A low-cost Behavioural Nudge and choice architecture intervention targeting school lunches increases children's consumption of fruit: a cluster randomised trial

Comparison of Food Selection with the National School Lunch Program Meal Pattern Guidelines and Assessment of Children's Food Intake and Waste Using Digital Photography in a School Cafeteria

Background: School lunch is an important nutritious food source for children. The National School Lunch Program (NSLP) meal patterns guidelines have been established to promote healthier school lunches. This pilot study compared food selection during lunch in a school cafeteria with the NSLP meal pattern guidelines. Food intake and waste were also examined in relation to food selection. Methods: In a cross-sectional design, data were collected from children in the 1st, 6th, and 10th grades from a school in the United States. The digital photography of foods method was used to assess children's food selection, intake, and waste at lunch over 3 weeks. Results were presented as percentage, frequency, and mean ± standard deviation. Results: About 48 children from 1st grade, 47 from 6th grade, and 50 from 10th grade participated each day. Food selection in these grades consistently fell below the NSLP guidelines, with 69%, 79.8%, and 86.9% of children selecting less than the guidelines for energy, respectively. On average, only 10.4% of children selected vegetables at or above the guidelines. About 41% of the selected energy, 43% of fruits, 43% of vegetables, and 56% of milk were discarded as plate waste across all grades. Conclusions: Selection of energy and vegetables was consistently below the NSLP guidelines, yet almost half of the selected fruits, vegetables, and milk were wasted by children. Initiatives to enhance meal quality and variety, along with nutrition education interventions and school policies, are needed to improve food selection and intake and reduce food waste.

The effect of Position and Availability interventions on adolescents' food choice: An online experimental study

Interventions that alter characteristics of the food environment have been found to reduce energy intake in adults. However, few studies have examined the effect of Availability (reducing the number of higher energy options) and Position (altering the order of options) interventions on food choices by younger populations. Hence, this study examined the individual and combined effects of Availability and Position interventions on adolescents' energy selection from restaurant menus. In this online experiment, adolescents (13-17 years; N = 434) were randomly assigned to one of four groups: (1) Availability and Position absent (control group) = 60% higher energy options, ordered randomly by energy content; (2) Availability present, Position absent = 40% higher energy options, ordered randomly by energy content; (3) Position present, Availability absent = 60% higher energy options, menu options were ordered from lower to higher energy; (4) Availability present, Position present = 40% higher energy options, menu options were ordered from lower to higher energy. The primary outcome was average energy selected per meal (starter, main, and dessert). Findings showed that both the Availability and Position interventions reduced adolescents' meal energy selection, whether presented as individual interventions or combined. Thus, reducing the availability of higher energy menu options, and ordering menu options from low to high energy, appear to be effective strategies for reducing adolescents' energy selection from overall meals. Further research is needed to determine whether these findings translate to real-life food choices.

Impact of a nudge-based food environment intervention in a hospital convenience store on staff's food intake and Na/K

BACKGROUND

A food environment intervention using nudge tactics was implemented at a hospital convenience store (CVS) in Tokyo to improve employees' eating habits. The objective of this study was to evaluate its effects on the urinary sodium-to-potassium ratio (Na/K), food intake, eating attitude, and behavior.

METHODS

Using a pre-post design; the intervention incorporated nudge tactics, healthier options, easy-to-pick food placement, and eye-catching information. We also used price incentives. The primary outcomes included changes in Na/K and sodium and potassium excretion assessed using spot urine samples at health checkups. Secondary outcomes were changes in staff food intake, eating attitude, and behavior which were assessed using questionnaire surveys. All outcomes were evaluated statistically. Furthermore, we investigated how the intervention led to outcomes using path analysis.

RESULTS

A total of 140 participant (52men and 88women) were analyzed. Significant changes were observed in Na/K (3.16 to 2.98 in median, p = 0.02) and potassium excretion (43.4 to 45.2 mmol/day in mean, p = 0.03). However, sodium excretion did not change significantly. The intake of fruits and dairy products increased with improved self-efficacy. The most influential factor for lowering Na/K and increasing potassium excretion was information from the CVS; purchasing "balanced meals" to lower Na/K and salads to increase potassium excretion were second.

CONCLUSIONS

Food environment intervention using nudge tactics can improve staff's food intake and lower Na/K.

TRIAL REGISTRATION

Registration number: UMIN000049444 (UMIN-CTR). Date of registration: November. 7. 2022.

Changing the food environment in secondary school canteens to promote healthy dietary choices: a qualitative study with school caterers

BACKGROUND

Typical adolescent diets do not meet current dietary recommendations. There is a need to address these dietary patterns to reduce the risk of obesity and other diet-related diseases. Schools provide an opportune setting to do so, as students consume a substantial proportion of their daily dietary intake whilst at school. There is a developing evidence base on the use of choice architecture (food choice cues) to promote healthy eating in school contexts. It is necessary to understand the acceptability and feasibility of implementing such interventions. We aimed to explore these factors from the perspectives of secondary school caterers.

METHODS

We conducted qualitative interviews with caterers from secondary schools across the West Midlands, UK and national/regional catering representatives. A semi-structured topic guide and visual aid were used to guide interviews. Interviews were recorded and transcribed. Framework analysis was conducted in NVivo v12.

RESULTS

Twelve participants took part. Seven themes were identified and grouped into three categories: Acceptability (Suitability; Salient cues; Student engagement), Barriers (Catering decision drivers; Limits of influence), and Enablers (Perceived role; Opportunities). Caterers considered healthy food cues to be suited to adolescents as they require minimal reflective motivation. Salient cues included enhancing the placement, presentation and portability of healthy items, improving the dining environment and focusing pricing/incentive strategies on increased quantity. Student engagement was considered important. Some catering decision drivers conflicted with healthy food cues, and many felt that their role in healthy eating was limited due to the overwhelming influence of external food environments, adolescent resistance, and features of the secondary school canteen setting e.g. short duration of lunchtime, lack of space. However, caterers appeared motivated to implement healthy food cues and identified key opportunities for implementation, including integration into whole-school approaches to healthy eating.

CONCLUSIONS

Interventions using healthy food cues appeared acceptable to secondary school caterers, key potential implementers of these strategies. Future interventions could incorporate strategies relating to placement, presentation and pricing to prompt healthy selections, and actions to engage the student body and improve the dining environment. Evaluations should consider potential impacts upon food purchasing, consumption and waste to address caterers' concerns about these issues.

Factors affecting public acceptance of healthy lifestyle nudges

In two online vignette studies, we investigated the effects of healthy lifestyle nudging and pricing interventions in two different contexts: a supermarket (Study 1) and a train station (Study 2). In Study 1 (N = 318) participants were randomly assigned to evaluate one of eight interventions described in a vignette and designed to either encourage healthier food choices or discourage unhealthy food choices in a supermarket setting. Two interventions comprised a small financial incentive to either encourage a healthy food choice or discourage an unhealthy food choice, but the other six interventions were nudges conceived to specifically impact agency, self-constitution or freedom of choice (three different aspects of autonomy). Relative to these nudges, the financial incentive interventions were not found to be less acceptable or more patronising. Overall, the encouragement of healthy food choices was rated as more acceptable and less patronising. The same pattern of results was found in Study 2 (N = 314). We conclude that interventions threatening specific aspects of one's autonomy do not necessarily affect its acceptance. However, the behavioural focus does affect intervention acceptance, that is, interventions focused on encouraging healthy choices are considered more acceptable than interventions that discourage the unhealthy option.

Effects of policies or interventions that influence the school food environment on children's health and nonhealth outcomes: a systematic review

CONTEXT

Globally, 1 in 3 children under 5 years is undernourished or overweight, and 1 in 2 suffers from hidden hunger due to nutrient deficiencies. As children spend a considerable time at school, school-based policies that aim to improve children's dietary intake may help address this double burden of malnutrition.

OBJECTIVE

This systematic review aimed to assess the effects of implementing policies or interventions that influence the school food environment on children's health and nonhealth outcomes.

DATA SOURCES, EXTRACTION, AND ANALYSIS

Eleven databases were searched up to April 2020 and the World Health Organization (WHO) released a call for data due in June 2020. Records were screened against the eligibility criteria, and data extraction and risk-of-bias assessment were conducted by 1 reviewer and checked by another. The synthesis was based on effect direction, and certainty of evidence was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach.

CONCLUSIONS

Seventy-four studies reporting 10 different comparisons were included. The body of evidence indicates that interventions addressing the school food environment may have modest beneficial effects on certain key outcomes. Nutrition standards for healthy foods and beverages at schools, interventions that change how food is presented and positioned, and fruit and vegetable provision may have a beneficial effect on the consumption of healthy foods and beverages. Regarding effects on the consumption of discretionary foods and beverages, nutrition standards may have beneficial effects. Nutrition standards for foods and beverages, changes to portion size served, and the implementation of multiple nudging strategies may have beneficial effects on energy intake. Regarding effects of purchasing or selecting healthier foods, changes to how food is presented and positioned may be beneficial. This review was commissioned and supported by the WHO (registration 2020/1001698-0). WHO reviewed and approved the protocol for the systematic review and reviewed the initial report of the completed systematic review.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no: CRD42020186265.

A choice architecture intervention targeting school meals and water frequency intake: A school-based randomized trial

Our aim was to evaluate the impact of choice architecture on school meals and water intake frequency. We conducted a school-based randomized trial in seven elementary municipal public schools (control = 3; intervention = 4) in Rio de Janeiro, Brazil. The interventions group received the following modifications: (1) banner of the daily school meal menu and two superheroes, (2) waterproof tablecloths, (3) posters on healthy eating habits, (4) displays with playful names, (5) new containers for fruits, and (6) colored footprints for one month. Changes in school meals and daily water frequency consumption were evaluated through intention-to-treat analyses, using generalized estimating equations models for repeated measures, considering the classes' cluster effect. Data from 974 students in the fifth and sixth elementary school grades were analyzed (control = 356; intervention = 618). At baseline, 47.1% of students were female, with a mean age of 12 years (SD = 1.4), 39.2% reported daily consumption of school meals, and 45.7% consumed water from the school drinking fountain three or more times a day. We observed an increase in the odds of daily water intake in the intervention group compared to the control (OR = 1.4 95% CI = 1.1-1.9), no changes in the school meals (OR = 1.2 95% CI = 0.9; 1.6). Low-complexity strategies based on choice architecture applied in the school environment can be promising in increasing water intake frequency among elementary students in public schools. TRIAL REGISTRATION: This study was registered on the Clinicaltrials.gov platform under the number NCT03136016. Access: https://clinicaltrials.gov/ct2/show/NCT03136016.

A Mixed Methods, Quasi-Experimental Evaluation Exploring the Impact of a Secondary School Universal Free School Meals Intervention Pilot

Food insecurity amongst households with children is a growing concern globally. The impacts in children include poor mental health and reduced educational attainment. Providing universal free school meals is one potential way of addressing these impacts. This paper reports findings on the impact of a universal free school meals pilot in two English secondary schools. We adopted a mixed-methods, quasi-experimental design. The intervention schools were one mainstream school (n = 414) and one school for students with special educational needs (n = 105). Two other schools were used as comparators (n = 619; n = 117). The data collection comprised a cross sectional student survey during the pilot (n = 404); qualitative interviews with students (n = 28), parents (n = 20) and school staff (n = 12); and student observations of lunchtimes (n = 57). Qualitative data were analysed using thematic analysis, and descriptive analyses and logistic regressions were conducted on the quantitative data. Self-reports of food insecurity were high at both intervention (26.6%) and comparator schools (25.8%). No effects of the intervention were seen in the quantitative findings on either hunger or food insecurity. Qualitative findings indicated that students, families and staff perceived positive impact on a range of outcomes including food insecurity, hunger, school performance, family stress and a reduction in stigma associated with means-tested free school meals. Our research provides promising evidence in support of universal free school meals in secondary schools as a strategy for addressing growing food insecurity. Future research should robustly test the impact of universal free school meals in a larger sample of secondary schools, using before and after measures as well as a comparator group.

Effects of nutritional intervention strategies in the primary prevention of overweight and obesity in school settings: systematic review and network meta-analysis

Objective

To examine the effects of different nutritional intervention strategies in the school setting on anthropometric and quality of diet outcomes by comparing and ranking outcomes in a network meta-analysis.

Design

Systematic review and network meta-analysis.

Data sources

PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, Education Resources Information Centre (ERIC), PsycInfo, CAB Abstracts, Campbell Library, Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-Centre) BiblioMap, Australian Education Index, Joanna Briggs Institute Evidence-Based Practice (JBI EBP) database, Practice-based Evidence in Nutrition (PEN) database, ClinicalTrials.gov, Current Controlled Trials, and World Health Organization International Clinical Trials Registry Platform.

Eligibility criteria for selecting studies

A systematic literature search was performed from inception to 2 May 2022. Cluster randomised controlled trials meeting these study criteria were included: generally healthy school students aged 4-18 years; intervention with ≥1 nutritional components in a school setting; and studies that assessed anthropometric measures (eg, body mass index, body fat) or measures related to the quality of diet (eg, intake of fruit and vegetables), or both. Random effects pairwise meta-analyses and network meta-analyses were performed with a frequentist approach. P scores, a frequentist analogue to surface under the cumulative ranking curve, ranging from 0 to 1 (indicating worst and best ranked interventions, respectively) were calculated. Risk of bias was assessed with Cochrane's RoB 2 tool. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework was used to rate the certainty of evidence.

Results

51 cluster randomised controlled trials involving 75 954 participants and seven intervention nodes were included. Inconsistency could not be assessed (except for intake of fruit and vegetables) because the network meta-analyses were based mainly on star shaped networks with no direct evidence for specific pairs of nutritional interventions. Overall, little or no evidence was found to support a difference in body mass index, body weight, body fat, or waist circumference and moderate improvements in intake of fruit and vegetables with nutritional interventions in a school setting. Low to moderate certainty of evidence further suggested that multicomponent nutritional interventions likely reduced the prevalence (odds ratio 0.66, 95% confidence interval 0.55 to 0.80) and incidence (0.67, 0.47 to 0.96) of overweight compared with a control group. Based on low certainty of evidence, nutrition education and multicomponent interventions may be more effective than a control group (ie, usual practice) for increasing intake of fruit and vegetables. Multicomponent nutritional interventions were ranked the most effective for reducing body mass index (P score 0.76) and intake of fat (0.82). Nutrition education was ranked as best for body mass index z score (0.99), intake of fruit and vegetables (0.82), intake of fruit (0.92), and intake of vegetables (0.88).

Conclusions

The findings suggest that nutritional interventions in school settings may improve anthropometric and quality of diet measures, potentially contributing to the prevention of overweight and obesity in childhood and adolescence. The findings should be interpreted with caution because the certainty of evidence was often rated as low. The results of the network meta-analysis could be used by policy makers in developing and implementing effective, evidence based nutritional intervention strategies in the school setting.

Systematic review registration

PROSPERO CRD42020220451.

School Menu Review Programme (PReME): evaluation of compliance with dietary recommendations during the period 2006-2020 in Catalonia

BACKGROUND

The School Menu Review Programme (PReME) has been offering complimentary revisions of meal plans to all schools in Catalonia since 2006. This study aims to assess the evolution of compliance with PReME's recommendations in the meals provided by school cafeterias in Catalonia during the period 2006-2020.

METHODS

Pre-post study with a sample of 6,387 meal plans from 2221 schools assessed during the period. The information was collected mainly by public health specialists within the annual technical and sanitary inspection of school kitchens and cafeterias. Meal plans were evaluated by Dietitian-Nutritionists team according to the criteria of the National Health System's "Consensus document on nutrition in schools" and the Public Health Agency of Catalonia's current guide "Healthy eating at school". Reports were sent to each participating school. A few months later, a new meal plan and another questionnaire were collected and evaluated in comparison with the first meal plan. Compliance with the recommendations was analysed based on the type of canteen management and the school category.

RESULTS

Compliance improved during the study period. The percentage of schools that complied with dietary recommendations in relation to the five PReME indicators (fresh fruit, pulses, daily vegetables, fresh food and olive oil for dressing) has steadily increased since PReME began, (over 70% in all indictors; p =  < 0.001), with variations depending on school category and cafeteria management. Furthermore, an improvement in the levels of compliance with de recommended food frequencies was observed. with statistically significant differences for all items (p < 0.001), except for pulses whose compliance had been high since the beginning of the study (p = 0.216).

CONCLUSIONS

The positive evolution in compliance with PReME's recommendations provides evidence of the programme's effectiveness, with an improvement in the quality of school meals delivered in Catalonia.

Lifestyle Interventions for Elevated Blood Pressure in Childhood-Approaches and Outcomes

PURPOSE OF REVIEW

The purpose of this review is to provide an overview of existing and emerging lifestyle treatments in the clinical management of primary elevated blood pressure and hypertension in pediatric patients. The authors hope to expand the knowledge base surrounding pediatric hypertension and update clinicians on best practices to improve outcomes.

RECENT FINDINGS

Elevated blood pressure is traditionally addressed with broad lifestyle recommendations such as limiting salt consumption and losing weight. This approach is not well adapted for pediatric patients. Novel and often underutilized approaches to the treatment of hypertension in pediatrics include psychological counseling for behavior modification, circadian nutrition, consistent use of interdisciplinary teams, manipulation of macronutrients, stress management, technology-infused interventions, and systemic changes to the food environment. Elevated blood pressure is a pervasive condition affecting cardiovascular disease and mortality risk. Increasingly, pediatric patients are presenting with elevated blood pressure with etiologies known to be affected by lifestyle behaviors. Weight management, dietary modifications, and daily physical activity are well-researched methods for improving individual blood pressure measurements. These strategies can sometimes be as effective as pharmacological interventions at lowering blood pressure. However, compliance with these individual recommendations is not consistent and has led to unsatisfactory results. There are emerging treatment trends that may provide non-traditional and more effective non-pharmacologic routes to blood pressure management in pediatric patients.

Adolescents' dietary behaviour: The interplay between home and school food environments

In the UK, school food standards have looked to improve the nutritional profile of school food provision and the choices made; however, adolescents' choices tend to bias towards micronutrient poor and energy dense options. This study aimed to explore how adolescents make their school food choices, along with how they engage with their environments whilst selecting food. Seven focus group interviews took place with adolescents (n = 28; 13-14 years) in a secondary school in Northern England. Discussions with participants were audio-recorded, transcribed verbatim and then analysed using an inductive thematic approach. Six themes emerged from the data: (1) parents' and adolescents' roles in the home food environment, (2) burgeoning food autonomy, (3) school food choice factors, (4) social aspects of school food, (5) home versus school, (6) food knowledge & beliefs. Adolescents identified two distinct environments during the focus group discussions: the home and school environments. Adolescents juxtaposed the two, in terms of food provision, food choices, rules and customs surrounding food choice. This juxtaposition emerged as an indirect but important influence on adolescents' school food choices. The school and home environments both (in)directly influence adolescents' school food choices, which involve an integration of multiple, often conflicting influences. Adolescents may adopt a number of unhelpful dietary rationalisations as they try to manage and reconcile these influences. Consultation, together with consideration of relevant food choice models, is required to identify opportunities to influence adolescents' food choices at school.

Online Pre-Order Systems for School Lunches: Insights from a Cross-Sectional Study in Primary Schools

Schools are increasingly using online pre-order systems for children to select school meals in advance. This study aimed to explore how children use and interact with these systems. Using a combination of direct observation and an online questionnaire, the operation of these systems in four UK primary schools was examined. This included how the menu options were displayed, how these were selected by children (4–11 years), and the interactions between children and others when making food selections. Where possible, most children pre-ordered their school lunch in the classroom, and differences in the food choice process among children were observed. These apparently related to children’s ages; older children (8–11 years) showed more independence when making food selections, whereas younger children were often supported by others. Most parents reported that their child was the decision maker when pre-ordering the school lunch, and the role of children in the selection of school lunches was evident. This may be accentuated by the online pre-order systems, and given the likely expansion of these systems in schools, there is an opportunity to implement interventions to influence children towards specific or different meal options from the school menu.

A pilot study of a school lunchroom intervention in a predominately Latinx sample

OBJECTIVE

The purpose of the study was to assess the feasibility of an environmental school lunchroom intervention ('Smarter Lunchrooms') and test initial efficacy within a predominately Latinx population.

DESIGN

We collected baseline and intervention lunchroom food consumption and waste data in a pre-post, single group design. Meal consumption data was analyzed using Nutrition Data System for Research software to obtain estimates of nutritional content.

MAIN OUTCOME MEASURES

Feasibility.

SECONDARY MEASURES

Plate Waste, Nutrient Intake.

RESULTS

Participants were 88 1st-4th graders (51% female; 77% Latinx). Our recruitment rate was 45%, we were able to implement 8 Smarter Lunchroom strategies, and we were able to collect 82 baseline plate photos (93%) and 80 intervention photos (90%) of school lunches. On average, students threw away more than half of their meals on both days. Fruit consumption and fiber per 1000 kcal were significantly poorer at intervention compared to baseline.

CONCLUSIONS

Our findings highlight challenges in collecting consumption data in a real-world setting. We describe directions for future research taking into consideration our "lessons learned" from this formative work.

Impact of decreasing the proportion of higher energy foods and reducing portion sizes on food purchased in worksite cafeterias: A stepped-wedge randomised controlled trial

BACKGROUND

Overconsumption of energy from food is a major contributor to the high rates of overweight and obesity in many populations. There is growing evidence that interventions that target the food environment may be effective at reducing energy intake. The current study aimed to estimate the effect of decreasing the proportion of higher energy (kcal) foods, with and without reducing portion size, on energy purchased in worksite cafeterias.

METHODS AND FINDINGS

This stepped-wedge randomised controlled trial (RCT) evaluated 2 interventions: (i) availability: replacing higher energy products with lower energy products; and (ii) size: reducing the portion size of higher energy products. A total of 19 cafeterias were randomised to the order in which they introduced the 2 interventions. Availability was implemented first and maintained. Size was added to the availability intervention. Intervention categories included main meals, sides, cold drinks, snacks, and desserts. The study setting was worksite cafeterias located in distribution centres for a major United Kingdom supermarket and lasted for 25 weeks (May to November 2019). These cafeterias were used by 20,327 employees, mainly (96%) in manual occupations. The primary outcome was total energy (kcal) purchased from intervention categories per day. The secondary outcomes were energy (kcal) purchased from nonintervention categories per day, total energy purchased per day, and revenue. Regression models showed an overall reduction in energy purchased from intervention categories of -4.8% (95% CI -7.0% to -2.7%), p < 0.001 during the availability intervention period and a reduction of -11.5% (95% CI -13.7% to -9.3%), p < 0.001 during the availability plus size intervention period, relative to the baseline. There was a reduction in energy purchased of -6.6% (95% CI -7.9% to -5.4%), p < 0.001 during the availability plus size period, relative to availability alone. Study limitations include using energy purchased as the primary outcome (and not energy consumed) and the availability only of transaction-level sales data per site (and not individual-level data).

CONCLUSIONS

Decreasing the proportion of higher energy foods in cafeterias reduced the energy purchased. Decreasing portion sizes reduced this further. These interventions, particularly in combination, may be effective as part of broader strategies to reduce overconsumption of energy from food in out-of-home settings.

TRIAL REGISTRATION

ISRCTN registry ISRCTN87225572.

Characteristics and practices of school-based cluster randomised controlled trials for improving health outcomes in pupils in the United Kingdom: a methodological systematic review

Background

Cluster randomised trials (CRTs) are increasingly used to evaluate non-pharmacological interventions for improving child health. Although methodological challenges of CRTs are well documented, the characteristics of school-based CRTs with pupil health outcomes have not been systematically described. Our objective was to describe methodological characteristics of these studies in the United Kingdom (UK).

Methods

MEDLINE was systematically searched from inception to 30^th June 2020. Included studies used the CRT design in schools and measured primary outcomes on pupils. Study characteristics were described using descriptive statistics.

Results

Of 3138 articles identified, 64 were included. CRTs with pupil health outcomes have been increasingly used in the UK school setting since the earliest included paper was published in 1993; 37 (58%) studies were published after 2010. Of the 44 studies that reported information, 93% included state-funded schools. Thirty six (56%) were exclusively in primary schools and 24 (38%) exclusively in secondary schools. Schools were randomised in 56 studies, classrooms in 6 studies, and year groups in 2 studies. Eighty percent of studies used restricted randomisation to balance cluster-level characteristics between trial arms, but few provided justification for their choice of balancing factors. Interventions covered 11 different health areas; 53 (83%) included components that were necessarily administered to entire clusters. The median (interquartile range) number of clusters and pupils recruited was 31.5 (21 to 50) and 1308 (604 to 3201), respectively. In half the studies, at least one cluster dropped out. Only 26 (41%) studies reported the intra-cluster correlation coefficient (ICC) of the primary outcome from the analysis; this was often markedly different to the assumed ICC in the sample size calculation. The median (range) ICC for school clusters was 0.028 (0.0005 to 0.21).

Conclusions

The increasing pool of school-based CRTs examining pupil health outcomes provides methodological knowledge and highlights design challenges. Data from these studies should be used to identify the best school-level characteristics for balancing the randomisation. Better information on the ICC of pupil health outcomes is required to aid the planning of future CRTs. Improved reporting of the recruitment process will help to identify barriers to obtaining representative samples of schools.

Nudging healthier food choices in a cafeteria setting: A sequential multi-intervention field study

Creating more health-fostering environments is high on the agenda of public and private actors. The behavioral approach to nudge people towards healthier food choices is gaining popularity despite limited understanding about where, and for whom, which specific nudges work. This study contributes by reporting on three different nudging interventions in the same setting and presents effects on different sub-populations. We find overall small effects that are heterogeneous, ranging from robustly more to even less healthy choices. We discuss the importance of transparency and reactance to health interventions and the potential interplay of interventions with habitual behavior among different sub-populations.

Nudge with caution: targeting fruit and vegetable consumption in primary schools

Most children in the UK are not eating enough fruit and vegetables to support optimum health. Evidence-based interventions are needed to change this trend. In the present pilot study, effectiveness of simple behavioural nudges on children's lunchtime consumption of fruit and vegetables was tested in two primary (elementary) schools. Children's (n = 107) lunchtime consumption was measured directly through the use of a validated digital photography protocol; measures were taken at baseline and again after a 3-week long intervention. Changes to the choice architecture of dining rooms included improved presentation and provision of target foods, attractive advertisements and labelling, and prompting by staff. For children who took school lunches (n = 67), both selection and consumption of fruit increased as the result of the intervention. Their selection of vegetables did not change over time, however, and their consumption ether remained unchanged or declined. No changes were observed in the comparison group (n = 40), who brought their lunch boxes from home. These results caution against using selection (serving sizes), as estimates of consumption or a measure of behaviour changes. They also show that all evaluations should consider the effects of each intervention on children's eating overall, rather than just report changes in target item consumption, to check for any unintended consequences of the intervention.

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.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future non-communicable diseases, including cardiovascular disease. Testing the effects of interventions to increase consumption of fruit and vegetables, including those focused on specific child-feeding strategies or broader multicomponent interventions targeting the home or childcare environment is required to assess the potential to reduce this disease burden.

OBJECTIVES

To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 January 2020. We searched Proquest Dissertations and Theses in November 2019. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included trials to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risks of bias of included trials; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included 80 trials with 218 trial arms and 12,965 participants. Fifty trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Fifteen trials examined the impact of parent nutrition education only in increasing child fruit and vegetable intake. Fourteen trials examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. Two trials examined the effect of a nutrition education intervention delivered to children in increasing child fruit and vegetable intake. One trial examined the impact of a child-focused mindfulness intervention in increasing vegetable intake. We judged 23 of the 80 included trials as free from high risks of bias across all domains. Performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining trials. There is low-quality evidence that child-feeding practices versus no intervention may have a small positive effect on child vegetable consumption, equivalent to an increase of 5.30 grams as-desired consumption of vegetables (SMD 0.50, 95% CI 0.29 to 0.71; 19 trials, 2140 participants; mean post-intervention follow-up = 8.3 weeks). Multicomponent interventions versus no intervention has a small effect on child consumption of fruit and vegetables (SMD 0.32, 95% CI 0.09 to 0.55; 9 trials, 2961 participants; moderate-quality evidence; mean post-intervention follow-up = 5.4 weeks), equivalent to an increase of 0.34 cups of fruit and vegetables a day. It is uncertain whether there are any short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.13, 95% CI -0.02 to 0.28; 11 trials, 3050 participants; very low-quality evidence; mean post-intervention follow-up = 13.2 weeks). We were unable to pool child nutrition education interventions in meta-analysis; both trials reported a positive intervention effect on child consumption of fruit and vegetables (low-quality evidence). Very few trials reported long-term effectiveness (6 trials), cost effectiveness (1 trial) or unintended adverse consequences of interventions (2 trials), limiting our ability to assess these outcomes. Trials reported receiving governmental or charitable funds, except for four trials reporting industry funding.

AUTHORS' CONCLUSIONS

Despite identifying 80 eligible trials of various intervention approaches, the evidence for how to increase children's fruit and vegetable consumption remains limited in terms of quality of evidence and magnitude of effect. Of the types of interventions identified, there was moderate-quality evidence that multicomponent interventions probably lead to, and low-quality evidence that child-feeding practice may lead to, only small increases in fruit and vegetable consumption in children aged five years and under. It is uncertain whether parent nutrition education or child nutrition education interventions alone are effective in increasing fruit and vegetable consumption in children aged five years and under. Our confidence in effect estimates for all intervention approaches, with the exception of multicomponent interventions, is limited on the basis of the very low to low-quality evidence. Long-term follow-up of at least 12 months is required and future research should adopt more rigorous methods to advance the field. This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Papass clinical trial protocol: a multi-component school-based intervention study to increase acceptance and adherence to school feeding

Background

One of the largest school feeding programs in the world is the National School Feeding Program of Brazil. However, results from the 2012 National School Health Survey indicated that only 22.8% of 9th grade students in Brazilian public school system consumed school meals. The literature presents few studies aiming to promote healthy food consumption in the school environment from interventions, which found inconclusive results. Thus, this study aims to present a protocol to evaluate the effectiveness of multi-component school-level interventions to increase adherence and acceptance to school feeding.

Methods

School-based multi-component clinical trial with students from 4th-9^h grade from 3 municipal schools of Sumidouro, Rio de Janeiro, Brazil, in 2019. The study design will be parallel, with 3 arms: Control group (without intervention); Intervention group 1 (changes in school environment) and Intervention group 2 (changes in menu and school environment). Interventions in the environment will be based on the principles of choices architecture and, the modification in the dishes that make up the menus offered to the students, on the factors that contribute to poor adherence and acceptance to school feeding, identified by focus groups. Adherence to school feeding will be assessed through a specific question in the questionnaire directed to the frequency of consuming school meals in the week, applied by researchers in three moments. Acceptance will be assessed from the acceptability test application with dishes served to students during the year. Statistical analyses will be performed using generalized linear models, which will be used to assess the impact of the intervention, and will include 3 main variables: intervention, time and the intervention x time interaction.

Discussion

This study will investigate if the impact of the implementation of interventions in the environment and in the dishes served to students may increase adherence and acceptance to school feeding. Positive results could show the effect of implementing interventions throughout Sumidouro’s public school system, as well as throughout the country, aiming to improve the consumption of school meals.

Trial registration

Brazilian Registry of Clinical Trials, RBR-7mf794. Date of registration: December 27, 2018.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future non-communicable diseases, including cardiovascular disease. Interventions to increase consumption of fruit and vegetables, such as those focused on specific child-feeding strategies and parent nutrition education interventions in early childhood may therefore be an effective strategy in reducing this disease burden.

OBJECTIVES

To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 August 2019. We searched Proquest Dissertations and Theses in May 2019. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included trials to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risks of bias of included trials; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included 78 trials with 214 trial arms and 13,746 participants. Forty-eight trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Fifteen trials examined the impact of parent nutrition education in increasing child fruit and vegetable intake. Fourteen trials examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. Two trials examined the effect of a nutrition education intervention delivered to children in increasing child fruit and vegetable intake. One trial examined the impact of a child-focused mindfulness intervention in increasing vegetable intake. We judged 20 of the 78 included trials as free from high risks of bias across all domains. Performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining trials. There is very low-quality evidence that child-feeding practices versus no intervention may have a small positive effect on child vegetable consumption equivalent to an increase of 4.45 g as-desired consumption of vegetables (SMD 0.42, 95% CI 0.23 to 0.60; 18 trials, 2004 participants; mean post-intervention follow-up = 8.2 weeks). Multicomponent interventions versus no intervention has a small effect on child consumption of fruit and vegetables (SMD 0.34, 95% CI 0.10 to 0.57; 9 trials, 3022 participants; moderate-quality evidence; mean post-intervention follow-up = 5.4 weeks), equivalent to an increase of 0.36 cups of fruit and vegetables per day. It is uncertain whether there are any short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.12, 95% CI -0.03 to 0.28; 11 trials, 3078 participants; very low-quality evidence; mean post-intervention follow-up = 13.2 weeks). We were unable to pool child nutrition education interventions in meta-analysis; both trials reported a positive intervention effect on child consumption of fruit and vegetables (low-quality evidence). Very few trials reported long-term effectiveness (6 trials), cost effectiveness (1 trial) and unintended adverse consequences of interventions (2 trials), limiting their assessment. Trials reported receiving governmental or charitable funds, except for four trials reporting industry funding.

AUTHORS' CONCLUSIONS

Despite identifying 78 eligible trials of various intervention approaches, the evidence for how to increase children's fruit and vegetable consumption remains limited. There was very low-quality evidence that child-feeding practice may lead to, and moderate-quality evidence that multicomponent interventions probably lead to small increases in fruit and vegetable consumption in children aged five years and younger. It is uncertain whether parent nutrition education interventions are effective in increasing fruit and vegetable consumption in children aged five years and younger. Given that the quality of the evidence is very low or low, future research will likely change estimates and conclusions. Long-term follow-up of at least 12 months is required and future research should adopt more rigorous methods to advance the field. This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Measuring lunchtime consumption in school cafeterias: a validation study of the use of digital photography

OBJECTIVE

The present study tested the validity of a digital image-capture measure of food consumption suitable for use in busy school cafeterias.

DESIGN

Lunches were photographed pre- and post-consumption, and food items were weighed pre- and post-consumption for comparison.

SETTING

A small research team recorded children's lunchtime consumption in one primary and one secondary school over seven working days.ParticipantsA primary-school sample of 121 children from North Wales and a secondary-school sample of 124 children from the West Midlands, UK, were utilised. Nineteen children were excluded because of incomplete data, leaving a final sample of 239 participants.

RESULTS

Results indicated that (i) consumption estimates based on images were accurate, yielding only small differences between the weight- and image-based judgements (median bias=0·15-1·64 g, equating to 0·45-3·42 % of consumed weight) and (ii) good levels of inter-rater agreement were achieved, ranging from moderate to near perfect (Cohen's κ=0·535-0·819). This confirmed that consumption estimates derived from digital images were accurate and could be used in lieu of objective weighed measures.

CONCLUSIONS

Our protocol minimised disruption to daily lunchtime routine, kept the attrition low, and enabled better agreement between measures and raters than was the case in the existing literature. Accurate measurements are a necessary tool for all those engaged in nutrition research, intervention evaluation, prevention and public health work. We conclude that our simple and practical method of assessment could be used with children across a range of settings, ages and lunch types.