit intake decreased across quartiles (P <.0001); whereas vegetable, meat, and fat-based condiment intakes increased (P <.0001). Fat per serving of grain, vegetables, dairy, and meat increased across quartiles (P <.0001).

CONCLUSIONS

Moderate-fat diets were not consistently associated with an increased proportion of children at risk for nutritional inadequacy, and higher-fat diets were not consistently protective against inadequacy. Dietary fat could be reduced by judicious selection of lower-fat foods without compromising nutritional adequacy.

Impact of dietary fat and fiber intake on nutrient intake of adolescents

OBJECTIVE

To evaluate the impact of fat and fiber intake on energy and nutrient intake of 15-year-old adolescents.

STUDY DESIGN

Twenty-four-hour dietary recalls were collected on a random sample of 15-year-olds. Subjects were then categorized into groups based on fat and fiber intake, with 319 students meeting criteria for 1 of 4 dietary intake quadrants: low fat, low fiber; low fat, high fiber; high fat, low fiber; and high fat, high fiber. Students with medium fat or fiber intakes were excluded from the study. Low-fat and high-fat intake were defined as <30% and >40% of total energy intake, respectively. Low- and high-fiber intake were defined as <15 g/day and >20 g/day, respectively.

RESULTS

Low-fat and high-fiber intake had a minimal impact on energy intake and did not adversely affect nutrient intake. High-fiber intake was associated with greater likelihood of adequate intake of vitamins A, B6, B12, and C; niacin; thiamin; riboflavin; folacin; magnesium; iron; zinc; phosphorus; and calcium. High-fat intake was associated with greater likelihood of adequate vitamin B12 intake. Significant differences in fat and fiber intake distributions were found for ethnic background and gender, with more non-white than white students in the high-fat groups and more males than females in the high-fiber groups.

CONCLUSIONS

A low-fat and high-fiber diet meeting current nutrition recommendations does not adversely affect energy or nutrient intake, increases nutrient density of the diet, and increases the likelihood of adequate intake for several key nutrients.

Nutrient intake and food group consumption of 10-year-olds by sugar intake level: the Bogalusa Heart Study

OBJECTIVE

The effect of total sugar intake on nutrient intake and food group consumption was examined in children.

METHODS

Twenty-four hour dietary recalls were collected on a sample of 568 ten-year-olds from two cross-sectional surveys. The population was stratified according to total sugar intake quartiles: < or = 25th (46 g/1000 kcal), 25-50th (67 g/1000 kcal), 50-75th (81 g/1000 kcal) and > or = 75th (106 g/1000 kcal).

RESULTS

No significant difference was shown in energy intakes across the quartiles and no significant race or gender differences were observed in mean total sugar intakes. However, with increasing total sugar intake, there was a significant linear decrease in mean intakes of protein, fat, saturated fat, starch, cholesterol, sodium, vitamins B6 and E, thiamin, niacin, iron, and zinc; and a significant linear increase in mean intakes of carbohydrate, fructose, lactose, sucrose, vitamin D, and calcium. Eating patterns reflected the differing nutrient intakes, with high sugar consumers having significantly higher intakes of total g of candy, beverages and milk and lower intakes of total g of meats, and cheese than lower sugar consumers. The nutritional quality of children's diets high in total sugar appear to be adequate regarding vitamin and mineral intakes and are closer to meeting current dietary fat recommendations.

Changing fruit and vegetable consumption among children: the 5-a-Day Power Plus program in St. Paul, Minnesota

OBJECTIVES

A randomized school based trial sought to increase fruit and vegetable consumption among children using a multicomponent approach.

METHODS

The intervention, conducted in 20 elementary schools in St. Paul, targeted a multiethnic group of children who were in the fourth grade in spring 1995 and the fifth grade in fall 1995. The intervention consisted of behavioral curricula in classrooms, parental involvement, school food service changes, and industry support and involvement. Lunchroom observations and 24-hour food recalls measured food consumption. Parent telephone surveys and a health behavior questionnaire measured psychosocial factors.

RESULTS

The intervention increased lunchtime fruit consumption and combined fruit and vegetable consumption, lunchtime vegetable consumption among girls, and daily fruit consumption as well as the proportion of total daily calories attributable to fruits and vegetables.

CONCLUSIONS

Multicomponent school-based programs can increase fruit and vegetable consumption among children. Greater involvement of parents and more attention to increasing vegetable consumption, especially among boys, remain challenges in future intervention research.

Lessons from the Child and Adolescent Trial for Cardiovascular Health (CATCH): interventions with children

School-based, primary prevention programs can be effective in improving children's dietary intake of fat and saturated fat and in increasing their self-reported levels of physical activity. School environments can be modified to provide healthier food options in the school cafeteria and to increase the amount of moderate to vigorous physical activity occurring during physical education class.

The effect of changes in dietary fat on the food group and nutrient intake of 4- to 10-year-old children

OBJECTIVE

To determine how young children changed their overall diet when they changed their fat intake after 3 months of participating in a nutrition education demonstration study designed to lower low-density lipoprotein cholesterol and cardiovascular risk.

METHODS

Three 24-hour dietary recalls were collected from 303 4- to 10-year-old children at baseline and 3 months later. At both times, mean number of servings from food groups, grams of fat contributed from food groups, and intake of calories and nutrients were calculated and compared among quartiles of children formed according to change in their percent of calories from total fat after 3 months.

RESULTS

Children who reduced their percent of calories from total fat most (ie, by an average of 8.5%) after 3 months consumed fewer servings from meats, eggs, dairy, fats/oils, and breads but tended to increase their number of servings from lower-fat foods within those food groups, particularly from dairy foods. These children also increased their mean intake of fruits, vegetables, and desserts, and maintained average intakes of all nutrients (except vitamin D) in excess of two thirds of the respective recommended dietary allowance.

CONCLUSIONS

Young children who reduced their percent of calories from total fat in accordance with the current National Cholesterol Education Program recommendations accomplished this by reducing their overall intake of higher-fat foods, replacing higher-fat foods with lower-fat foods within several food groups, particularly within the dairy group (eg, drinking skim milk instead of whole milk) and by consuming more servings of fruits, vegetables, and very-low-fat desserts. These behaviors did not compromise their mean calorie or nutrient intakes, showing that it is possible for young children to lower their fat intake safely to reduce their risk of future heart disease.

School-based programs for health-risk reduction

Based on implications from the pediatric studies of cardiovascular risk, it has become imperative that practical methods be developed to begin prevention of heart disease early in life. Schools provide an excellent setting for introducing comprehensive health education and promotion as a public health approach to the general population. A number of school-based health education programs have been developed (Heart Ahead/Heart Smart, CATCH, Gimme 5) for children in kindergarten through high school, in which education and environmental changes have been shown to be effective in promoting healthful behaviors. The effective implementation of health education depends to a large extent on the training and motivation of teachers, administrators, and food service staff. Training Institutes can be important for increasing personal awareness, disseminating information and materials, motivating health education efforts for teachers, food service staff and their students, and evaluating the health risk of school personnel.