Fresh Kids: the efficacy of a Health Promoting Schools approach to increasing consumption of fruit and water in Australia

Decreasing consumption of sugar-sweetened beverages and Raising tap water consumption through Interventions based on Nutrition and sustainability for Kids: study protocol of the "DRINK" cluster randomised controlled trial

BACKGROUND

Effectiveness of actions to reduce sugar-sweetened beverage (SB) consumption in children still needs to be improved. Furthermore, the growing concern about sustainable food systems encourages to develop sustainability-based interventions. The objective of this cluster randomised controlled trial is to evaluate the long-term effectiveness of nutrition- and environmental sustainability-based interventions on the reduction in SB intake and on the increase in tap water consumption in 3rd to 6th grade primary school children (8 to 11 years of age).

METHODS

Forty-eight French-speaking Belgian primary schools (equivalent to around 3500 pupils involved in the evaluation) are randomised using a factorial plan: (i) control, (ii) nutrition-based intervention, (iii) sustainability-based intervention, and (iv) both. The interventions (encouragement of water breaks; provision of posters, leaflets, reusable cups, and glass bottles; website; meetings at school) were undertaken from February 2022 to June 2023. Evaluation includes questionnaires for the children and their parents on various determinants of dietary behaviour, a 4-day diary to collect information on the child's beverage consumption, and audits at schools. The first evaluation was conducted in Spring 2021 before any intervention, with the two post-intervention evaluations being held in 2022 and 2023. The main quantitative judgement criterion will be the change over time in the mean SB consumption (in ml/day) in the intervention groups compared with the control group. Given the context of the research (school), the safety of the intervention, and the content of data collection, a consent was acknowledged as unnecessary by the Ethical Committee of the Faculty of Psychology (ULB; n°073/2021), but children and parents are explicitly informed of their right to refuse to fill in the questionnaires.

DISCUSSION

Multicomponent interventions based on nutrition and on environmental sustainability, alone or mixed, will provide an original and topical insight into health promotion at school around dietary behaviours. The dissemination plan will enable to widely inform stakeholders, school staff, and families, in addition to the scientific community through the usual medium (articles, conferences), about the research findings in 2024-2025.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN99843102. Retrospectively registered on 25 May 2021.

Evaluation of Social Impact Within Primary School Health Promotion: A Systematic Review

BACKGROUND

Health promotion programs and interventions are designed to encourage behavioral changes in children, encouraging them to make safe and healthy life choices. This systematic review seeks to examine how social impact is measured in primary school health promotion interventions.

METHOD

A systematic search and review process was used to identify and examine primary school health promotion interventions. The PRISMA guidelines were followed to source articles from 6 electronic databases reporting school health promotion programs or interventions in Australia, Canada, New Zealand, or the United Kingdom.

RESULTS

A total of 77 studies were located, representing 55 health promotion interventions delivered in primary school settings. Of these interventions, only 8 (15%) measured or attempted to measure social impact, whereas another 8 (15%) alluded to social impact. The predominant theories reported were social based theories (theories which examine the social influences on people, environments, and behaviors) (n = 17, 59%), with almost a third not informed by an overt health promotion framework or model (n = 34, 59%). A systematic rating system identified some level of stakeholder engagement (n = 30, 53%).

CONCLUSIONS

This systematic review highlights the need for social impact measurement within health promotion to illuminate the role of school programs in delivering lasting change.

Content analysis of school websites: policies and programs to support healthy eating and the environment

Preschools and primary schools are important settings for the development of healthy eating habits and awareness of environmentally friendly practices. This study explored South Australian government schools' policies and programs in relation to healthy eating and environmentally friendly aspects of food choice (such as packaging), and whether any schools approached these issues in combination. Websites of 18 government preschools and primary schools in the Greater Adelaide region, stratified by low, medium and high socioeconomic status were reviewed for publicly available policies and other relevant content. A content analysis was undertaken, with policies and programs analysed deductively and thematically. Healthy eating (n = 8) and environment (n = 3) related policies were found on preschool websites only. The main themes observed across the three categories of interest (healthy eating, environmentally friendly practices and low-waste healthy foods) included the presence/absence of formal policy, promotional strategies and implementation. Expectations of children bringing healthy 'nude' foods that were environmentally friendly were mentioned informally on the websites but were not part of policy documents. Policies and programs around healthy eating and environmentally friendly practices (in combination) were lacking. There is scope to address this gap to improve health and sustainable outcomes within the school environment context.

Parents' and teachers' views of the promotion of healthy eating in Australian primary schools

BACKGROUND

Primary schools have long been identified as appropriate settings for improving the healthy eating behaviours of children and helping them develop food skills. This qualitative study explored the views of Australian primary school parents and teachers about schools' strengths and weaknesses in promoting healthy eating and equipping children with food skills.

METHODS

Nineteen parents and 17 teachers from Victoria participated in semi-structured interviews. Audio recordings were transcribed and underwent thematic analysis using Nvivo.

RESULTS

This study demonstrated that parents and teachers believed that several facilitators helped promote children's healthy eating. These included food and nutrition education (FNE) programs, the community-based nature of schools, and teacher role modelling and the authority schools possess over children. Time scarcity, lack of teacher expertise, lack of leadership and funding were reported as barriers. School food environments such as canteens, lunch orders, fundraising events and school fairs were identified as both weaknesses and strengths by parents and teachers, which indicated inconsistent implementation of school nutrition policies across schools.

CONCLUSIONS

Australian primary schools demonstrate some useful efforts to promote healthy eating among children. However, there are numerous facilitators and barriers which impact on the promotion of healthy eating. These factors need to be addressed in order to develop healthy eating habits further among elementary students. These results provide directions for policymakers and school managers, as they point to the areas that need to be improved to assist the design of schools that better promote healthy eating among children.

Identifying dietary patterns in Irish schoolchildren and their association with nutritional knowledge and markers of health before and after intervention

The aim of the study was to identify dietary patterns (DP) and examine differences in anthropometric measures, blood pressure (BP), cardiorespiratory fitness and nutritional knowledge of 6- and 10-year-old children at baseline and following a nutrition and physical activity intervention, with respect to DP and treatment group. This is a longitudinal study. Food diary, nutritional knowledge questionnaire and 550-m walk/run test measured dietary intake, nutritional knowledge and cardiorespiratory fitness, respectively. BP, weight, height and waist circumference were also measured and BMI and waist-to-height ratio (WHtR) were derived. All measurements were performed at baseline and following intervention. Two primary schools (one intervention, one control) in Cork, Ireland, were selected. Participants were 6- (n 39, age 5·9 (sd 0·6) years) and 10- (n 49, age 9·8 (sd 0·5) years)-year-olds. Two DP were identified, using k-means cluster analysis, for both 6- (unhealthy and nutrient-dense) and 10-year-olds (processed and Western diet) at baseline. DP derived post-intervention were (1) plant-based and (2) processed foods for 6-year-olds and (1) nutrient-dense and (2) unhealthy for 10-year-olds. There was no statistically significant difference in DP for 6- and 10-year-olds at baseline and post-intervention (P > 0·05). Following the intervention, a multivariate ANOVA showed there were no statistically significant differences in nutritional knowledge, BMI, WHtR, cardiorespiratory fitness and BP based on DP and intervention/control group for both age groups (P > 0·05). Three out of four dietary patterns identified for 6- and 10-year-olds were unfavourable. While no statistically significant evidence of intervention impact was found on DP, a positive trend was emerging among 10-year-olds.

Dietary habits and metabolic response improve in obese children whose mothers received an intervention to promote healthy eating: randomized clinical trial

BACKGROUND

Lifestyles habits such as eating unhealthy foodscommence at home and are associated with the development of obesity and comorbidities such as insulin resistance, metabolic syndrome, and chronic degenerative diseases, which are the main causes of death in adults. The present study compared changes in dietary habits, behaviors and metabolic profiles of obese children whose mothers attended at the hospital to group sessions, with those who received the usual nutritional consultation.

METHODS

Randomized clinical trial, 177 mother/obese child pairs participated, 90 in the intervention group and 87 in the control group. The intervention group attended six group education sessions to promote healthy eating, being this an alternative of change of habits in children with obesity. The control group received the usual nutritional consultation; both groups were followed up for 3 months. Frequency of food consumption, behaviors during feeding in the house and metabolic profile was evaluated. Mixed effect linear regression models were used to evaluate the effect of the intervention on the variables of interest, especially in HOMA-IR.

RESULTS

The intervention group reduced the filling of their dishes (p = 0.009), forcing the children to finish meals (p = 0.003) and food substitution (p <  0.001), moreover increased the consumption of roasted foods (p = 0.046), fruits (p = 0.002) and vegetables (p <  0.001). The children in the control group slightly increased HOMA-IR levels (0.51; 95% CI - 0.48 to 1.50), while the children in the intervention group significantly decreased (- 1.22; 95% CI - 2.28 to - 1.16). The difference in HOMA-IR between the control and intervention group at the end of the follow-up was - 1.67; 95% CI: - 3.11 to - 0.24.

CONCLUSIONS

The educational intervention improved some eating habits at home, as well as HOMA-IR levels; why we consider that it can be an extra resource in the management of childhood obesity.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT04374292 (Date assigned: May 5, 2020). Retrospectively registered.

Interventions to increase the consumption of water among children: A systematic review and meta-analysis

The aim of this study was to conduct a systematic review and meta-analysis on the effectiveness of interventions to increase children's water consumption. A systematic literature search was conducted in seven electronic databases. Studies published in English before 18 February 2019 that evaluated any type of intervention that measured change in water consumption among children aged 2 to 12 years by applying any type of design were included. Of the 47 interventions included in the systematic review, 24 reported a statistically significant increase in water consumption. Twenty-four interventions (17 randomized controlled trials and seven studies with other controlled designs) were included in the meta-analysis. On average, children in intervention groups consumed 29 mL/d (confidence interval [CI] = 13-46 mL/d) more water than did children in control groups. This effect was larger in eight interventions focused specifically on diet (MD = 73 mL/d, CI = 20-126 mL/d) than in 16 interventions focused also on other lifestyle factors (MD = 15 mL/d, CI = 1-29 mL/d). Significant subgroup differences were also found by study setting and socioecological level targeted but not by children's age group, intervention strategy, or study design. In conclusion, there is evidence that, on average, lifestyle interventions can lead to small increases in children's daily water consumption. More research is needed to further understand the specific intervention elements that have the greatest effect.

Adherence to components of Health Promoting Schools in schools of Bengaluru, India

Schools provide a crucial platform for health promotion as the school years are a vital stage in one's life, where lifelong general and oral health-related behaviours are developed and established. The components of Health Promoting Schools (HPSs) suggested by World Health Organization provide guidance for facilitating health promotion within this setting. This study aimed to assess the adherence to the components of HPSs amongst schools in Bengaluru, India utilizing a comprehensive tool developed for the purpose. A cross-sectional survey was conducted among randomly selected 61 schools. Data were collected through structured interviews with the head of the schools, direct observation of school premises and verification of records. The significant findings of the study were that 80.3% of the schools had proper ventilation and separate washrooms for boys and girls, 83.6 and 88.5% of the schools had natural light and adequate water supply correspondingly. Only 39.3% of the schools had washrooms that were cleaned daily, and 55.7% of the schools were in proximity to business that sold tobacco products. Oral health education was not integrated into the curriculum in 39.3% of the schools, and 29.5% of the schools had no playgrounds. The study tool appeared to be sensitive in identifying the finer components of HPSs, indicating the lack of strict adherence to the components of HPSs in Bengaluru. This information can be utilized to design appropriate interventions at micro, meso and macro level to strengthen the capacity of schools for the attainment of health promotion.

A randomized controlled trial to assess the potential efficacy, feasibility and acceptability of an m-health intervention targeting parents of school aged children to improve the nutritional quality of foods packed in the lunchbox 'SWAP IT'

BACKGROUND

Scalable interventions that improve the nutritional quality of foods in children's lunchboxes have considerable potential to improve child public health nutrition. This study assessed the potential efficacy, feasibility and acceptability of an m-health intervention, 'SWAP IT', to improve the energy and nutritional quality of foods packed in children's lunchboxes.

METHODS

The study employed a 2X2 factorial cluster randomized-controlled trial design. Twelve primary schools in New South Wales, Australia were randomly allocated to one of four groups: (i) no intervention;(ii) physical activity intervention only;(iii) lunchbox intervention only; or(iv) physical activity and lunchbox intervention combined. The two intervention strategies were evaluated separately. This paper focuses on the effects of the lunchbox intervention only. The lunchbox intervention comprised four strategies: 1) school nutrition guidelines; 2) lunchbox lessons; 3) information pushed to parents via a school-communication app and 4) parent resources addressing barriers to packing healthy lunchboxes. Outcome measures were taken at baseline and immediately post-intervention (10 weeks) and included measures of effectiveness (mean energy (kJ) packed in lunchboxes, total energy and percentage energy from recommended foods consistent with Australian Dietary Guidelines), feasibility (of delivering intervention to schools, parent app engagement and behaviour change) and acceptability to school staff and parents. Linear mixed models were used to assess intervention efficacy.

RESULTS

Of the 1915 lunchbox observations, at follow-up there was no significant differences between intervention and control group in mean energy of foods packed within lunchboxes (- 118.39 kJ, CI = -307.08, 70.30, p = 0.22). There was a significant increase favouring the intervention in the secondary outcome of mean lunchbox energy from recommended foods (79.21 kJ, CI = 1.99, 156.43, p = 0.04), and a non-significant increase in percentage of lunchbox energy from recommended foods in intervention schools (4.57%, CI = -0.52, 9.66, p = 0.08). The views of the messages pushed via the app ranged from 387 to 1550 views per week (mean views =1025 per week). A large proportion (71%) of parents reported awareness of the intervention, making healthier swaps in the lunchbox (55%), and pushed content was helpful (84%).

CONCLUSION

The study is the first RCT to assess the potential of a multi-component m-health lunchbox intervention. The intervention was feasible, acceptable and potentially effective in improving the nutritional quality of foods packed within children's lunchboxes.

TRIAL REGISTRATION

Australian Clinical Trials Registry ACTRN: ACTRN12616001228471 .

Environmental interventions to reduce the consumption of sugar-sweetened beverages and their effects on health

BACKGROUND

Frequent consumption of excess amounts of sugar-sweetened beverages (SSB) is a risk factor for obesity, type 2 diabetes, cardiovascular disease and dental caries. Environmental interventions, i.e. interventions that alter the physical or social environment in which individuals make beverage choices, have been advocated as a means to reduce the consumption of SSB.

OBJECTIVES

To assess the effects of environmental interventions (excluding taxation) on the consumption of sugar-sweetened beverages and sugar-sweetened milk, diet-related anthropometric measures and health outcomes, and on any reported unintended consequences or adverse outcomes.

SEARCH METHODS

We searched 11 general, specialist and regional databases from inception to 24 January 2018. We also searched trial registers, reference lists and citations, scanned websites of relevant organisations, and contacted study authors.

SELECTION CRITERIA

We included studies on interventions implemented at an environmental level, reporting effects on direct or indirect measures of SSB intake, diet-related anthropometric measures and health outcomes, or any reported adverse outcome. We included randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after (CBA) and interrupted-time-series (ITS) studies, implemented in real-world settings with a combined length of intervention and follow-up of at least 12 weeks and at least 20 individuals in each of the intervention and control groups. We excluded studies in which participants were administered SSB as part of clinical trials, and multicomponent interventions which did not report SSB-specific outcome data. We excluded studies on the taxation of SSB, as these are the subject of a separate Cochrane Review.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies for inclusion, extracted data and assessed the risks of bias of included studies. We classified interventions according to the NOURISHING framework, and synthesised results narratively and conducted meta-analyses for two outcomes relating to two intervention types. We assessed our confidence in the certainty of effect estimates with the GRADE framework as very low, low, moderate or high, and presented 'Summary of findings' tables.

MAIN RESULTS

We identified 14,488 unique records, and assessed 1030 in full text for eligibility. We found 58 studies meeting our inclusion criteria, including 22 RCTs, 3 NRCTs, 14 CBA studies, and 19 ITS studies, with a total of 1,180,096 participants. The median length of follow-up was 10 months. The studies included children, teenagers and adults, and were implemented in a variety of settings, including schools, retailing and food service establishments. We judged most studies to be at high or unclear risk of bias in at least one domain, and most studies used non-randomised designs. The studies examine a broad range of interventions, and we present results for these separately.Labelling interventions (8 studies): We found moderate-certainty evidence that traffic-light labelling is associated with decreasing sales of SSBs, and low-certainty evidence that nutritional rating score labelling is associated with decreasing sales of SSBs. For menu-board calorie labelling reported effects on SSB sales varied.Nutrition standards in public institutions (16 studies): We found low-certainty evidence that reduced availability of SSBs in schools is associated with decreased SSB consumption. We found very low-certainty evidence that improved availability of drinking water in schools and school fruit programmes are associated with decreased SSB consumption. Reported associations between improved availability of drinking water in schools and student body weight varied.Economic tools (7 studies): We found moderate-certainty evidence that price increases on SSBs are associated with decreasing SSB sales. For price discounts on low-calorie beverages reported effects on SSB sales varied.Whole food supply interventions (3 studies): Reported associations between voluntary industry initiatives to improve the whole food supply and SSB sales varied.Retail and food service interventions (7 studies): We found low-certainty evidence that healthier default beverages in children's menus in chain restaurants are associated with decreasing SSB sales, and moderate-certainty evidence that in-store promotion of healthier beverages in supermarkets is associated with decreasing SSB sales. We found very low-certainty evidence that urban planning restrictions on new fast-food restaurants and restrictions on the number of stores selling SSBs in remote communities are associated with decreasing SSB sales. Reported associations between promotion of healthier beverages in vending machines and SSB intake or sales varied.Intersectoral approaches (8 studies): We found moderate-certainty evidence that government food benefit programmes with restrictions on purchasing SSBs are associated with decreased SSB intake. For unrestricted food benefit programmes reported effects varied. We found moderate-certainty evidence that multicomponent community campaigns focused on SSBs are associated with decreasing SSB sales. Reported associations between trade and investment liberalisation and SSB sales varied.Home-based interventions (7 studies): We found moderate-certainty evidence that improved availability of low-calorie beverages in the home environment is associated with decreased SSB intake, and high-certainty evidence that it is associated with decreased body weight among adolescents with overweight or obesity and a high baseline consumption of SSBs.Adverse outcomes reported by studies, which may occur in some circumstances, included negative effects on revenue, compensatory SSB consumption outside school when the availability of SSBs in schools is reduced, reduced milk intake, stakeholder discontent, and increased total energy content of grocery purchases with price discounts on low-calorie beverages, among others. The certainty of evidence on adverse outcomes was low to very low for most outcomes.We analysed interventions targeting sugar-sweetened milk separately, and found low- to moderate-certainty evidence that emoticon labelling and small prizes for the selection of healthier beverages in elementary school cafeterias are associated with decreased consumption of sugar-sweetened milk. We found low-certainty evidence that improved placement of plain milk in school cafeterias is not associated with decreasing sugar-sweetened milk consumption.

AUTHORS' CONCLUSIONS

The evidence included in this review indicates that effective, scalable interventions addressing SSB consumption at a population level exist. Implementation should be accompanied by high-quality evaluations using appropriate study designs, with a particular focus on the long-term effects of approaches suitable for large-scale implementation.

Is an Iranian Health Promoting School status associated with improving school food environment and snacking behaviors in adolescents?

The Iranian Health Promoting Schools (IHPS) program was first piloted and then formally established in Iran in 2011 as a framework to promote healthy environment and behaviors such as proper dietary practice among adolescents. This study examined the role of IHPS in improving the school food environment and snacking behaviors among adolescents. In this cross-sectional study, 1320 eighth grade students from 40 middle schools with IHPS and non-IHPS program were selected using a proportional stratified random sampling method. A modified 55-item qualitative Food Frequency Questionnaire was used to assess the frequency of consumption of healthy and unhealthy snacks in the studied adolescents. Mixed effect negative binomial regression models were used to analyze the data. The association was also adjusted for individual variables, including gender, socio-economic status, pocket money, family structure and nutritional knowledge level. No significant difference was observed between the average of healthy and unhealthy snack items in IHPS and non-IHPS schools (p > 0.05). On the basis of adjusted analysis, being from/in IHPS was not associated with weekly frequency consumption of unhealthy [prevalence rate ratio (PRR) = 0.99; 95% CI: 0.85-1.16] and healthy (PRR = 1.08; 95% CI: 0.96-1.2) snacks among the adolescents. There was no difference regarding school food environment and snacking behaviors in IHPS and non-IHPS schools. This might indicate that there has been a weakness in institutionalizing the comprehensive concepts of the HPS approach in the studied schools. Addressing the proper understanding of HPS approach and the need for development of HPS through matching and adaptability with health promotion actions to reach defined standards, is necessary.

Active and Healthy Lifestyle - Nationwide Programs in Israeli Schools

The World Health Organization (WHO) announced the 'Global School Health Initiative' in 1995 following recommendations formulated in the Ottawa Charter for Health Promotion. Hence, the aims of the present study were to describe the various programs for nurturing an active and healthy lifestyle implemented during 2011-12 in schools in Israel, and to identify variables that may explain the success versus lack of success in implementing these programs. Participants were a nationwide representative sample of 126 school principals from six supervisory districts of the Ministry of Education, including six sectors, from the elementary, junior-high and senior-high school levels. Semi-structured telephone interviews were recorded and processed using the ATLAS.ti software for qualitative analysis. Physical education teachers, sciences teachers and social coordinators led the programs' implementation. The programs included four main activities domains: health, physical education, nutrition and sustainability. Three types of program implementation were observed: leading principles, teaching methods, and external programs. Parents were involved mostly in elementary schools. Evidence of program integration into school life was presented by changes in children's behaviors, whereas difficulties stemmed from lack of budget and teaching hours. Science and physical education lessons constituted the anchor for the programs. The schools needed a committed leader to help conduct and maintain the program. Thus, the role of the school principal was to initiate the idea of developing a program, encourage its implementation, select a leader for the program, and then, most importantly, to reinforce the teachers' enthusiasm.

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.

Identifying Eating Occasion-Based Opportunities to Improve the Overall Diets of Australian Adolescents

Adolescents in Australia have a poor dietary intake, leading to large numbers of them being at risk for inadequate intake of micronutrients, and excessive intake of less healthful dietary components. This study examined dietary intakes at multiple eating occasions to identify opportunities for more targeted recommendations and strategies to improve dietary intakes among adolescents. Data from the first 24-h recall of 14-18 years old in the 2011-2012 National Nutrition and Physical Activity Survey were analysed (n = 772). Participant-defined eating occasions were classified as breakfast, lunch, dinner or other eating occasions combined. The mean percent contribution to the total day intake of top shortfall nutrients (calcium, magnesium, vitamin A, iron), discretionary calories, saturated fat, free sugars and sodium, as well as nutrient density, the foods consumed and the percent of consumers at each eating occasion, were calculated. Breakfast had the lowest prevalence of consumers (81%), contributed the least to total daily energy (14.6%) and almost a quarter of daily calcium and iron. Other eating occasions combined contributed 47.5% of free sugars and were top contributors of daily calcium (34.6%) and magnesium (31.7%). Discretionary foods contributed 32.4% of the energy at lunch, and the sodium content at lunch was 415 mg/1000 kJ. Key opportunities identified for adolescents were to increase breakfast consumption, given the high nutrient densities of breakfasts consumed; improve overall lunch quality, particularly the sodium content; promote the intake of milk, fruit and a variety of vegetables at both lunch and dinner; maintain healthful choices at in-between meal eating occasions while focusing on decreasing the intake of discretionary foods.

Formative Research to Design a Promotional Campaign to Increase Drinking Water among Central American Latino Youth in an Urban Area

Latinos consume more sugary drinks and less water than other demographic groups. Our objective was to understand beverage choice motivations and test promotional concepts that can encourage Central American Latino urban youth to drink more water. Two rounds of focus group discussions were conducted (n = 10 focus groups, 61 participants, 6-18 years old). Data were transcribed verbatim and analyzed using inductive and deductive coding approaches. Youth motivations for drinking water were shaped by level of thirst, weather, energy, and perceptions of health benefits. Youth were discouraged from drinking water due to its taste and perceptions of the safety and cleanliness of tap water. Youth beverage preference depended on what their friends were drinking. Availability of water versus other beverages at home and other settings influenced their choice. Promotional materials that included mixed language, informative messages about the benefits of drinking water, and celebrities or athletes who were active, energized, and drinking water were preferred. A promotional campaign to increase water consumption among these Latino youth should include bicultural messages to underscore the power of water to quench true thirst, highlight the health benefits of drinking water, and address the safety of tap water.

Oral health education program among pre-school children: an application of health-promoting schools approach

Background: Preschool children have a limit ability to take care of their teeth. The aim of this study was to determine the effect of an intervention based on Albanian’s Health Promoting Schools Model (Albanian’s HPSM) on the oral health behaviors among a group of Iranian female preschool (5-6 years old) children.

Methods: In this quasi-experimental study, 120 children in seventh district of Tehran, Iran were randomly recruited and assigned to either the intervention or the control groups. A scale was designed and validated to assess the oral health behaviors among the children and knowledge,attitude, self-efficacy beliefs, perceived barriers and oral health behaviors among the parents and the schoolteachers. An expert panel approved the content validity of the scale (CVR = 0.89,CVI = 0.90). The reliability was also approved applying intraclass correlation coefficient (range,0.83–0.92) and Cronbach alpha (range, 0.83–0.96). Based on the preliminary data, a 6-week intervention was designed and conducted to the intervention group. One month following the intervention, both groups were followed-up. The data were analyzed using covariance and paired t tests.

Results: Following the intervention, significant differences were found in the oral health behaviors of the children in the intervention group (P < 0.05) and knowledge, attitude, oral health behaviors, self-efficacy, and perceived barriers of their parents and the schoolteachers (P < 0.05).

Conclusion: Using Albanian’s health-promoting schools (HPSs) approach was useful in improving the oral hygiene behaviors among the preschool children.

A Systematic Review to Assess Sugar-Sweetened Beverage Interventions for Children and Adolescents across the Socioecological Model

Sugar-sweetened beverage (SSB) consumption among children and adolescents is a determinant of childhood obesity. Many programs to reduce consumption across the socioecological model report significant positive results; however, the generalizability of the results, including whether reporting differences exist among socioecological strategy levels, is unknown. This systematic review aimed to examine the extent to which studies reported internal and external validity indicators defined by the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) model and assess reporting differences by socioecological level: Intrapersonal/interpersonal (Level 1), environmental/policy (Level 2), and multilevel (Combined Level). A systematic literature review was conducted in six major databases (PubMed, Web of Science, Cinahl, CAB Abstracts, Education Research Information Center, and Arcola) to identify studies from 2004-2015 meeting inclusion criteria (children aged 3 to 12 years, adolescents aged 13 to 17 years, and young adults aged 18 years, experimental or quasiexperimental, and substantial SSB component). Interventions were categorized by socioecological level, and data were extracted using a validated RE-AIM protocol. One-way analysis of variance assessed differences between levels. There were 55 eligible studies accepted, including 21 Level 1, 18 Level 2, and 16 Combined Level studies. Thirty-six studies (65%) were conducted in the United States, 19 studies (35%) were conducted internationally, and 39 studies (71%) were implemented in schools. Across levels, reporting averages were low for all RE-AIM dimensions (reach=29%, efficacy or effectiveness=45%, adoption=26%, implementation=27%, and maintenance=14%). Level 2 studies had significantly lower reporting on reach and effectiveness (10% and 26%, respectively) compared with Level 1 (44% and 57%, respectively) or Combined Level studies (31% and 52%, respectively) (P<0.001). Adoption, implementation, and maintenance reporting did not vary among levels. Interventions to reduce SSB consumption in children and adolescents across the socioecological spectrum do not provide the necessary information for dissemination and implementation in community nutrition settings. Future interventions should address both internal and external validity to maximize population influence.

Grab a Cup, Fill It Up! An Intervention to Promote the Convenience of Drinking Water and Increase Student Water Consumption During School Lunch

OBJECTIVES

We evaluated a low-cost strategy for schools to improve the convenience and appeal of drinking water.

METHODS

We conducted a group-randomized, controlled trial in 10 Boston, Massachusetts, schools in April through June 2013 to test a cafeteria-based intervention. Signage promoting water and disposable cups were installed near water sources. Mixed linear regression models adjusting for clustering evaluated the intervention impact on average student water consumption over 359 lunch periods.

RESULTS

The percentage of students in intervention schools observed drinking water during lunch nearly doubled from baseline to follow-up compared with controls (+ 9.4%; P < .001). The intervention was associated with a 0.58-ounce increase in water intake across all students (P < .001). Without cups, children were observed drinking 2.4 (SE = 0.08) ounces of water from fountains; with cups, 5.2 (SE = 0.2) ounces. The percentage of intervention students observed with sugar-sweetened beverages declined (-3.3%; P < .005).

CONCLUSIONS

The current default of providing water through drinking fountains in cafeterias results in low water consumption. This study shows that an inexpensive intervention to improve drinking water's convenience by providing cups can increase student water consumption.

Reducing Sugar-Sweetened Beverage Intake Among Students: School-Based Programs and Policies That Work

The amount of sugar-sweetened beverages (SSBs) consumed by U.S. youth has nearly doubled since the 1970s. The majority of children between 2 and 19 years drink SSBs on any given day. Many serious health problems such as childhood overweight and obesity, type 2 diabetes, kidney disease, and cardiovascular problems have been linked to SSBs. This article provides an overview of school-based interventions and policies that have successfully contributed to a reduction in sugar-sweetened intake among children. School nurses and nurses in other community-based settings are well positioned to promote intake of more healthful beverages among children using strategies recommended in this article.

Availability of drinking water in US public school cafeterias

This study examined the availability of free drinking water during lunchtime in US public schools, as required by federal legislation beginning in the 2011-2012 school year. Data were collected by mail-back surveys in nationally representative samples of US public elementary, middle, and high schools from 2009-2010 to 2011-2012. Overall, 86.4%, 87.4%, and 89.4% of students attended elementary, middle, and high schools, respectively, that met the drinking water requirement. Most students attended schools with existing cafeteria drinking fountains and about one fourth attended schools with water dispensers. In middle and high schools, respondents were asked to indicate whether drinking fountains were clean, and whether they were aware of any water-quality problems at the school. The vast majority of middle and high school students (92.6% and 90.4%, respectively) attended schools where the respondent perceived drinking fountains to be clean or very clean. Approximately one in four middle and high school students attended a school where the survey respondent indicated that there were water-quality issues affecting drinking fountains. Although most schools have implemented the requirement to provide free drinking water at lunchtime, additional work is needed to promote implementation at all schools. School nutrition staff at the district and school levels can play an important role in ensuring that schools implement the drinking water requirement, as well as promote education and behavior-change strategies to increase student consumption of water at school.

Evaluation sociologique d’un projet d’amélioration de l’offre alimentaire (hors restauration scolaire) dans des collèges et lycées d’Aquitaine : perception et analyse des élèves sur les actions d’éducation pour la santé

Le projet « Amélioration de l’offre alimentaire (hors restauration scolaire) et accompagnement pédagogique» a été mis en place en 2007–2008 et 2008–2009 dans 26 établissements du second degré d’Aquitaine. Il avait pour but de favoriser la consommation de fruits et pain chez les adolescents et de limiter la disponibilité des produits gras et sucrés au foyer des élèves. L’évaluation sociologique de ce projet a montré que l’adhésion des élèves dépendait fortement de la cohérence et des modalités de mise en place. Ainsi, l’adhésion des élèves, voire le changement de leurs habitudes alimentaires, est favorisé par la justification du changement d’offre via des actions d’éducation à la santé ludiques impliquant les élèves, l’intégration du projet dans une dynamique globale d’établissement (implication des équipes éducative, médicale et de restauration scolaire) et la prise en compte des préoccupations des adolescents (éloignées des aspects santé de l’alimentation).

Predictors of positive outcomes of a school food provision policy in Australia

This study identified predictors of parents' and school principals' perceptions of the impact of a Western Australian school food policy. An initial qualitative phase involving focus groups with parents and interviews with school principals, teachers, canteen managers and Parents & Citizens Committee members provided general feedback on the policy and identified various factors that appeared to be related to its successful implementation. In the following quantitative phase of the study, 1200 parents responded to a telephone questionnaire and 310 principals responded to an internet-based questionnaire. The primary outcome variables were, respectively, the extent to which parents reported that their children's diets were healthier as a result of the policy, and the extent to which principals reported that their schools complied with the policy. Logistic regression models were generated for the parent and principal samples. Those parents reporting that their children's diets were healthier were more likely to agree that the policy reflected their beliefs and their children's dietary needs and preferences, that their child talked about the traffic light food classification system and that this system influenced their food choices in the supermarket. Those principals reporting full compliance with the policy were more likely to agree that implementing the policy was not overly difficult. Specific factors facilitating school compliance were canteen manager training and conducive kitchen setup. Provision of appropriate information and training prior to implementation may assist schools in implementing new food policies, thereby enhancing their impact beyond the school environment.

Stakeholder support for school food policy expansions

The aim of this study was to assess the extent to which parents and school-based stakeholders (principals, teachers, canteen managers and Parents & Citizen Committee presidents) are supportive of potential expansions to a new school food policy. Eight additional policy components elicited in preliminary focus groups with parents and 19 additional policy components elicited from interviews with school stakeholders (including the eight also elicited from parents) were presented to 1200 parents and 607 school stakeholders, respectively. Each of the 8 potential policy components presented to parents was supported by more than two-thirds of parents, and 13 of the 19 policy components presented to school stakeholders received support from around two-thirds or more of the school stakeholder respondents. For all eight common policy components, parents exhibited significantly higher levels of support than school stakeholders. This information is of value to policy makers in their deliberations relating to the appropriate nature and timing of school food policy modifications.

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.

The implementation and effectiveness of school-based nutrition promotion programmes using a health-promoting schools approach: a systematic review

Objective

To evaluate implementation and effectiveness of nutrition promotion programmes using the health-promoting schools (HPS) approach, to indicate areas where further research is needed and to make recommendations for practice in this field.

Design

The searched electronic databases included: CINAHL, Cochrane Library, Health Reference Center, Informit Search, MEDLINE, ProQuest, PsycINFO, PubMed, ScienceDirect, Scopus, Social Services Abstracts and Web of Science. Inclusion criteria were: (i) controlled or before-and-after studies evaluating a nutrition intervention and involving the HPS approach, either fully or in part; (ii) provision of information about components and delivery of the intervention; and (iii) report on all evaluated outcomes.

Setting

Schools.

Subjects

Students, parents and school staff.

Results

All included studies described intervention delivery and six reported on process evaluation. In intervention schools school environment and ethos were more supportive, appropriate curriculum was delivered and parents and/or the community were more engaged and involved. Students participated in interventions at differing levels, but the majority was satisfied with the intervention. The evidence indicates that nutrition promotion programmes using the HPS approach can increase participants’ consumption of high-fibre foods, healthier snacks, water, milk, fruit and vegetables. It can also reduce participants’ ‘breakfast skipping’, as well as reduce intakes of red food, low-nutrient dense foods, fatty and cream foods, sweet drinks consumption and eating disorders. It can help to develop hygienic habits and improved food safety behaviours.

Conclusions

More professional training for teachers in the HPS approach, further qualitative studies, longer intervention periods, improved follow-up evaluations and adequate funding are required for future school-based nutrition promotion programmes.

Healthier food choices as a result of the revised healthy diet programme Krachtvoer for students of prevocational schools

BACKGROUND

Krachtvoer is a Dutch healthy diet programme for prevocational schools, developed in 2001 and revised for a broader target group in 2007, based on the findings of an evaluation of the first version. The goal of this study was to report on the short- and longer-term total and subgroup effects of the revised programme on students' fruit, fruit juice, breakfast, and snack consumption.

METHODS

Schools were randomized to the experimental condition, teaching the Krachtvoer programme, or to the control condition teaching the regular nutrition lessons. Self-reported consumption of fruit, fruit juice, breakfast and snacks was measured at baseline directly before programme implementation, one to four weeks after finishing programme implementation, and after six months. Mixed linear and logistic regression analyses were conducted.

RESULTS

In total 1117 students of 13 experimental schools and 758 students of 11 control schools participated in the study. Short- and longer-term favourable intervention effects were found on fruit consumption (mean difference between experimental and control group 0.15 servings at both posttests). Regarding fruit juice consumption, only short-term favourable effects were revealed (mean difference between experimental and control group 0.05 glasses). Intervention effects on breakfast intakes were limited. No changes in snack frequency were reported, but students made healthier snack choices as a result of the programme. Some favourable as well as unfavourable effects occurred in subgroups of students.

CONCLUSIONS

The effects on fruit consumption and snack choices justify the current nationwide dissemination of the programme. Achieving changes in breakfast consumption may, however, require other strategies.

Government food service policies and guidelines do not create healthy school canteens

OBJECTIVE

In 2006, the Victorian Government adopted the School Canteens and other school Food Services (SCFS) Policy that bans the sale of sweet drinks and confectionary and recommends the proportions of menu items based on a traffic light system of food classification. This study aims to determine whether compliance with the policy improves the nutritional profile of the menus.

METHODS

Items from food service menus were assessed for compliance with the SCFS policy and categorised as 'everyday' ('green'), 'select carefully' ('amber') or 'occasionally' ('red') (n=106). Profile analysis assessed differences in the nutritional profile of the menus between sub-groups.

RESULTS

Overall, 37% of menus contained items banned under the policy. The largest proportion of items on the assessed menus were from the 'amber' category (mean: 51.0%), followed by 'red' (29.3%) and 'green' (20.3%). No menus met the traffic light-based recommendations and there was no relationship between policy compliance and the proportion of items in each of the three categories.

CONCLUSIONS AND IMPLICATIONS

To increase the healthiness of the school food service we recommend a greater investment in resources and infrastructure to implement existing policies, and establishing stronger monitoring and support systems.

Primary school interventions to promote fruit and vegetable consumption: a systematic review and meta-analysis

OBJECTIVE

The consumption of fruits and vegetables (FV) may contribute to the prevention of many diseases. However, children at school age do not eat an enough amount of those foods. We have systematically reviewed the literature to assess the effectiveness of school interventions for promoting the consumption of FV.

METHODS

We performed a search in MEDLINE, EMBASE, CINAHL and CENTRAL. We pooled results and stratified the analysis according to type of intervention and study design.

RESULTS

Nineteen cluster studies were included. Most studies did not describe randomization method and did not take the cluster's effect into account. Pooled results of two randomized controlled trials (RCTs) of computer-based interventions showed effectiveness in improving consumption of FV [Standardized Mean Difference (SMD) 0.33 (95% CI 0.16, 0.50)]. No significant differences were found in pooled analysis of seven RCTs of multicomponent interventions or pooling results of two RCTs evaluating free/subsidized FV interventions.

CONCLUSIONS

Meta-analysis shows that computer-based interventions were effective in increasing FV consumption. Multicomponent interventions and free/subsidized FV interventions were not effective. Improvements in methodology are needed in future cluster studies. Although these results are preliminary, computer-based interventions could be considered in schools, given that they are effective and cheaper than other alternatives.

The use of mentoring programs to improve energy balance behaviors in high-risk children

This study tested the impact of a multicomponent intervention entitled "Partners of all Ages Reading About Diet and Exercise" (PARADE) a child-focused energy balance intervention incorporated into mentoring programs. We used a group randomized nested cohort design randomizing mentoring program sites (n = 119) and children (N = 782; females = 49%; African American = 37%; mean (s.d.) age = 8.5 (1.5) years) to intervention or usual care conditions. PARADE mentors delivered eight lesson plans addressing key concepts related to diet and activity; eight child-focused computer-tailored storybooks with messages targeting that child's diet and activity patterns and eight parent action support newsletters. When compared to the control group, PARADE children were more knowledgeable of diet and activity guidelines (P < 0.01), challenged themselves more to eat five fruits and vegetables (FV) (P < 0.01) and be active 1 h daily (P < 0.01), and to ask for FV for snack (P = 0.015). Calories from high fat foods decreased in overweight/obese children, but not for normal weight children (P = 0.059). There were no significant differences in fruit and vegetable intake, total calories, percent time being active, or BMI z-score. The combination of one-to-one mentoring, child-focused computer based tailoring, and parent support may impact important behavioral change precursors in environments over which the child has control, especially among normal weight children. Further, work is needed to evaluate the impact of family-focused multicomponent interventions, including computer-tailored approaches, directed toward both the parent and the child.