The effectiveness of lunchbox interventions on improving the foods and beverages packed and consumed by children at centre-based care or school: a systematic review and meta-analysis

A collaborative network trial to evaluate the effectiveness of implementation strategies to maximize adoption of a school-based healthy lunchbox program: a study protocol

Introduction

An important impediment to the large-scale adoption of evidence-based school nutrition interventions is the lack of evidence on effective strategies to implement them. This paper describes the protocol for a "Collaborative Network Trial" to support the simultaneous testing of different strategies undertaken by New South Wales Local Health Districts to facilitate the adoption of an effective school-based healthy lunchbox program ('SWAP IT'). The primary objective of this study is to assess the effectiveness of different implementation strategies to increase school adoption of the SWAP across New South Wales Local Health Districts.

Methods

Within a Master Protocol framework, a collaborative network trial will be undertaken. Independent randomized controlled trials to test implementation strategies to increase school adoption of SWAP IT within primary schools in 10 different New South Wales Local Health Districts will occur. Schools will be randomly allocated to either the intervention or control condition. Schools allocated to the intervention group will receive a combination of implementation strategies. Across the 10 participating Local Health Districts, six broad strategies were developed and combinations of these strategies will be executed over a 6 month period. In six districts an active comparison group (containing one or more implementation strategies) was selected. The primary outcome of the trial will be adoption of SWAP IT, assessed via electronic registration records captured automatically following online school registration to the program. The primary outcome will be assessed using logistic regression analyses for each trial. Individual participant data component network meta-analysis, under a Bayesian framework, will be used to explore strategy-covariate interactions; to model additive main effects (separate effects for each component of an implementation strategy); two way interactions (synergistic/antagonistic effects of components), and full interactions.

Discussion

The study will provide rigorous evidence of the effects of a variety of implementation strategies, employed in different contexts, on the adoption of a school-based healthy lunchbox program at scale. Importantly, it will also provide evidence as to whether health service-centered, collaborative research models can rapidly generate new knowledge and yield health service improvements.

Clinical trial registration

This trial is registered prospectively with the Australian New Zealand Clinical Trials Registry (ACTRN12623000558628).

How (not) to talk about plant-based foods: using language to support the transition to sustainable diets

Reducing meat consumption is essential to curb further climate change and limit the catastrophic environmental degradation resulting from the current global food system. However, consumers in industrialised countries are hesitant to reduce their meat intake, often because they find plant-based foods less appealing. Despite the climate emergency, eating meat is still perceived as the norm, and recommended in most national dietary guidelines. To support the transition to more sustainable diets by providing insights for increasing the appeal of plant-based foods to mainstream consumers, this review presents recent research findings on how people think and communicate about meat-based and plant-based foods. The key findings we review include: (1) while vegans think about plant-based foods in terms of enjoyable eating experiences, omnivores think about plant-based foods in terms of health, vegan identity and other abstract information that does not motivate consumption in the moment. (2) Packages of ready-meals and social media posts on Instagram present plant-based foods with fewer references to enjoyable eating experiences than meat-based foods. (3) Presenting plant-based foods with language that references enjoyable eating experiences increases their appeal, especially for habitual meat eaters. This language includes words about sensory features of the food (e.g., crunchy, creamy), eating context (e.g. pub; with family) and immediate positive consequences of eating (e.g. comforting, delicious). In contrast, the term 'vegan' is strongly associated with negative stereotypes. Hence, rather than referring to being vegan, meat-free or healthy, the language used for plant-based foods should refer to sensory appeal, attractive eating situations and enjoyment.

Healthy eating interventions delivered in early childhood education and care settings for improving the diet of children aged six months to six years

BACKGROUND

Dietary intake during early childhood can have implications on child health and developmental trajectories. Early childhood education and care (ECEC) services are recommended settings to deliver healthy eating interventions as they provide access to many children during this important period. Healthy eating interventions delivered in ECEC settings can include strategies targeting the curriculum (e.g. nutrition education), ethos and environment (e.g. menu modification) and partnerships (e.g. workshops for families). Despite guidelines supporting the delivery of healthy eating interventions in this setting, little is known about their impact on child health.

OBJECTIVES

To assess the effectiveness of healthy eating interventions delivered in ECEC settings for improving dietary intake in children aged six months to six years, relative to usual care, no intervention or an alternative, non-dietary intervention. Secondary objectives were to assess the impact of ECEC-based healthy eating interventions on physical outcomes (e.g. child body mass index (BMI), weight, waist circumference), language and cognitive outcomes, social/emotional and quality-of-life outcomes. We also report on cost and adverse consequences of ECEC-based healthy eating interventions.

SEARCH METHODS

We searched eight electronic databases including CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, ERIC, Scopus and SportDiscus on 24 February 2022. We searched reference lists of included studies, reference lists of relevant systematic reviews, the World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov and Google Scholar, and contacted authors of relevant papers.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), including cluster-RCTs, stepped-wedge RCTs, factorial RCTs, multiple baseline RCTs and randomised cross-over trials, of healthy eating interventions targeting children aged six months to six years that were conducted within the ECEC setting. ECEC settings included preschools, nurseries, kindergartens, long day care and family day care. To be included, studies had to include at least one intervention component targeting child diet within the ECEC setting and measure child dietary or physical outcomes, or both.

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently screened titles and abstracts and extracted study data. We assessed risk of bias for all studies against 12 criteria within RoB 1, which allows for consideration of how selection, performance, attrition, publication and reporting biases impact outcomes. We resolved discrepancies via consensus or by consulting a third review author. Where we identified studies with suitable data and homogeneity, we performed meta-analyses using a random-effects model; otherwise, we described findings using vote-counting approaches and via harvest plots. For measures with similar metrics, we calculated mean differences (MDs) for continuous outcomes and risk ratios (RRs) for dichotomous outcomes. We calculated standardised mean differences (SMDs) for primary and secondary outcomes where studies used different measures. We applied GRADE to assess certainty of evidence for dietary, cost and adverse outcomes.

MAIN RESULTS

We included 52 studies that investigated 58 interventions (described across 96 articles). All studies were cluster-RCTs. Twenty-nine studies were large (≥ 400 participants) and 23 were small (< 400 participants). Of the 58 interventions, 43 targeted curriculum, 56 targeted ethos and environment, and 50 targeted partnerships. Thirty-eight interventions incorporated all three components. For the primary outcomes (dietary outcomes), we assessed 19 studies as overall high risk of bias, with performance and detection bias being most commonly judged as high risk of bias. ECEC-based healthy eating interventions versus usual practice or no intervention may have a positive effect on child diet quality (SMD 0.34, 95% confidence interval (CI) 0.04 to 0.65; P = 0.03, I2 = 91%; 6 studies, 1973 children) but the evidence is very uncertain. There is moderate-certainty evidence that ECEC-based healthy eating interventions likely increase children's consumption of fruit (SMD 0.11, 95% CI 0.04 to 0.18; P < 0.01, I2 = 0%; 11 studies, 2901 children). The evidence is very uncertain about the effect of ECEC-based healthy eating interventions on children's consumption of vegetables (SMD 0.12, 95% CI -0.01 to 0.25; P =0.08, I2 = 70%; 13 studies, 3335 children). There is moderate-certainty evidence that ECEC-based healthy eating interventions likely result in little to no difference in children's consumption of non-core (i.e. less healthy/discretionary) foods (SMD -0.05, 95% CI -0.17 to 0.08; P = 0.48, I2 = 16%; 7 studies, 1369 children) or consumption of sugar-sweetened beverages (SMD -0.10, 95% CI -0.34 to 0.14; P = 0.41, I2 = 45%; 3 studies, 522 children). Thirty-six studies measured BMI, BMI z-score, weight, overweight and obesity, or waist circumference, or a combination of some or all of these. ECEC-based healthy eating interventions may result in little to no difference in child BMI (MD -0.08, 95% CI -0.23 to 0.07; P = 0.30, I2 = 65%; 15 studies, 3932 children) or in child BMI z-score (MD -0.03, 95% CI -0.09 to 0.03; P = 0.36, I2 = 0%; 17 studies; 4766 children). ECEC-based healthy eating interventions may decrease child weight (MD -0.23, 95% CI -0.49 to 0.03; P = 0.09, I2 = 0%; 9 studies, 2071 children) and risk of overweight and obesity (RR 0.81, 95% CI 0.65 to 1.01; P = 0.07, I2 = 0%; 5 studies, 1070 children). ECEC-based healthy eating interventions may be cost-effective but the evidence is very uncertain (6 studies). ECEC-based healthy eating interventions may have little to no effect on adverse consequences but the evidence is very uncertain (3 studies). Few studies measured language and cognitive skills (n = 2), social/emotional outcomes (n = 2) and quality of life (n = 3).

AUTHORS' CONCLUSIONS

ECEC-based healthy eating interventions may improve child diet quality slightly, but the evidence is very uncertain, and likely increase child fruit consumption slightly. There is uncertainty about the effect of ECEC-based healthy eating interventions on vegetable consumption. ECEC-based healthy eating interventions may result in little to no difference in child consumption of non-core foods and sugar-sweetened beverages. Healthy eating interventions could have favourable effects on child weight and risk of overweight and obesity, although there was little to no difference in BMI and BMI z-scores. Future studies exploring the impact of specific intervention components, and describing cost-effectiveness and adverse outcomes are needed to better understand how to maximise the impact of ECEC-based healthy eating interventions.

Healthy eating interventions delivered in early childhood education and care settings for improving the diet of children aged six months to six years

BACKGROUND

Dietary intake during early childhood can have implications on child health and developmental trajectories. Early childhood education and care (ECEC) services are recommended settings to deliver healthy eating interventions as they provide access to many children during this important period. Healthy eating interventions delivered in ECEC settings can include strategies targeting the curriculum (e.g. nutrition education), ethos and environment (e.g. menu modification) and partnerships (e.g. workshops for families). Despite guidelines supporting the delivery of healthy eating interventions in this setting, little is known about their impact on child health.

OBJECTIVES

To assess the effectiveness of healthy eating interventions delivered in ECEC settings for improving dietary intake in children aged six months to six years, relative to usual care, no intervention or an alternative, non-dietary intervention. Secondary objectives were to assess the impact of ECEC-based healthy eating interventions on physical outcomes (e.g. child body mass index (BMI), weight, waist circumference), language and cognitive outcomes, social/emotional and quality-of-life outcomes. We also report on cost and adverse consequences of ECEC-based healthy eating interventions.

SEARCH METHODS

We searched eight electronic databases including CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, ERIC, Scopus and SportDiscus on 24 February 2022. We searched reference lists of included studies, reference lists of relevant systematic reviews, the World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov and Google Scholar, and contacted authors of relevant papers.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), including cluster-RCTs, stepped-wedge RCTs, factorial RCTs, multiple baseline RCTs and randomised cross-over trials, of healthy eating interventions targeting children aged six months to six years that were conducted within the ECEC setting. ECEC settings included preschools, nurseries, kindergartens, long day care and family day care. To be included, studies had to include at least one intervention component targeting child diet within the ECEC setting and measure child dietary or physical outcomes, or both.

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently screened titles and abstracts and extracted study data. We assessed risk of bias for all studies against 12 criteria within RoB 1, which allows for consideration of how selection, performance, attrition, publication and reporting biases impact outcomes. We resolved discrepancies via consensus or by consulting a third review author. Where we identified studies with suitable data and homogeneity, we performed meta-analyses using a random-effects model; otherwise, we described findings using vote-counting approaches and via harvest plots. For measures with similar metrics, we calculated mean differences (MDs) for continuous outcomes and risk ratios (RRs) for dichotomous outcomes. We calculated standardised mean differences (SMDs) for primary and secondary outcomes where studies used different measures. We applied GRADE to assess certainty of evidence for dietary, cost and adverse outcomes.  MAIN RESULTS: We included 52 studies that investigated 58 interventions (described across 96 articles). All studies were cluster-RCTs. Twenty-nine studies were large (≥ 400 participants) and 23 were small (< 400 participants). Of the 58 interventions, 43 targeted curriculum, 56 targeted ethos and environment, and 50 targeted partnerships. Thirty-eight interventions incorporated all three components. For the primary outcomes (dietary outcomes), we assessed 19 studies as overall high risk of bias, with performance and detection bias being most commonly judged as high risk of bias. ECEC-based healthy eating interventions versus usual practice or no intervention may have a positive effect on child diet quality (SMD 0.34, 95% confidence interval (CI) 0.04 to 0.65; P = 0.03, I2 = 91%; 6 studies, 1973 children) but the evidence is very uncertain. There is moderate-certainty evidence that ECEC-based healthy eating interventions likely increase children's consumption of fruit (SMD 0.11, 95% CI 0.04 to 0.18; P < 0.01, I2 = 0%; 11 studies, 2901 children). The evidence is very uncertain about the effect of ECEC-based healthy eating interventions on children's consumption of vegetables (SMD 0.12, 95% CI -0.01 to 0.25; P =0.08, I2 = 70%; 13 studies, 3335 children). There is moderate-certainty evidence that ECEC-based healthy eating interventions likely result in little to no difference in children's consumption of non-core (i.e. less healthy/discretionary) foods (SMD -0.05, 95% CI -0.17 to 0.08; P = 0.48, I2 = 16%; 7 studies, 1369 children) or consumption of sugar-sweetened beverages (SMD -0.10, 95% CI -0.34 to 0.14; P = 0.41, I2 = 45%; 3 studies, 522 children). Thirty-six studies measured BMI, BMI z-score, weight, overweight and obesity, or waist circumference, or a combination of some or all of these. ECEC-based healthy eating interventions may result in little to no difference in child BMI (MD -0.08, 95% CI -0.23 to 0.07; P = 0.30, I2 = 65%; 15 studies, 3932 children) or in child BMI z-score (MD -0.03, 95% CI -0.09 to 0.03; P = 0.36, I2 = 0%; 17 studies; 4766 children). ECEC-based healthy eating interventions may decrease child weight (MD -0.23, 95% CI -0.49 to 0.03; P = 0.09, I2 = 0%; 9 studies, 2071 children) and risk of overweight and obesity (RR 0.81, 95% CI 0.65 to 1.01; P = 0.07, I2 = 0%; 5 studies, 1070 children). ECEC-based healthy eating interventions may be cost-effective but the evidence is very uncertain (6 studies). ECEC-based healthy eating interventions may have little to no effect on adverse consequences but the evidence is very uncertain (3 studies). Few studies measured language and cognitive skills (n = 2), social/emotional outcomes (n = 2) and quality of life (n = 3).

AUTHORS' CONCLUSIONS

ECEC-based healthy eating interventions may improve child diet quality slightly, but the evidence is very uncertain, and likely increase child fruit consumption slightly. There is uncertainty about the effect of ECEC-based healthy eating interventions on vegetable consumption. ECEC-based healthy eating interventions may result in little to no difference in child consumption of non-core foods and sugar-sweetened beverages. Healthy eating interventions could have favourable effects on child weight and risk of overweight and obesity, although there was little to no difference in BMI and BMI z-scores. Future studies exploring the impact of specific intervention components, and describing cost-effectiveness and adverse outcomes are needed to better understand how to maximise the impact of ECEC-based healthy eating interventions.

Interventions to Strengthen Environmental Sustainability of School Food Systems: Narrative Scoping Review

School food systems play a role in the wider food system, but there is a scarcity of literature exploring interventions that aim to improve the environmental sustainability of school food systems. The present review aimed to understand and describe the types of interventions that have previously been explored to strengthen the sustainability of school food systems along with their impact. We applied a scoping review methodology guided by Arksey and O'Malley, which included a review of the online database Scopus and the grey literature. Information relating to intervention design, study population, evaluation method and impact were extracted. In total, 6016 records were screened for eligibility, 24 of which were eligible for inclusion. The most common types of interventions were school lunch menus designed to be more sustainable; school food waste reduction; sustainable food system education using school gardens; and dietary interventions with added environmental components. This review highlights a range of interventions which could positively influence the environmental sustainability of school food systems. Further research is needed to explore the effectiveness of such interventions.

Influence of pilot and small trials in meta-analyses of behavioral interventions: a meta-epidemiological study

BACKGROUND

Pilot/feasibility or studies with small sample sizes may be associated with inflated effects. This study explores the vibration of effect sizes (VoE) in meta-analyses when considering different inclusion criteria based upon sample size or pilot/feasibility status.

METHODS

Searches were to identify systematic reviews that conducted meta-analyses of behavioral interventions on topics related to the prevention/treatment of childhood obesity from January 2016 to October 2019. The computed summary effect sizes (ES) were extracted from each meta-analysis. Individual studies included in the meta-analyses were classified into one of the following four categories: self-identified pilot/feasibility studies or based upon sample size but not a pilot/feasibility study (N ≤ 100, N > 100, and N > 370 the upper 75th of sample size). The VoE was defined as the absolute difference (ABS) between the re-estimations of summary ES restricted to study classifications compared to the originally reported summary ES. Concordance (kappa) of statistical significance of summary ES between the four categories of studies was assessed. Fixed and random effects models and meta-regressions were estimated. Three case studies are presented to illustrate the impact of including pilot/feasibility and N ≤ 100 studies on the estimated summary ES.

RESULTS

A total of 1602 effect sizes, representing 145 reported summary ES, were extracted from 48 meta-analyses containing 603 unique studies (avg. 22 studies per meta-analysis, range 2-108) and included 227,217 participants. Pilot/feasibility and N ≤ 100 studies comprised 22% (0-58%) and 21% (0-83%) of studies included in the meta-analyses. Meta-regression indicated the ABS between the re-estimated and original summary ES where summary ES ranged from 0.20 to 0.46 depending on the proportion of studies comprising the original ES were either mostly small (e.g., N ≤ 100) or mostly large (N > 370). Concordance was low when removing both pilot/feasibility and N ≤ 100 studies (kappa = 0.53) and restricting analyses only to the largest studies (N > 370, kappa = 0.35), with 20% and 26% of the originally reported statistically significant ES rendered non-significant. Reanalysis of the three case study meta-analyses resulted in the re-estimated ES rendered either non-significant or half of the originally reported ES.

CONCLUSIONS

When meta-analyses of behavioral interventions include a substantial proportion of both pilot/feasibility and N ≤ 100 studies, summary ES can be affected markedly and should be interpreted with caution.

Improving adolescents' dietary behaviours in the school-setting: challenges and opportunities

Adolescence is a critical time of physical, psychological and social development, and thus, optimal nutritional intakes are required during this life stage. Despite this, adolescence is recognised as a period of nutritional vulnerability, with many reportedly failing to meet current dietary guidelines. The school-setting presents a favourable environment to intervene and promote positive dietary behaviours and is also inclusive regardless of socio-economic status. However, a lack of consensus exists on how best to utilise schools to facilitate improvements in dietary behaviours among this age group. Whilst previous research has focused on identifying the factors motivating dietary choices within the school-setting, less is known on the optimum strategies to enhance these dietary choices which could positively contribute to the design of future interventions. It is reported that adolescents have good nutritional knowledge, although this does not appear to be a central consideration when making their dietary choices. Alternative factors at the individual (taste, visual appeal, familiarity, food quality, price, portion size, value for money, time/ convenience), social (peer influence), physical (product placement) and macro environment (food availability) levels have been frequently cited as important influences on adolescents' dietary choices in school. Although school-based interventions have shown potential in achieving positive dietary change among adolescents, more research is needed to determine the most effective methods in improving dietary behaviours in schools. This review summarises the key factors which influence adolescents' school-based dietary choices and the effectiveness of previously conducted interventions, identifying promising components for consideration when developing future dietary interventions within the school-setting.

School lunchboxes as an opportunity for health and environmental considerations: a scoping review

Very little research has focussed on children's school lunchboxes from both a health and environment standpoint. This scoping review explores studies that considered children's lunchbox food consumption trends at school and the environmental impacts of lunchbox contents. We conducted a scoping review of peer-reviewed literature with a focus on lunchboxes of children in preschool or primary school settings that contained food packed from home, through the lens of food and nutrition in combination with environmental outcomes-particularly food and/or packaging waste. The review included 10 studies, with articles from Australia, USA, Spain, New Zealand and the UK. Half of them were intervention studies aiming to shift knowledge levels and attitudes of teachers, parents and children with regard to reducing packaged food choices and food waste, and improving dietary habits. Acknowledging the complexity of lunchbox packing and consumption practices, this review recommends the consideration of socio-ecological influences on children's health and sustainability behaviour, and mobilizing their pro-environmental agency.

Are mothers under lunchbox pressure? An exploration of the experiences of Victorian mothers preparing lunchboxes for their children

ISSUE ADDRESSED

A healthy diet is particularly important during childhood. Research suggests that more than 95% of Australian primary school aged children do not eat a diet consistent with the Australian Dietary Guidelines, putting them at risk of poor health. Interventions to improve the quality of children's lunchboxes may help address this issue. However, there is limited understanding of the factors impacting lunchbox preparation.

METHODS

This study explored the experiences of 10 mothers of Victorian primary school students. Mothers took part in semi-structured interviews exploring their views on lunchbox preparation and food choices. The study used a Constructivist Grounded Theory methodology and data were analysed using an inductive, thematic approach.

RESULTS

Analysis of the interviews yielded four main themes. (i) Mothers experienced a range of non-nutritional barriers that impacted the food choices they made for their children. (ii) Children's preferences influenced parental food choices. (iii) Mothers experienced and/or perceived judgement about the food choices they make for their children. And (iv) Mothers identified a lack of support and information from schools about what was appropriate for school lunch.

CONCLUSION

Findings of this study indicate that mothers are concerned with balancing nutrition and child preferences within the broader context of guidelines, perceived or real judgement and income constraints. SO WHAT?: The school environment may be an ideal setting to promote healthy eating but support for parents is needed. This is the first study in Victoria exploring mothers' perspectives on lunchbox preparation and provides initial information on which future research can build.

Content of lunchboxes of Dutch primary school children and their perceptions of alternative healthy school lunch concepts

OBJECTIVE

To investigate the content of lunchboxes of primary school children and to examine children's support and preferences for alternative healthy school lunch concepts.

DESIGN

A cross-sectional study among Dutch children from seven primary schools. The content of the lunchboxes was assessed by photographs. Support and preferences for alternative lunch concepts were examined via a self-reported questionnaire. Linear regression analyses were used to investigate the associations between children's support and preferences and sex, educational group and migration background.

SETTING

The Netherlands.

PARTICIPANTS

Primary school children.

RESULTS

A total of 660 children were included (average 9·9 years old). Most lunchboxes contained sandwiches and a drink. Few lunchboxes contained fruit or vegetables. The alternative school lunch concepts elicited mixed support among children. The lunch concepts 'Sandwiches prepared by the children themselves' and a 'hot lunch buffet' had the highest mean support, while the concept 'a healthy lunch brought from home' was the most preferred concept. Small significant differences were observed depending on sex, educational group and migration background.

CONCLUSION

Lunchboxes of Dutch children contained sandwiches and a drink but rarely fruit and vegetables. Among different alternatives, children reported the highest support for the preparation of their own sandwiches in class or a hot lunch buffet. Future studies should investigate if these alternative lunch concepts improve the dietary intake of children.

Perceived effect of warning label on parental food purchasing and drivers of food selection among South African parents–An exploratory study

Household food purchasing decision is a complex process influenced by factors such as marketing, cost, children food preference and parental choices. Most food products targeted toward children are unhealthy and are aggressively marketed to increase desirability among parents and children making healthier food selection even harder. The warning label (WL) is identified as a simple front-of-package labeling format that assist consumers to easily identify unhealthy foods and reduce their purchasing. This was a qualitative study that aimed to investigate the perceived effect of the warning label (WL) on parental food purchasing and drivers of food selection among parents. The study was conducted in a mainly rural part of South Africa, in Limpopo Province. Data were collected from 44 adult participants, all parents with children aged below 16 years selected using the snowball sampling method. Seven focus groups diversified according to age, literacy, income and urbanicity were utilized for data collection. Using a focus group discussion guide, parents were shown images of six products (crisps, soda, juice, biscuits, cereals, and yogurt) superimposed with the WL and questions asked were based on those images. Thematic analysis revealed that although some parents felt undeterred by the WL, some felt they would alter their food purchasing in the presence of the WL. Other parents felt they would reduce the frequency or the amount purchased or completely stop purchasing labeled products for their children. Motives behind perceived behavior modification included children's health being perceived as a priority and labeled products being viewed as unhealthy. Factors such as pressure from children, taste, poor nutrition knowledge and affordability seemed to influence parental food selection. These findings have important policy implications by providing evidence to policymakers that the WL may alter parental food purchasing and also provide insight into drivers of food selection among South African parents.

Healthy Food Environments in Early Learning Services: An Analysis of Manager Survey Responses, Menus and Policies in Regional New Zealand Early Childhood Education and Care Centres

Healthy food environments in early childhood play an important role in establishing health-promoting nutritional behaviours for later life. We surveyed Early Learning Services (ELS) in the Hawke’s Bay region of New Zealand and describe common barriers and facilitators to providing a healthy food environment, through descriptive survey analysis and thematic analysis of open-ended questions. We used a policy analysis tool to assess the strength and comprehensiveness of the individual centre’s nutrition policies and we report on the healthiness of menus provided daily in the centres. Sixty-two centres participated and 96.7% had policies on nutrition compared to 86.7% with policies on drinks. Of the 14 full policies provided for analysis, identified strengths were providing timelines for review and encouraging role modelling by teachers. The main weaknesses were communication with parents and staff, lack of nutrition training for staff and absence of policies for special occasion and fundraising food. With regard to practices in the ELS, food for celebrations was more likely to be healthy when provided by the centre rather than brought from home. Food used in fundraising was more likely to be unhealthy than healthy, though <20% of centres reported using food in fundraising. Only 40% of menus analysed met the national guidelines by not including any ‘red’ (unhealthy) items. Centre Managers considered the biggest barriers to improving food environments to be a lack of parental support and concerns about food-related choking. These results highlight the need for future focus in three areas: policies for water and milk-only, celebration and fundraising food; increased nutrition-focused professional learning and development for teachers; and communication between the centre and parents, as a crucial pathway to improved nutrition for children attending NZ early childhood education and care centres.

The Lunchbox Study: A Pilot Examination of Packed Lunches of Children with Autism Spectrum Disorder

Background: This study examined foods packed and consumed by children with autism spectrum disorder (ASD) and calculated the percentage of packed school lunches meeting National School Lunch Program (NSLP) standards. Fruit and vegetable (FV) consumption was further examined by investigating its association with the number and type of foods packed. Methods: Participants included 59 private school students observed for five school meals. Servings of foods and beverages packed and consumed and the percentages of correspondence between food packed and consumed were calculated. Next, the percentages of lunches meeting NSLP guidelines were calculated. Finally, mealtime means were calculated for the number of foods packed, FVs packed, and FVs consumed. Results: There was a high correspondence between foods packed and consumed. Fresh fruits and sugar-added drinks were most often packed and consumed. The percentage of meals meeting NSLP guidelines was higher than previous non-ASD samples. More FV consumption was associated with more FVs packed and fewer total foods packed. FV consumption was highest with 4 < 5 foods packed, including 2+ FVs. Conclusions: Future studies should compare foods packed and consumed by children with and without ASD. The FV consumption findings suggest parents may increase children’s FV consumption by packing approximately four total foods with two FVs.

An mHealth Intervention to Reduce the Packing of Discretionary Foods in Children's Lunch Boxes in Early Childhood Education and Care Services: Cluster Randomized Controlled Trial

Background

Interventions in early childhood education and care (ECEC) services have the potential to improve children’s diet at the population level.

Objective

This study aims to test the efficacy of a mobile health intervention in ECEC services to reduce parent packing of foods high in saturated fat, sugar, and sodium (discretionary foods) in children’s (aged 3-6 years) lunch boxes.

Methods

A cluster randomized controlled trial was undertaken with 355 parent and child dyads recruited by phone and in person from 17 ECEC services (8 [47%] intervention and 9 [53%] control services). Parents in the intervention group received a 10-week fully automated program targeting barriers to packing healthy lunch boxes delivered via an existing service communication app. The program included weekly push notifications, within-app messages, and links to further resources, including websites and videos. The control group did not receive any intervention. The primary outcomes were kilojoules from discretionary foods and associated nutrients (saturated fat, free sugars, and sodium) packed in children’s lunch boxes. Secondary outcomes included consumption of kilojoules from discretionary foods and related nutrients and the packing and consumption of serves of discretionary foods and core food groups. Photography and weights of foods in children’s lunch boxes were recorded by trained researchers before and after the trial to assess primary and secondary outcomes. Outcome assessors were blinded to service allocation. Feasibility, appropriateness, and acceptability were assessed via an ECEC service manager survey and a parent web-based survey. Use of the app was assessed via app analytics.

Results

Data on packed lunch box contents were collected for 88.8% (355/400) of consenting children at baseline and 84.3% (337/400) of children after the intervention. There was no significant difference between groups in kilojoule from discretionary foods packed (77.84 kJ, 95% CI −163.49 to 319.18; P=.53) or the other primary or secondary outcomes. The per-protocol analysis, including only data from children of parents who downloaded the app, also did not find any statistically significant change in primary (−1.98 kJ, 95% CI −343.87 to 339.90; P=.86) or secondary outcomes. Approximately 61.8% (102/165) of parents in the intervention group downloaded the app, and the mean service viewing rate of weekly within-app messages was 26% (SD 14.9). Parents who responded to the survey and participating services agreed that it was appropriate to receive lunch box information via the app (40/50, 80% and 6/8, 75%, respectively).

Conclusions

The intervention was unable to demonstrate an impact on kilojoules or associated nutrients from discretionary foods packed in children’s lunch boxes. Low app downloads and program message views indicate a need to explore how to improve factors related to implementation before further testing similar mobile health interventions in this setting.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12618000133235; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374379

The Let's Eat Healthy and Move at School program for adolescents in South Korea: Program design, implementation, and evaluation plan using intervention mapping

Purpose

This study aimed to systematically develop an obesity prevention program for adolescents to promote healthy eating and physical activity in schools.

Methods

The development of the Let's Eat Healthy and Move at School program for adolescents followed the six steps of intervention mapping (IM). IM is a widely used protocol for developing systematic and effective interventions based on theories and evidence.

Results

To better understand the problem and identify the needs of adolescents, interviews were conducted with teachers, school nurses, and students (step 1). In step 2, the desired behaviors and their determinants were established and combined into a matrix comprising 16 change objectives. In step 3, theoretical methods such as persuasive communication and consciousness-raising were chosen. The program was segmented into three educational activity sessions in step 4. In step 5, an implementation manual was developed for program instructors to ensure effective and accurate implementation. Finally, practices for evaluating the program's effectiveness and procedures were designed in step 6.

Conclusion

The Let’s Eat Healthy and Move at School program will provide adolescents with guidelines to promote healthy living and prevent obesity in everyday life using strategies for sustainable adolescent obesity prevention and management.

Intervención para modificar hábitos alimentarios en los refrigerios de escolares de una ciudad fronteriza México / Estados Unidos

El objetivo del presente estudio fue evaluar el efecto de una intervención en educación nutricional como estrategia para modificar la calidad de los refrigerios escolares de acuerdo con los estándares gubernamentales. Se evaluaron alumnos de 12 escuelas primarias públicas de nivel socioeconómico medio. Se formó un grupo intervención (GI) y un grupo control (GC), con seguimiento durante dos años. En ambos grupos se tomaron mediciones de peso, estatura y circunferencia de cintura. Se registró, durante cinco días consecutivos, los alimentos incluidos en la lonchera de los niños, previa firma de un consentimiento informado de los padres. Durante la intervención se realizaron pláticas sobre alimentación en el salón de clase para los escolares y a los padres de familia se les entregaron folletos sobre recomendaciones de un refrigerio adecuado. En el GC solo se entregaron folletos sin tener contacto con alumnos y padres de familia. Al final de la intervención, el GI disminuyó calorías (p = 0.001), proteínas (p = 0.01), carbohidratos (p = 0.008) y azúcar (p = 0.0001); mientras que en el GC disminuyó el contenido de carbohidratos y azúcar. Además, el GI aumentó el consumo de cereales integrales, verduras, frijoles y pan integral. En conclusión, la escuela es el lugar ideal para realizar intervenciones a largo plazo, sin embargo, es necesario promover la incorporación de profesionales de la salud (nutriólogos) con programas y actividades planeadas durante los seis años de primaria.

Efficacy of a school-based physical activity and nutrition intervention on child weight status: Findings from a cluster randomized controlled trial

Despite the benefits of factorial designs in quantifying the relative benefits of different school-based approaches to prevent unhealthy weight gain among students, few have been undertaken. The aims of this 2 × 2 cluster randomized factorial trial was to evaluate the impact of a physical activity and nutrition intervention on child weight status and quality of life. Twelve primary schools in New South Wales, Australia randomly allocated to one of four groups: (i.) physical activity (150 min of planned in-school physical activity); (ii.) nutrition (a healthy school lunch-box); (iii.) combined physical activity and nutrition; or (iv.) control. Outcome data assessing child weight and quality of life were collected at baseline and 9-months post-baseline. Within Grades 4-6 in participating schools, 742 students participated in anthropometric measurements, including child body mass index (BMI) and waist circumference, at baseline and follow-up. Findings indicated that students that received the nutrition intervention had higher odds of being classified in the BMI category of underweight/healthy weight (OR 1.64 95%CI 1.07, 2.50; p = 0.0220), while those who received the physical activity intervention reported a lower waist circumference (mean difference - 1.86 95%CI -3.55, -0.18; p = 0.030). There were no significant effects of the nutrition or physical activity intervention on child BMI scores or child quality of life, and no significant synergistic effects of the two interventions combined. Future research assessing the longer-term impact of both intervention strategies, alone and combined, is warranted to better understand their potential impact on child health. TRIAL REGISTRATION: Australian Clinical Trials Registry ACTRN: ACTRN12616001228471.

Cost and Cost Effectiveness of a Pilot m-Health Intervention Targeting Parents of School-Aged Children to Improve the Nutritional Quality of Foods Packed in the Lunchbox

The SWAP IT program aims to improve the nutritional quality of school lunchboxes via a multicomponent m-health intervention, involving: weekly support messages to parents; physical resources; school nutrition guidelines and lunchbox lessons. SWAP IT has been reported to be effective. This study aims to determine the cost and cost effectiveness of the SWAP IT m-health intervention. The retrospective trial-based economic evaluation was conducted in 12 Catholic primary schools in New South Wales, Australia. Schools were randomised to intervention or usual care. The costs (AUD, 2019) were evaluated from societal perspectives. The direct cost to uptake the intervention and the incremental cost-effectiveness ratios (ICER) were calculated. ICERS were calculated for two outcomes: reduction in total kJ and reduction in discretionary kJ from the lunchbox. The total cost was calculated to be AUD 55, 467. The mean incremental cost per student to receive the intervention was calculated to be AUD 31/student. The cost per reduction in total lunchbox energy was AUD 0.54. The ICER for the reduction in energy from discretionary foods in the lunchbox was AUD 0.24. These findings suggest that this m-health intervention has potential to be cost effective in reducing the kilojoules from discretionary foods packed in school lunchboxes.

A Multicomponent mHealth-Based Intervention (SWAP IT) to Decrease the Consumption of Discretionary Foods Packed in School Lunchboxes: Type I Effectiveness-Implementation Hybrid Cluster Randomized Controlled Trial

Background

There is significant opportunity to improve the nutritional quality of foods packed in children’s school lunchboxes. Interventions that are effective and scalable targeting the school and home environment are therefore warranted.

Objective

This study aimed to assess the effectiveness of a multicomponent, mobile health–based intervention, SWAP IT, in reducing the energy contribution of discretionary (ie, less healthy) foods and drinks packed for children to consume at school.

Methods

A type I effectiveness–implementation hybrid cluster randomized controlled trial was conducted in 32 primary schools located across 3 local health districts in New South Wales, Australia, to compare the effects of a 6-month intervention targeting foods packed in children’s lunchboxes with those of a usual care control. Primary schools were eligible if they were not participating in other nutrition studies and used the required school communication app. The Behaviour Change Wheel was used to co-design the multicomponent SWAP IT intervention, which consisted of the following: school lunchbox nutrition guidelines, curriculum lessons, information pushed to parents digitally via an existing school communication app, and additional parent resources to address common barriers to packing healthy lunchboxes. The primary outcome, mean energy (kilojoules) content of discretionary lunchbox foods and drinks packed in lunchboxes, was measured via observation using a validated school food checklist at baseline (May 2019) and at 6-month follow-up (October 2019). Additional secondary outcomes included mean lunchbox energy from discretionary foods consumed, mean total lunchbox energy packed and consumed, mean energy content of core lunchbox foods packed and consumed, and percentage of lunchbox energy from discretionary and core foods, all of which were also measured via observation using a validated school food checklist. Measures of school engagement, consumption of discretionary foods outside of school hours, and lunchbox cost were also collected at baseline and at 6-month follow-up. Data were analyzed via hierarchical linear regression models, with controlling for clustering, socioeconomic status, and remoteness.

Results

A total of 3022 (3022/7212, 41.90%) students consented to participate in the evaluation (mean age 7.8 years; 1487/3022, 49.22% girls). There were significant reductions between the intervention and control groups in the primary trial outcome, mean energy (kilojoules) content of discretionary foods packed in lunchboxes (–117.26 kJ; 95% CI –195.59 to –39.83; P=.003). Relative to the control, the intervention also significantly reduced secondary outcomes regarding the mean total lunchbox energy (kilojoules) packed (–88.38 kJ; 95% CI –172.84 to –3.92; P=.04) and consumed (–117.17 kJ; 95% CI –233.72 to –0.62; P=.05). There was no significant difference between groups in measures of student engagement, consumption of discretionary foods outside of school hours, or cost of foods packed in children’s lunchboxes.

Conclusions

The SWAP IT intervention was effective in reducing the energy content of foods packed for and consumed by primary school–aged children at school. Dissemination of the SWAP IT program at a population level has the potential to influence a significant proportion of primary school–aged children, impacting weight status and associated health care costs.

Trial Registration

Australian Clinical Trials Registry ACTRN12618001731280; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=376191&isReview=true

International Registered Report Identifier (IRRID)

RR2-10.1186/s12889-019-7725-x

The Association between Australian Childcare Centre Healthy Eating Practices and Children's Healthy Eating Behaviours: A Cross-Sectional Study within Lunchbox Centres

The association between healthy eating practices and child dietary intake in childcare centres where parents pack foods from home has received little attention. This study aimed to: (1) Describe the nutritional content of foods and beverages consumed by children in care; and (2) Assess the association between centre healthy eating practices and child intake of fruit and vegetable servings, added sugar(grams), saturated fat(grams) and sodium(milligrams) in care. A cross-sectional study amongst 448 children attending 22 childcare centres in New South Wales, Australia, was conducted. Child dietary intake was measured via weighed lunchbox measurements, photographs and researcher observation, and centre healthy eating practices were assessed via researcher observation of centre nutrition environments. Children attending lunchbox centres consumed, on average 0.80 servings (standard deviation 0.69) of fruit and 0.27 servings (standard deviation 0.51) of vegetables in care. The availability of foods within children’s lunchboxes was associated with intake of such foods (p < 0.01). Centre provision of intentional healthy eating learning experiences (estimate −0.56; p = 0.01) and the use of feeding practices that support children’s healthy eating (estimate −2.02; p = 0.04) were significantly associated with reduced child intake of saturated fat. Interventions to improve child nutrition in centres should focus on a range of healthy eating practices, including the availability of foods packed within lunchboxes.

Improving the school food environment for the prevention of childhood obesity: What works and what doesn't

The food environment has a significant influence on dietary choices, and interventions designed to modify the food environment could contribute to the prevention of childhood obesity. Many interventions have been implemented at the school level, but effectiveness in addressing childhood obesity remains unclear. We undertook a systematic review, a meta-analysis, and meta-regression analyses to assess the effectiveness of interventions on the food environment within and around schools to improve dietary intake and prevent childhood obesity. Estimates were pooled in a random-effects meta-analysis with stratification by anthropometric or dietary intake outcome. Risk of bias was formally assessed. One hundred papers were included. Interventions had a significant and meaningful effect on adiposity (body mass index [BMI] z score, standard mean difference: -0.12, 95% confidence interval: 0.15, 0.10) and fruit consumption (portions per day, standard mean difference: +0.19, 95% confidence interval: 0.16, 0.22) but not on vegetable intake. Risk of bias assessment indicated that n = 43 (81%) of non-randomized controlled studies presented a high risk of bias in the study design by not accounting for a control. Attrition bias (n = 34, 79%) and low protection of potential contamination (n = 41, 95%) presented the highest risk of bias for randomized controlled trials. Changes in the school food environment could improve children's dietary behavior and BMI, but policy actions are needed to improve surrounding school food environments to sustain healthy dietary intake and BMI.

Current Systems-Level Evidence on Nutrition Interventions to Prevent and Treat Cardiometabolic Risk in the Pediatric Population: An Evidence Analysis Center Scoping Review

Improving and maintaining cardiometabolic health remains a major focus of health efforts for the pediatric population. Recent research contributes understanding of the systems-level nutrition factors influencing cardiometabolic health in pediatric individuals. This scoping review examines current evidence on interventions and exposures influencing pediatric cardiometabolic health to inform registered dietitian nutritionists working at each systems level, ranging from individual counseling to public policy. A literature search of MEDLINE, CINAHL, Cochrane Databases of Systematic Reviews, and other databases was conducted to identify evidence-based practice guidelines, systematic reviews, and position statements published in English from January 2017 until April 2020. Included studies addressed nutrition interventions or longitudinal exposures for participants 2 to 17 years of age who were healthy or had cardiometabolic risk factors. Studies were categorized according level of the social-ecological framework addressed. The databases and hand searches identified 2614 individual articles, and 169 articles were included in this scoping review, including 6 evidence-based practice guidelines, 141 systematic reviews, and 22 organization position statements. The highest density of systematic reviews focused on the effects of dietary intake (n = 58) and interventions with an individual child or family through counseling or education (n = 54). The least frequently examined levels of interventions or exposures were at the policy level (n = 12). Registered dietitian nutritionists can leverage this considerable body of recent systematic reviews to inform a systems-level, collaborative approach to prevention and treatment of pediatric cardiometabolic risk factors.

Obesity Prevention within the Early Childhood Education and Care Setting: A Systematic Review of Dietary Behavior and Physical Activity Policies and Guidelines in High Income Countries

As a strategy for early childhood obesity prevention, a variety of dietary behavior and physical activity policies and guidelines published by leading health agencies and early childhood education and care (ECEC) licensing and accreditation bodies exist. Given the potential diversity in recommendations from these policies, this narrative review sought to synthesize, appraise and describe the various policies and guidelines made by organizational and professional bodies to highlight consistent recommendations and identify opportunities to strengthen such policies. An electronic bibliographic search of seven online databases and grey literature sources was undertaken. Records were included if they were policies or guidelines with specific recommendations addressing dietary behavior and/or physical activity practice implementation within the ECEC setting; included children aged >12 months and <6 years and were developed for high income countries. Recommended dietary behavior and physical activity policies and practices were synthesized into broad themes using the Analysis Grid for Environments Linked to Obesity framework, and the quality of included guidelines appraised. Our search identified 38 eligible publications mostly from the US and Australia. Identified guidelines were largely consistent in their recommendation and frequently addressed the physical and sociocultural environment and were well-aligned with research evidence. Broader consideration of policy and economic environments may be needed to increase the impact of such policies and guidelines within the ECEC setting.

Consolidating evidence on the effectiveness of interventions promoting fruit and vegetable consumption: an umbrella review

BACKGROUND

The overarching objective was to examine the effectiveness of intervention strategies to promote fruit and vegetable consumption. To do this, systematic review evidence regarding the effects of intervention strategies was synthesized; organized, where appropriate, by the setting in which the strategies were implemented. Additionally, we sought to describe gaps in the review of evidence; that is, where evidence regarding the effectiveness of recommended policy actions had not been systematically synthesised.

METHODS

We undertook a systematic search of electronic databases and the grey literature to identify systematic reviews describing the effects of any intervention strategy targeting fruit and/or vegetable intake in children or adults of any age.

RESULTS

The effects of 32 intervention strategies were synthesised from the 19 included reviews. The strategies were mapped across all three broad domains of the NOURISHING framework (i.e. food environment, food system and behaviour change communication), but covered just 14 of the framework's 65 sub-policy areas. There was evidence supporting the effectiveness of 19 of the 32 intervention strategies. The findings of the umbrella review suggest that intervention strategies implemented within schools, childcare services, homes, workplaces and primary care can be effective, as can eHealth strategies, mass media campaigns, household food production strategies and fiscal interventions.

CONCLUSIONS

A range of effective strategy options are available for policy makers and practitioners interested in improving fruit and/or vegetable intake. However, the effects of many strategies - particularly those targeting agricultural production practices, the supply chain and the broader food system - have not been reported in systematic reviews. Primary studies assessing the effects of these strategies, and the inclusion of such studies in systematic reviews, are needed to better inform national and international efforts to improve public health nutrition.

TRIAL REGISTRATION

The review protocol was deposited in a publicly available Open Science framework prior to execution of the search strategy. https://osf.io/unj7x/.

Opportunities for intervention and innovation in school food within UK schools

We have recently been funded by the UK Prevention Research Partnership (UKPRP) to develop a UK school food network. The overarching aim is to build a community working towards a more health-promoting food and nutrition system in UK schools (primary and secondary). Here we describe the current status of school food research, including a review of the literature supporting the health-promoting schools approach and outline the opportunities for intervention and innovation establishment of the network present. Key potential school food research themes are described, and their prioritisation within the network, as well as network activities that have been planned, with the ultimate ambition of reducing socio-economic diet-related inequalities, and, consequently, non-communicable disease risk.

Stakeholder Generated Ideas for Alternative School Food Provision Models in Australia Using the Nominal Group Technique

Good nutrition is important for children's learning, growth, and development, yet food intake during school hours does not align with recommendations. In Australia, most school children currently bring a packed lunch from home, but what if there was a different way? This project aimed to engage a diverse range of stakeholders to (1) generate, refine and prioritize ideas for novel models of food provision to Australian children within school hours, and (2) to determine and rank the potential barriers and facilitators to changing the school food provision system. This study used nominal group technique virtual workshops-three idea generation workshops (n = 21 participants) and one consensus workshop (n = 11 participants). School lunch prepared onsite was the top ranked food provision model option based on impact and achievability. Potential barriers (n = 26) and facilitators (n = 28) to changing the school food system were generated. The top ranked barrier and facilitator related to government support. This study highlights that there is an opportunity to explore partnerships and utilize existing skills and infrastructure to introduce a universal school-provided lunch model in Australia. The next steps should focus on building the business case capturing the social value of investing in school lunches, including considering parent-paid and subsidized options.

Processed and Packed: How Refined Are the Foods That Children Bring to School for Snack and Lunch?

BACKGROUND

Increasing consumption of highly processed foods has been associated with adverse health outcomes among children. In the US, children consume up to half of their daily energy intake at school.

OBJECTIVES

We sought to characterize foods that children bring from home to school according to processing level and to evaluate the effectiveness of a school-based intervention, Great Taste Less Waste (GTLW), in reducing the proportion of energy brought from highly processed foods from home compared with control.

DESIGN

Secondary data analysis of a 7-month school-based, cluster-randomized trial.

PARTICIPANTS/SETTING

Third- and fourth-grade students (n = 502, mean age: 9.0 ± 0.62 years) at 10 public elementary schools in Eastern Massachusetts (school year 2012-2013).

INTERVENTION

GTLW included a 22-lesson classroom curriculum, homework activities, monthly parent newsletters, a food shopping and packing guide for parents, food demonstrations, school-wide announcements, and a poster contest.

MAIN OUTCOME MEASURES

The energy content of foods brought to school was estimated from digital photographs, and foods were assigned to 1 of 3 processing levels (less processed or unprocessed, moderately processed, or highly processed) based on an established classification system.

STATISTICAL ANALYSES PERFORMED

The percentage of energy brought from foods categorized into each processing level was calculated and compared pre- and postintervention using hierarchical linear models.

RESULTS

Most of the food brought from home to school was highly processed (70% of food energy brought). Foods categorized as snack foods and desserts contributed the greatest percentage of total energy to the highly processed category at baseline and follow-up (72% and 69%, respectively). Energy from foods brought for snack tended to be more highly processed than those brought for lunch. No significant differences were observed from pre- to postintervention in the GTLW group compared with control for the percentage of energy brought from highly processed foods in adjusted models (β: -1.1, standard error: 2.2, P = .6) or any other processing level.

CONCLUSIONS

Highly processed foods were prevalent in home-packed lunches and snacks, and these patterns persisted after a targeted intervention. Further research is needed to identify strategies to improve the healthfulness of foods brought from home to school.

Effect of a free healthy school meal on fruit, vegetables and unhealthy snacks intake in Norwegian 10- to 12-year-old children

BACKGROUND

Norwegian children have a lower intake of fruit, vegetables, and a higher intake of unhealthy snacks compared to dietary guidelines. Such dietary inadequacies may be detrimental for their current and future health. Schools are favorable settings to establish healthy eating practices. Still, no school meal arrangement is provided in Norway, and most children typically bring packed lunches from home. The aim of this study was to investigate whether serving a free healthy school meal for one year resulted in a higher intake of fruit and vegetables and a lower intake of unhealthy snacks in total among 10-12-year-olds in Norway.

METHODS

The School Meal Project in Southern Norway was a non-randomized trial in two elementary schools in rural areas in the school year 2014/2015. The study sample consisted of 10- to 12-year-old children; an intervention group (N = 55) and a control group (N = 109) resulting in a total of 164 school children at baseline. A food frequency questionnaire was completed by the children at baseline, at five months follow-up and after one year to assess fruit, vegetable, and snacks intake. Multiple linear regression analyses were performed to assess intervention effects on overall intake of fruit and vegetables and unhealthy snacks.

RESULTS

Serving of a free healthy school meal for one year was associated with a higher weekly intake of vegetables on sandwiches in the intervention group compared to the control group, adjusted for baseline intake (B: 1.11 (95% CI: .38, 1.85)) at the end of the intervention. No other significant intervention effects were found for the remaining fruit and vegetables measures. Serving of a free healthy school meal was not associated with a lower weekly intake of unhealthy snacks (i.e. potato chips, candy, sugar sweetened beverages) in the intervention group compared to the control group.

CONCLUSIONS

A free healthy school meal was associated with a higher weekly intake of vegetables on sandwiches but did not significantly change any other investigated dietary behaviors. However, given the inadequate intake of vegetables among children and that even moderate improvements have public health relevance, a free healthy school meal for all school children could be beneficial.

TRIAL REGISTRATION

ISRCTN61703361 . Date of registration: December 3rd, 2018. Retrospectively registered.

A cross-sectional study of packed lunchbox foods and their consumption by children in early childhood education and care services

AIM

To (a) describe lunchbox foods packed and consumed by children attending early childhood education and care services; (b) compare the serves of foods packed and consumed with nutrition guideline recommendations; and (c) explore associations between parent characteristics and serves of food groups packed in lunchboxes.

METHODS

A cross sectional study was conducted on a sample of early childhood education and care services where parents provide food in the Hunter New England region of NSW, Australia. Lunchbox contents were assessed using photography and pre- and post-meal weights. Descriptive statistics were used to describe packing and consumption of core food groups and discretionary foods.

RESULTS

Data on food packed and consumed were collected for 355 children's lunchboxes from 17 services (preschools n = 14, long day care services n = 3). Less than half (44%) of lunchboxes contained vegetables, and 54% contained at least one serve of discretionary foods. Less than 1% of lunchboxes met all setting-specific nutrition guidelines. On average, children consumed 68% of lunchbox contents, with the lowest consumption rate being for vegetables. An association was found between parent education level and packing of discretionary foods (-0.36, P = <.01) but not for packing of fruit or vegetables.

CONCLUSIONS

Lunchboxes contained an over-representation of discretionary foods and under-representation of vegetables, and children had a low preference for consuming vegetables compared with other food groups. Interventions to support parent packing of lunchboxes in line with nutrition guidelines and strategies to expand child preference for foods such as vegetables are warranted.

The effect of teacher-delivered nutrition education programs on elementary-aged students: An updated systematic review and meta-analysis

Research shows that schools can make a positive impact on children’s nutritional outcomes. However, it is also reported that schools and teaching staff note many barriers, which may restrict nutritional education programming and delivery. This is concerning, considering the view that teachers are the key agents for promoting health and nutrition within schools. The purpose of the updated systematic review and meta-analysis was to ascertain the impact that nutrition education programs have on elementary-aged students’ energy intake, fruit, vegetable, sugar consumption and nutritional knowledge. A systematic literature search was conducted using electronic databases (The Cochrane Central Register of Controlled Trials (CENTRAL); A + Education; ERIC; PsycINFO; MEDLINE; ProQuest Central, Journals@Ovid and SAGE Health Sciences Full-Text Collection) from 1990 to 31st October 2018. This process yielded 34 studies for inclusion in this systematic review and meta-analysis. Of these studies, seven studies had a focus on energy intake, five had a focus on sugar consumption, 21 of the studies looked at fruit and vegetable consumption and 13 studies focused on nutritional knowledge. The results suggest that the teaching of nutrition education in elementary schools by qualified teachers can make an important contribution to the knowledge and dietary habits of children. The small and medium effect sizes indicate that prudent, evidence-based decisions need to be made by policy makers and pedagogues as to the teaching strategies employed when delivering nutrition education programs to elementary-aged students.

The review is reported in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (van Sluijs et al., 2007).

The Efficacy of Workplace Interventions on Improving the Dietary, Physical Activity and Sleep Behaviours of School and Childcare Staff: A Systematic Review

There is a need for effective interventions that improve the health and wellbeing of school and childcare staff. This review examined the efficacy of workplace interventions to improve the dietary, physical activity and/or sleep behaviours of school and childcare staff. A secondary aim of the review was to assess changes in staff physical/mental health, productivity, and students’ health behaviours. Nine databases were searched for controlled trials including randomised and non-randomised controlled trials and quasi-experimental trials published in English up to October 2019. PRISMA guidelines informed screening and study selection procedures. Data were not suitable for quantitative pooling. Of 12,396 records screened, seven articles (based on six studies) were included. Most studies used multi-component interventions including educational resources, work-based wellness committees and planned group practice (e.g., walking groups). Multiple outcomes were assessed, findings were mixed and on average, there was moderate risk of bias. Between-group differences in dietary and physical activity behaviours (i.e., fruit/vegetable intake, leisure-time physical activity) favoured intervention groups, but were statistically non-significant for most outcomes. Some of the studies also showed differences favouring controls (i.e., nutrient intake, fatty food consumption). Additional robust studies testing the efficacy of workplace interventions to improve the health of educational staff are needed.

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.

Cross-sectional associations between lunch-type consumed on a school day and British adolescents' overall diet quality

Diet quality of children consuming school meals tends to be better than that of children consuming packed lunches (from home) or food bought outside school. This study investigates the association between different types of lunch consumed in a school day and diet quality of UK adolescents. A total of 2118 British adolescents were included from the National Diet and Nutrition Survey (Years 1-8; between 2008 and 2016). All participants attended school and were aged 11-18 years with valid 3 or 4-day diary records and the analyses were stratified by age group (11-14 and 15-18 years). The Diet Quality Index for Adolescents (DQI-A) tool consisting of three components; diet quality, diversity and equilibrium, was used to assess adherence to dietary recommendations. Overall DQI-A scores range from -33 to 100%. Overall mean DQI-A score for all adolescents was low at 21.1%. Fewer (17.4%) adolescents reported buying lunches from cafés and shops, compared to adolescents consuming cooked school meals and packed lunches (28.3% and 36.6%, respectively), and they had the lowest DQI-A% score of 14.8%. Adolescents having cooked school meals (reference group) had a higher overall DQI-A% of 21.8%. Diet quality scores of older adolescents having packed lunches and shop/café-bought lunches were 5.5% higher (CI 2.7 to 8.4%; p < 0.01) and 5.0% lower (CI 8.1 to 2.0%; p < 0.01) than cooked school meals respectively, after adjusting for gender, region, energy under-reporting and equivalised household income. For younger adolescents the results were attenuated particularly among packed lunch consumers. UK adolescents generally consume a poor quality diet and adolescents purchasing lunches from outside the school gates have the lowest quality diets. Unlike with older children there is little difference between school meals and packed lunches for younger children. Regulation policies on food outlets around secondary schools as well as improving food choices within school premises are needed.

The Unique Extended Selection Cohorts Design for the Evaluation of the School-Based Jump-In Intervention on Dietary Habits: A Study Protocol

Background: To promote healthy dietary and physical activity behaviour among primary school children, the city of Amsterdam structurally implements the school-based Jump-in intervention in over half of its primary schools. Previously shown to be effective in stimulating physical activity and outside recess play, our study is the first to evaluate Jump-in’s effect on children’s dietary behaviour. Evaluating the effectiveness and implementation process of an intervention in a real-life setting requests an alternative study design. Methods: we chose a mixed-methods, quasi-experimental Extended Selection Cohorts design to evaluate Jump-in’s effectiveness and implementation process. Children and parents from the first ten primary schools that enrolled in the programme in 2016–2017 were invited to participate. The primary outcomes were children’s dietary behaviour and behavioural determinants, assessed by child and parent questionnaires, and photographs of the food and drinks children brought to school. Process indicators, contextual factors and satisfaction with the programme were assessed by interviews with health promotion professionals, school principals, school project coordinators, and teachers; focus group discussions with parents and children; and document analysis. Discussion: Conducting research in a real-life setting is accompanied by methodological challenges. Using an Extended Selection Cohorts design provides a valuable alternative when a Randomized Controlled design is not feasible.

A repeated cross-sectional survey assessing changes in diet and nutrient quality of English primary school children's packed lunches between 2006 and 2016

OBJECTIVE

Mandatory school meal standards were introduced in 2006 in England; however, no legislation exists for packed lunches. This study analyses provision of foods and nutrients in packed lunches in 2016 to highlight differences in diet and nutrient quality since 2006.

DESIGN

Two cross-sectional surveys of children's packed lunches were conducted in 2006 and 2016. Data were analysed using multilevel regression models taking into account the clustering of children within primary schools.

SETTING

Data were collected from 1148 children who attended 76 schools across England in 2006 and from 323 children attending 18 schools across England in 2016.

PARTICIPANTS

Children were included if they regularly ate a packed lunch prepared at home (approximately half of children take a packed lunch to school) and were aged 8-9 years (in year 4), for both surveys.

OUTCOME MEASURES

Data collected in both years included provision of weight and type of food, nutrients and proportion of lunches meeting individual and combined school meal standards.

RESULTS

Frequency of provision and portion size of some food types changed substantially between surveys. Frequency of provision of confectionery in lunches reduced by 9.9% (95% CI -20.0 to 0.2%), sweetened drinks reduced by 14.4% (95% CI -24.8 to -4.0%), and cakes and biscuits not containing chocolate increased by 9.6% (95% CI 3.0 to 16.3%). Vegetable provision in lunches remained low. Substantial changes were seen in the percentage of lunches meeting some nutrient standards: non-milk extrinsic sugars (19%, 95% CI 10 to 29%), vitamin A (-8%, 95% CI -12 to -4%), vitamin C (-35%, 95% CI -42 to -28%) and zinc (-8%, 95% CI -14 to -1%).

CONCLUSIONS

Packed lunches remain low quality with few meeting standards set for school meals. Provision of sugars has reduced due to reductions in provision and portion size of sugary drinks and packaged sweet foods; however, provision of some nutrients has worsened.

Protocol for an effectiveness- implementation hybrid trial to assess the effectiveness and cost-effectiveness of an m-health intervention to decrease the consumption of discretionary foods packed in school lunchboxes: the 'SWAP IT' trial

BACKGROUND

At a population level, small reductions in energy intake have the potential to contribute to a reduction in the prevalence of childhood obesity. In many school systems, there is the potential to achieve a reduction in energy intake through modest improvements in foods packed in children's school lunchboxes. This study will assess the effectiveness and cost-effectiveness of a multi-component intervention that uses an existing school-based communication application to reduce the kilojoule content from discretionary foods and drinks consumed by children from school lunchboxes whilst at school.

METHODS

A Type I hybrid effectiveness-implementation cluster randomised controlled trial will be conducted in up to 36 primary schools in the Hunter New England, Central Coast and Mid North Coast regions of New South Wales, Australia. Designed using the Behaviour Change Wheel, schools will be randomly allocated to receive either a 5-month (1.5 school terms) multi-component intervention that includes: 1) school lunchbox nutrition guidelines; 2) curriculum lessons; 3) information pushed to parents via an existing school-based communication application and 4) additional parent resources to address common barriers to packing healthy lunchboxes or a control arm (standard school practices). The study will assess both child level dietary outcomes and school-level implementation outcomes. The primary trial outcome, mean energy (kJ) content of discretionary lunchbox foods packed in children's lunchboxes, will be assessed at baseline and immediately post intervention (5 months or 1.5 school terms). Analyses will be performed using intention to treat principles, assessing differences between groups via hierarchical linear regression models.

DISCUSSION

This study will be the first fully powered randomised controlled trial internationally to examine the impact of an m-health intervention to reduce the mean energy from discretionary food and drinks packed in the school lunchbox. The intervention has been designed with scalability in mind and will address an important evidence gap which, if shown to be effective, has the potential to be applied at a population level.

TRIAL REGISTRATION

Australian Clinical Trials Registry ACTRN:12618001731280 registered on 17/10/2018. Protocol Version 1.

Eating Healthy, Growing Healthy: Outcome Evaluation of the Nutrition Education Program Optimizing the Nutritional Value of Preschool Menus, Poland

Staff education can improve the quality of nutrition in childcare centers, but an objective assessment of the change is necessary to assess its effectiveness. This study evaluated the effectiveness of the multicomponent educational program for improving the nutritional value of preschools menus in Poland measured by the change in nutrients content before (baseline) and 3-6 months after education (post-baseline). A sample of 10 daily menus and inventory reports reflecting foods and beverages served in 231 full-board government-sponsored preschools was analyzed twice: at baseline and post-baseline (in total 4620 inventory reports). The changes in 1. the supply of nutrients per 1 child per day; 2. the nutrient-to-energy ratio of menus; 3. the number of preschools serving menus consistent with the healthy diet recommendations, were assessed. Education resulted in favorable changes in the supply of energy, fat and saturated fatty acids. The nutrient-to-energy ratio for vitamins A, B1, B2, B6, C, folate and minerals Calcium, copper, iron, magnesium, phosphorus, potassium and zinc increased significantly. The percentage of preschools implementing the recommendations for energy, share of fat, saturated fatty acids and sucrose as well as calcium, iron and potassium increased significantly. However, no beneficial effects of education on the content of iodine, potassium, vitamin D and folate were observed. This study indicates the potentially beneficial effect of education in optimizing the quality of the menu in preschools. However, the magnitude of change is still not sufficient to meet the nutritional standards for deficient nutrients.

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 .