The Role of Schools in Obesity Prevention

An examination of the predictors of change in BMI among 38 026 school students in Makkah, Saudi Arabia

BACKGROUND

The prevalence of childhood obesity has substantially increased in the Gulf Cooperation Council countries, including Saudi Arabia. The Rashaka initiative is a Saudi national school-based multicomponent intervention that was introduced in the school year 2016-2017 to address childhood overweight and obesity. This study aims to examine the effect of the Rashaka initiative on students' body mass index (BMI) for two academic years (2016-2017 and 2018-2019) and to analyse predictors of BMI change.

METHODS

Secondary data for this pre-post study was provided by the Ministry of Health for 38 026 students from 89 intermediate and secondary schools that implemented the initiative in Makkah City, Saudi Arabia. It was analysed using non-parametric tests and multiple regressions at a 5% level of significance.

RESULTS

Over 2 y of implementation, BMI was reduced significantly across the schools (p < 0.001). Based on the regression modelling, school gender and education stage were found to be the only significant predictors of BMI change. Girls and intermediate schools had greater BMI reductions than boys and secondary schools (p < 0.001 and p = 0.031).

CONCLUSIONS

This study provides tentative evidence for the effectiveness of the Rashaka intervention in Makkah City. In addition, our study has identified that the Rashaka initiative may require modification to improve its effect on boys and students in secondary schools.

Effect of nutrition education intervention on nutrition knowledge, attitude, and diet quality among school-going adolescents: a quasi-experimental study

BACKGROUND

Nutrition education is being used to encourage school adolescents to adopt healthy eating habits. To the best of our knowledge, very little study has been undertaken in Nepal to examine the effectiveness of nutrition education programs. This study aimed to assess the effect of nutrition education on nutritional knowledge, attitude, and diet quality among school-going adolescents in selected private schools in Nepal.

METHODS

A quasi-experimental study was conducted among 226 students aged 12 - 19 years of two selected private schools in Banepa municipality of Nepal. Students (n = 113) from the first school were assigned to intervention and the same number of students from the second school were enrolled in the study as the control. Over 12 weeks, students in the intervention group received one hour of nutrition education in the form of mini-lectures and interactive discussions, whilst students in the control group received no education. The student's two-sample t-test was used to compare two groups and to assess the effectiveness of the nutrition education program.

RESULTS

Between the intervention and control group, the magnitude of difference in knowledge score was 1.80 (95% CI: 1.11 - 2.49), emotional eating was 0.98 (95% CI: 0.42 - 1.54), uncontrolled eating was 3.60 (95% CI: 2.10 - 5.09), and cognitive restraint of eating was 2.26 (95% CI: 1.51 - 3.01).

CONCLUSIONS

A tailored health education intervention was found to be effective in increase nutritional knowledge and attitude among school-going adolescents. Adopting nutrition education interventions as part of public health school intervention builds positive knowledge, attitudes, and healthy eating habits in school-going adolescents.

Impact of the COVID-19 pandemic on the adaptability and resiliency of school food programs across Canada

Introduction

Following the sudden closure of schools due to the pandemic in 2020, many school food program (SFP) operators lost their operating venues and had to innovate to continue distributing meals to children. Our objective was to assess the impact of the COVID-19 pandemic on the delivery, adaptability, and resiliency of school food programs across Canada by conducting a systematic rapid review.

Materials and methods

Systematic literature searches identified newspaper articles and social media sources related to the adaptations and challenges faced by school food programs across Canada in response to the COVID-19 pandemic. Included sources were assessed and thematically categorized according to the dimensions of the Analysis Grid for Environments Linked to Obesity (ANGELO) and Getting To Equity (GTE) frameworks to identify factors impacting the delivery, adaptability, and resiliency of school food programs in Canada.

Results

School food programs in Canada made various efforts to meet existing and new challenges associated with the delivery of these programs to keep feeding school children, particularly those most vulnerable, during the pandemic. Distribution of food kits, prepared meals and gift cards/coupons were successful pathways in ensuring support for food accessibility to students and their families. Increased collaborations between community members and organizations/stakeholders to help maintain food delivery or collectively offer new modes to deliver foods were most frequently cited as key to facilitating school food programming. However, maintenance and sustainability related to operating costs and funding were identified as key challenges to successful school food programming.

Conclusion

Our study highlights the swift and substantial transformation school food programs,, underwent in response to the pandemic, driven by the urgent need to ensure that students still had access to nutritious meals and the importance of policy and resource support to bolster the adaptability and resiliency of these programs. Findings on facilitators and challenges to school food programs during the early months of the COVID-19 pandemic can inform development of guidelines to design a robust national Canadian school food program and help make existing programs more sustainable, adaptable, and resilient.

Factors that influence food choices in secondary school canteens: a qualitative study of pupil and staff perspectives

Background

Adolescence is recognised as a period of nutritional vulnerability, with evidence indicating that United Kingdom adolescents have suboptimal dietary intakes with many failing to meet dietary recommendations. Additionally, adolescence is a time of transition when they become more independent in their dietary choices and begin to develop their own sense of autonomy and are less reliant on their parent's guidance, which is reported to lead to less favourable dietary behaviours. Reducing the prevalence of poor dietary intakes and the associated negative health consequences among this population is a public health priority and schools represent an important setting to promote positive dietary behaviours. The aim of this school-based study was to explore the factors and barriers which influence food choices within the school canteen and to identify feasible strategies to promote positive dietary behaviours within this setting.

Methods

Thirteen focus groups with 86 pupils in Year 8 (n = 37; aged 11-12 years) and Year 9 (n = 49; aged 12-13 years) in six secondary schools across Northern Ireland, United Kingdom were conducted. Additionally, one-to-one virtual interviews were conducted with 29 school staff [principals/vice-principals (n = 4); teachers (n = 17); and caterers (n = 7)] across 17 secondary schools and an Education Authority (EA) senior staff member (n = 1). Focus groups and interviews were audio-recorded, transcribed, and analysed following an inductive thematic approach.

Results

Using the ecological framework, multiple factors were identified which influenced pupils' selection of food in the school canteen at the individual (e.g., time/convenience), social (e.g., peer influence), physical (e.g., food/beverage placement), and macro environment (e.g., food provision) level. Suggestions for improvement of food choices were also identified at each ecological level: individual (e.g., rewards), social (e.g., pupil-led initiatives), physical (e.g., labelling), and macro environment (e.g., whole-school approaches).

Conclusion

Low-cost and non-labour intensive practical strategies could be employed, including menu and labelling strategies, placement of foods, reviewing pricing policies and whole-school initiatives in developing future dietary interventions to positively enhance adolescents' food choices in secondary schools.

School environments and obesity: a systematic review of interventions and policies among school-age students in Latin America and the Caribbean

BACKGROUND

The rapid rise in obesity rates among school children in Latin America and the Caribbean (LAC) could have a direct impact on the region's physical and mental health, disability, and mortality. This review presents the available interventions likely to reduce, mitigate and/or prevent obesity among school children in LAC by modifying the food and built environments within and around schools.

METHODS

Two independent reviewers searched five databases: MEDLINE, Web of Science, Cochrane Library, Scopus and Latin American and Caribbean Health Sciences Literature for peer-reviewed literature published from 1 January 2000 to September 2021; searching and screening prospective studies published in English, Spanish and Portuguese. This was followed by data extraction and quality assessment using the Cochrane risk-of-bias tool (RoB 2) and the Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I), adopting also the PRISMA 2020 guidelines. Due to the heterogeneity of the intervention's characteristics and obesity-related measurements across studies, a narrative synthesis was conducted.

RESULTS

A total of 1342 research papers were screened, and 9 studies were included; 4 in Mexico, and 1 each in Argentina, Brazil, Chile, Colombia, and Ecuador. Four studies reported strategies for modifying food provision; four other targeted the built environment, (modifying school premises and providing materials for physical activity); a final study included both food and built environment intervention components. Overall, two studies reported that the intervention was significantly associated with a lower increase over time in BMI/obesity in the intervention against the control group. The remaining studies were non-significant.

CONCLUSIONS

Data suggest that school environmental interventions, complementing nutritional and physical education can contribute to reduce incremental childhood obesity trends. However, evidence of the extent to which food and built environment components factor into obesogenic environments, within and around school grounds is inconclusive. Insufficient data hindered any urban/rural comparisons. Further school environmental intervention studies to inform policies for preventing/reducing childhood obesity in LAC are needed.

Healthy Eats-Evaluation of a Social Marketing Program Delivered in Primary School Settings in Queensland

One in four school children in Australia are overweight or obese. In response, the Healthy Eats program was developed, piloted, and delivered using a whole-of-school approach underpinned by the socio-ecological model to increase fruit and vegetable consumption among children aged 8-10 years in regional Queensland, Australia. This research presents an outcome evaluation of the Healthy Eats program using pre-post data collected throughout 2021 (cross-sectional for knowledge and longitudinal for behaviour) from 19 schools to assess whether changes occurred in students' nutritional knowledge (n = 1868 (pre = 933, post = 935)) and fruit and vegetable consumption (n = 1042 (pre = 521, post = 521)). Knowledge data was collected via self-reports two weeks prior and immediately after the Nutrition Module. Behavioural data on daily fruit and vegetable consumption was gathered via student passports (i.e., surveys) one week before and for four consecutive weeks after the Nutrition Module. Chi-Square Difference tests and t-Tests were conducted with a significance level set at p < 0.05. Across all 19 schools, knowledge of the daily recommended serves of fruit and vegetables improved significantly following participation in the program, aligning knowledge closer to the Australian dietary guidelines. Behavioural results for fruit consumption were favourable, with clear improvements reported. Increases in vegetable consumption were demonstrated in two of the eight schools. A discussion on the knowledge-action gap is provided, including recommendations for future iterations of the Healthy Eats program.

The Project "Colourful Means Healthy" as an Educational Measure for the Prevention of Diet-Related Diseases: Investigating the Impact of Nutrition Education for School-Aged Children on Their Nutritional Knowledge

METHODS

An educational project called Cooking and Educational Workshops "Colourful means healthy" was conducted at the Department of Dietetics of the Faculty of Public Health in Bytom of the Medical University of Silesia in Katowice, Poland, between 1 July 2017 and 30 June 2019. The participants/recipients of the project were second-grade primary schoolchildren (317 pupils aged 7-9 years).

OBJECTIVE

The aim of this article is to assess the change in knowledge of the principles of healthy eating among children aged 7-9 years following the nutritional education we carried out as part of the "Colourful means healthy" project. As part of project evaluation, the participating children were asked to rate selected food products in terms of their influence on human health (healthy vs. unhealthy).

RESULTS

There was a statistically significant difference between the percentage of correct answers provided by the pupils before and after nutrition education. Thus, one may conclude that conducting an educational programme caused the participants' nutrition knowledge to increase.

CONCLUSION

The present study demonstrated the potential of nutrition education in the form of cooking and educational workshops in terms of increasing nutrition knowledge. As such, workshops like these can be a useful measure for improving eating habits and eliminating dietary errors in the study population. However, future research is needed in order to verify whether such cooking and educational workshops can produce beneficial and lasting changes in dietary habits over the long term.

Characterizing food environments near schools in California: A latent class approach simultaneously using multiple food outlet types and two spatial scales

It is challenging to evaluate associations between the food environment near schools with either prevalence of childhood obesity or with socioeconomic characteristics of schools. This is because the food environment has many dimensions, including its spatial distribution. We used latent class analysis to classify public schools in urban, suburban, and rural areas in California into food environment classes based on the availability and spatial distribution of multiple types of unhealthy food outlets nearby. All urban schools had at least one unhealthy food outlet nearby, compared to seventy-two percent of schools in rural areas did. Food environment classes varied in the quantity of available food outlets, the relative mix of food outlet types, and the outlets' spatial distribution near schools. Regardless of urbanicity, schools in low-income neighborhoods had greater exposure to unhealthy food outlets. The direction of associations between food environment classes and school size, type, and race/ethnic composition depends on the level of urbanicity of the school locations. Urban schools attended primarily by African American and Asian children are more likely to have greater exposures to unhealthy food outlets. In urban and rural but not suburban areas, schools attended primarily by Latino students had more outlets offering unhealthy foods or beverages nearby. In suburban areas, differences in the spatial distribution of food outlets indicates that food outlets are more likely to cluster near K-12 schools and high schools compared to elementary schools. Intervention design and future research need to consider that the associations between food environment exposures and school characteristics differ by urbanicity.

The Relationship between School Infrastructure and School Nutrition Program Participation and Policies in New York City

School nutrition programs (SNP) provide much needed access to fruits, vegetables, and other healthy foods at low or no cost. Yet, the infrastructure of school kitchens and cafeteria vary across schools, potentially contributing to systematic barriers for SNP operation and equity. The purpose of this paper is to examine the association between school infrastructure and outcomes including meal participation, untraditional lunch periods, and having an open campus. Regression analyses were conducted using administrative data for 1804 schools and school nutrition manager survey data (n = 821) in New York City (NYC). Co-location was significantly associated with open campus status (OR = 2.84, CI: 1.11, 7.26) and high school breakfast participation (β = -0.056, p = 0.003). Overcrowding was associated with breakfast (elementary: β = -0.046, p = 0.03; middle: β = 0.051, p = 0.04; high: β = 0.042, p = 0.04) and lunch participation (elementary: β = -0.031, p = 0.01) and untraditional lunchtimes (elementary: OR = 2.47, CI: 1.05, 5.83). Higher enrollment to cafeteria capacity ratios was associated with breakfast (elementary: β = -0.025, p = 0.02) and lunch (elementary: β = -0.015, p = 0.001; high: β = 0.014, p = 0.02) participation and untraditional lunchtimes (middle: OR = 1.66, CI: 1.03, 2.68). Infrastructure characteristics are an important source of variation across NYC schools that may hinder the equity of school nutrition programs across the city.

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.

Effect Evaluation of Sahtak bi Sahnak, a Lebanese Secondary School-Based Nutrition Intervention: A Cluster Randomised Trial

Objective

To evaluate the effectiveness of Sahtak bi Sahnak on dietary knowledge and adherence to dietary guidelines in Lebanese adolescents.

Design/setting

A cluster randomised controlled trial was conducted in public and private secondary schools located in urban and rural regions in Lebanon.

Participants

Sixteen secondary schools including 1,572 adolescents were randomly assigned to the intervention (n = 739) or control group (n = 833).

Intervention

Sahtak bi Sahnak is an educational school-based intervention dedicated to improving dietary adherence to nutritional guidelines, increasing the level of dietary knowledge, and preventing the development of obesity during adolescence. It was systematically designed based on the Intervention Mapping framework. The total length of the intervention was around seven educational sessions, until all of the 11 lessons were covered. Each education session lasted 20-40 min.

Main Outcome Measures

Dietary knowledge and adherence levels were measured at baseline and post-intervention using validated questionnaires.

Statistical Analysis

Multivariate multilevel regression models were used to examine intervention effects on outcomes, controlled for background characteristics (i.e., age, gender, location, type of school, grade, BMI z-score).

Results

The intervention group showed significant improvements in total dietary knowledge (B = 12.74, p < 0.001) and intake of healthy items (B = 1.89, p < 0.001), compared to the control group. Intake of unhealthy items decreased significantly (B = -1.43, p < 0.001), compared to the control group. These results were adjusted for age, gender, type of school, location, BMI z-score, study group, and score at baseline.

Conclusion and Implications

Sahtak bi Sahnak is an effective and culturally appropriate school-based intervention for targeting diet among a variety of Lebanese adolescents.

Context, importance, and process for creating a body mass index surveillance system to monitor childhood obesity within the New York City public school setting

The Office of School Health, a joint program of the Departments of Health and Education, administers New York City’s (NYC) body mass index (BMI) surveillance system to monitor childhood obesity. We describe the context, importance, and process for creating a multi-agency, school-based BMI surveillance system using BMI collected from annual FITNESSGRAM® physical fitness assessments conducted as part of a larger physical activity and wellness curriculum in NYC public schools. We also summarize our current system and methodology, highlighting the types of data and data sources that comprise the system and partnership between the Departments of Health and Education that enable data sharing. Strategies for addressing threats to data quality, including missing data, biologically implausible values, and imprecise/subjective weight or height equipment are discussed. We also review current and future surveillance data products, and provide recommendations for collecting, analyzing, interpreting, and reporting BMI data for childhood obesity surveillance. Collaboration between Departments of Health and Education as well as attention to safeguards of BMI reporting and data quality threats have enabled NYC to collect high quality BMI data to accurately monitor childhood obesity trends. These findings have implications for youth BMI surveillance systems in the United States and globally.

Effects of parental public health insurance eligibility on parent and child health outcomes

Many states expanded their Medicaid programs to low-income adults under the Affordable Care Act (ACA). These expansions increased Medicaid coverage among low-income parents and their children. Whether these improvements in coverage and healthcare use lead to better health outcomes for parents and their children remains unanswered. We used longitudinal data on a large, nationally representative cohort of elementary-aged children from low-income households from 2010 to 2016. Using a difference-in-differences approach in state Medicaid policy decisions, we estimated the effect of the ACA Medicaid expansions on parent and child health. We found that parents' self-reported health status improved significantly post-expansion in states that expanded Medicaid through the ACA by 4 percentage points (p < 0.05), a 4.7% improvement. We found no significant changes in children's use of routine doctor visits or parents' assessment of their children's health status. We observed modest decreases in children's body mass index (BMI) of about 2% (p < 0.05), especially for girls.

Harmonizing Ratings From Different School Environment Assessment Methods: A Simplified Approach

BACKGROUND

This study describes a method for harmonizing data collected with different tools to compute a rating of compliance with national recommendations for school physical activity (PA) and nutrition environments.

METHODS

We reviewed questionnaire items from 84 elementary schools that participated in the Childhood Obesity Research Demonstration (CORD) project, which was 3 distinct childhood obesity prevention projects in 7 communities in California, Massachusetts, and Texas. Each project used tools specific to its programs, schools, and communities. While this approach increased the feasibility of data collection, it created a challenge with the need to combine data across projects. We evaluated all questionnaire items and retained only those items that assessed one or more recommendations and constructed several items to indicate compliance or noncompliance with the respective associated recommendations.

RESULTS

Ten constructed items covered 11 of the 20 recommendations. Analysis indicated that the scores detected variability in compliance both among communities and among school within communities.

CONCLUSIONS

The scores captured differences in compliance with the national recommendations at multiple levels. Our method, designed for creating common scores, may be useful in integrated data analysis, systematic reviews, or future studies requiring harmonizing of data collected via different tools.

Barriers, Enablers, and Possible Solutions for Student Wellness: A Qualitative Analysis of Student, Administrators, and Staff Perspectives

BACKGROUND

Child well-being, which includes physical, mental, and social health, has a critical effect on academic performance. Schools face many challenges in meeting needs for child well-being. Schools in low-resource areas, including the Mississippi Delta, face greater challenges when meeting student needs.

METHODS

Eleven focus groups with middle school students and 12 interviews with teachers, staff, and administration in one Mississippi Delta middle school were completed in 2019. The Social Ecological Model and Theory of Organizational Readiness for Change were used as a framework for the study.

RESULTS

Focus group data with middle school students and interviews with teachers, staff, and administrators show that academic stressors play a major role in student well-being; yet, teachers, staff, and administrators face immense pressure to achieve high test scores. However, students seem to be encouraged by a positive school environment, which could help minimize some stressors.

CONCLUSIONS

It seems that small improvements to the school environment could have a significant effect on student well-being, especially when school infrastructure and limited resources do not support comprehensive changes.

The effects of the built environment on the general health, physical activity and obesity of adults in Queensland, Australia

The built environment has been identified as a key factor for health intervention and obesity prevention. However, it is still unclear to what extent the built environment is associated with obesity and general health and to what extent such an association is mediated through variation in physical activity. This study aims to examine the associations between individual characteristics, the built environment, physical activity, general health and body mass index to reveal the pathways through which the built environment is associated with the prevalence of obesity. Using data from 1,788 adults aged 18 to 65 in Queensland from Wave 16 of the Household, Income, and Labour Dynamics in Australia survey, we use geographic information system-based methods to quantify built environment factors in 5D dimensions: Density, Diversity, Design, Distance and Destination accessibility. We then employ multi-level mixed-effect models to test the hypothesised relationships between individual characteristics, the built environment, physical activity, general health and body mass index. The results indicate that physical activity is positively associated with general health and negatively associated with the prevalence of obesity. Adjusting for individual characteristics, we find that built-environment factors have direct effects on physical activity but indirect effects on general health and obesity. Among these factors, greater green space exposure plays a key role in enhancing general health and reducing obesity. Low-density and car-dependent neighbourhoods can be activity-friendly and mitigate obesity if these neighbourhoods are also equipped with easy access to green space.

Designing Video Games for Nutrition Education: A Participatory Approach

OBJECTIVE

To describe the participatory approach used to inform the development of a video game designed to increase children's nutrition knowledge. The objectives were to (1) assess children's nutrition areas of focus, (2) explore parents' and children's perceptions of video games for nutrition education, and (3) collect information on children's video game preferences.

DESIGN

Qualitative research design using 10 focus group interviews and 5 workshops. Children's nutrition knowledge and game player type were assessed by questionnaires.

SETTING

South Island, New Zealand.

PARTICIPANTS

Sixty-two primary school children, aged 7-11 years. Ten parents completed an online questionnaire.

PHENOMENON OF INTEREST

Participatory approach in designing digital nutrition education resources.

ANALYSIS

A general inductive approach was used to develop the themes.

RESULTS

The following 3 themes were identified through thematic analysis: (1) positive impacts associated with video games for nutrition education, (2) factors for engagement, and (3) barriers for sustained use.

CONCLUSIONS AND IMPLICATIONS

Both children and parents perceived that video games offered an avenue to increase nutrition knowledge. However, negative views such as screen time usage need to be addressed before widespread adoption. The participatory design approach provided information about game mechanics that will inspire the game design and enhance engagement of video games for nutrition education.

Residents' Insights on Their Local Food Environment and Dietary Behaviors: A Cross-City Comparison Using Photovoice in Spain

Perceptions of local food environments and the ability of citizens to engage in participatory research may vary, even if participants share similar cultural and socioeconomic contexts. In this study, we aimed to describe participants’ narratives about their local food environment in two cities in Spain. We used the participatory methodology of Photovoice to engage participants in Madrid (n = 24) and Bilbao (n = 17) who took and discussed photographs about their local food environment (Madrid; n = 163 and Bilbao; n = 70). Common themes emerged across both cities (food insecurity, poverty, use of public spaces for eating and social gathering, cultural diversity and overconsumption of unhealthy foods); however, in Bilbao citizens perceived that there was sufficient availability of healthy foods despite that living in impoverished communities. Photovoice was a useful tool to engage participating citizens to improve their local food environments in both cities. This new approach allowed for a photovoice cross-city comparison that could be useful to fully understand the complexity and diversity of residents’ perceptions regardless of their place of residence.

Normative misperceptions of unhealthy snacking amongst 11- to 12-year-old secondary school students

Younger adolescents are at an age where they have increasing control of their diet, and where peers become an important social reference for acceptable and normative dietary behaviours. These normative perceptions are often inaccurate and can lead to the development of unhealthy eating practices; although, the role of normative misperceptions of peers' unhealthy snacking behaviours in younger adolescents' personal snacking behaviours is not clear. The current study was a cross-sectional analysis of baseline data from a social norms-based healthy eating intervention sampling two secondary schools in deprived areas of England. Students aged 11-12 years (n = 252) completed self-report measures of their demographic characteristics and personal behaviours, attitudes, intentions, and normative perceptions (descriptive and injunctive norms), relating to unhealthy snacking. Results indicated students overestimated peers' daily unhealthy snacks consumption by approximately 3.2 portions, misperceived peers to have more positive attitudes towards unhealthy snacking and more negative attitudes towards reducing snacking. The greater these misperceptions of peers' behaviours and attitudes, the more likely students were to consume unhealthy snacks and have positive attitudes about unhealthy snacking. Girls had a stronger intention to reduce their snacking behaviours if they had more positive attitudes to reducing snacking behaviours and misperceived peers to also have a positive attitude. In summary, 11- to 12-year-olds misperceive the snacking behaviour and attitudes of their peers, and such normative misperceptions are associated with students' own snacking behaviours and attitudes. Interventions which challenge these misperceptions may assist in reducing the social acceptability of unhealthy snacking and in reducing unhealthy snacking amongst young adolescents.

High prevalence of overall overweight/obesity and abdominal obesity amongst adolescents: An emerging nutritional problem in rural high schools in Limpopo Province, South Africa

BACKGROUND

As the gap in nutritional profiles between urban and rural rapidly reduces because of nutrition transition, rural adolescents are likely to engage in urban lifestyle behaviours.

AIM

The study determined the prevalence of overweight/obesity amongst adolescents in rural high schools and the association with selected factors.

SETTING

Fetakgomo Municipality in rural Limpopo Province, South Africa.

METHODS

A cross-sectional study was conducted amongst 378 adolescents selected through multistage sampling from high schools. Data collected were socio-demography, nutritional knowledge, dietary practices and anthropometry. The International Obesity Task Force age and sex-specific body mass index (BMI) cut-off values were used to determine overweight/obesity, whilst adult BMI cut-off values were used for those ≥ 18 years. Waist-to-height ratio (WHtR) greater than 0.5 indicated abdominal obesity, as well as waist circumference (WC) and waist-to-hip ratio (WHR) above the cut-off values.

RESULTS

The proportion of overweight/obesity amongst adolescents was 35%, whilst 25% had abdominal obesity by WHR and 21% by WHtR. Multivariate logistic regression showed that being a girl (AOR = 2.9, 95% CI: 1.74-4.85), older adolescent (AOR = 3.1, 95% CI: 1.57-6.29) and living in a household with employed adults (AOR = 2.3, 95% CI: 1.19-4.51) were associated with increased odds of being overweight/obese. Eating breakfast was associated with reduced odds of being overweight/obese (AOR = 0.6, 95% CI: 0.34-0.97).

CONCLUSION

Overweight/obesity and abdominal obesity amongst adolescents were more prevalent than underweight. The Integrated School Health Programme should have clear guidelines on food items served and sold at schools.

Barriers and facilitators to the implementation of nutrition standards for school food: a mixed-methods systematic review protocol

Background: The importance of nutrition during childhood and the high prevalence of child and adolescent obesity has resulted in several countries implementing nutritional standards for school food as a way of providing healthy school food environments. Yet, there has been less focus on the barriers and facilitators influencing the process of implementing school food standards. This mixed-methods systematic review aims to address this evidence gap by synthesising the empirical evidence on the factors that may influence the implementation of school food standards.

Methods: This mixed-methods systematic review will use qualitative, quantitative and mixed-methods evidence from peer-reviewed publications retrieved from the following databases; PubMed, CINAHL, Scopus, EMBASE, Medline, PsycINFO and Web of Science. Grey literature will be accessed through Google Scholar, Open Access Theses and Dissertations, OpenGrey, RIAN, EThOS, ProQuest, WorldCat, Networked Digital Library of Theses and Dissertations, and public health organisation websites will also be accessed. Screening reference lists and citation chaining of all included studies will also be undertaken. No restrictions on publication date or language will be applied, however, only primary research studies relevant to supply-side stakeholders will be eligible for inclusion. Study quality will be assessed using the Mixed Methods Appraisal Tool. Study titles and abstracts will be screened to decide whether the full-text manuscript should be retrieved. For screening reliability, a second review author will assess a random sample of 20%. Kappa statistics will be used to assess inter-rater reliability, with values of 0.75 and higher representing high agreement. Two authors will independently extract data and factors reported to influence implementation. This will be synthesized using the Theoretical Domains Framework.

Discussion: A comprehensive understanding of these factors can provide guidance to relevant stakeholders to enhance the adoption, implementation and sustainability of nutrition standards for school meals.

Systematic review registration: PROSPERO CRD42019117904

Cluster randomised controlled trial of a menu box delivery service for Australian long day care services to improve menu guideline compliance: a study protocol

INTRODUCTION

Globally, children are not meeting the recommended serves of the five food group foods, particularly vegetables. Childcare is an opportune setting to improve children's diet quality. This study aims to assess the effectiveness of a menu box delivery service tailored to the long day care setting to improve menu compliance with recommendations and improve children's food intake while in care.

METHODS AND ANALYSIS

This study will employ a cluster randomised controlled trial and will recruit eight long day care centres, randomly allocated to the intervention or comparison groups. The intervention group will trial the delivery of a weekly menu box service that includes all ingredients and recipes required to provide morning snack, lunch and afternoon snack. The menu boxes are underpinned by a 4-week menu developed by dietitians and meet menu planning guidelines. The comparison group will receive access to online menu planning training and a menu assessment tool for cooks. The primary outcomes are child dietary intake and menu guideline compliance. Secondary outcomes include within-trial cost-effectiveness and process evaluation measures including intervention acceptability, usability and fidelity. If effective, the menu box delivery will provide an easy strategy for childcare cooks to implement a centre menu that meets menu planning guidelines and improves child intake of five food group foods, including vegetables.

ETHICS AND DISSEMINATION

This study was approved by the Flinders University Social and Behavioural Research Ethics Committee. Study outcomes will be disseminated in peer-reviewed publications, via local, national and international presentations. Non-traditional outputs including evidence summaries and development of a business case will be used to disseminate study findings to relevant stakeholder groups. Data will be used in a doctoral thesis.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12620000296932).

Secondary School Nutrition Policy Compliance in Ontario and Alberta, Canada: A Follow-Up Study Examining Vending Machine Data from the COMPASS Study

(1) Objective: To longitudinally assess food and beverages sold in vending machines in secondary schools (grades 9-12) participating in the COMPASS study (2015/2016 and 2018/2019) and (2) to examine if patterns and trends observed in previous years (2012/2013 to 2014/2015) are consistent with lack of policy compliance in Ontario and Alberta, Canada. (2) Methods: Policy compliance was assessed through comparing nutritional information on drink (e.g., sports drinks) and snack (e.g., chocolate bars) products in vending machines to Policy and Program Memorandum (P/PM) 150 in Ontario (required policy) and the Alberta Nutrition Guidelines for Children and Youth (recommended policy). Longitudinal results and descriptive statistics were calculated. (3) Results: Longitudinal results indicate that between Y4 (2015/2016) and Y7 (2018/2019), snack and drink vending machines remained mostly non-compliant in Ontario and Alberta, with a small proportion of Ontario drink machines changing from non-compliant to compliant. At the school level, descriptive results indicate the proportion of Ontario schools with policy-compliant snack and drink machines decreased between Y4 and Y7. Alberta schools were non-compliant for drink and snack machines. (4) Conclusions: Secondary schools continue to be non-compliant with provincial policies. School nutrition policies need to be simplified in order to make it easier for schools to be compliant. Enforcement of compliancy is also an area that deserves consideration.

Long-Term Dietary and Physical Activity Interventions in the School Setting and Their Effects on BMI in Children Aged 6-12 Years: Meta-Analysis of Randomized Controlled Clinical Trials

Preventive actions and potential obesity interventions for children are mainly researched throughout the school period, either as part of the school curricula or after regular school hours, via interventions mostly lasting less than 12 months. We aimed to perform a meta-analysis on randomized controlled clinical trials to evaluate the evidence of the efficacy of long-term school-based interventions in the management of childhood obesity in terms of BMI from a dietary and physical activity-based approach. Eleven randomized controlled clinical trials were examined using the random effects model, and the results showed that there were no significant effects associated with physical activity + nutrition intervention in school children aged 6-12 years, with a pooled standardized mean difference (SMD) (95% CI) of -0.00 (-0.05, 0.04). No effects were observed after subgroup analysis based on the intervention length. The findings from our study indicate that long-term school-based interventions on physical activity and dietary habits received by children aged 6-12 years seem to have no effect on BMI. However, the promotion of such interventions should not be discouraged, as they promote additional positive health outcomes for other domains of children's health.

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.

Three-Year Follow-Up of the POIBA Intervention on Childhood Obesity: A Quasi-Experimental Study

Childhood obesity has increased worldwide over the past four decades. This quasi-experimental study aimed to assess the effectiveness of a multicomponent and multilevel school-based intervention (POIBA) at 3 years of follow-up. The nutrition intervention focused on food groups, food pyramid, nutrients, portions, and balanced menus. In total, 3624 children participated in the study. Anthropometric measurements and information on food frequency and behavior, physical activity, and daily screen use were collected in the intervention (IG) and comparison group (CG). Positive unadjusted changes toward adherence to recommendations were found for water, meat, sweets, and fried potato consumption, proper breakfast, not having dinner in front of the TV, out-of-school physical activity, and daily screen use. Three scores were used to calculate the proportion of children making more than one change to improve healthy habits regarding physical activity (global Activity score), nutrition (global Nutrition score), and both (global score). Students exposed to the intervention had a significantly better global Activity score (16.2% IG vs. 11.9% CG; p = 0.012) and Global score (63.9% IG vs. 58.5% CG; p = 0.025). Intervention effects on obesity incidence at 3-year follow-up lost significance but maintained the positive trend. In conclusion, school-based interventions including a family component could be useful to address the childhood obesity problem.

School as a Protective Setting for Excess Weight Gain and Child Obesity: A Meta-Analysis

BACKGROUND

The structure provided by school settings even with no specific obesity-intervention may prevent weight gain. This meta-analytic study considered this premise by examining weight outcomes from control groups in published randomized controlled trials of school-year obesity-related interventions conducted in-school and out-of-school.

METHODS

A systematic review and random-effects meta-analysis were conducted in accordance with Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Databases were systematically searched and resulted in 1976 unique citations, with 14 retained for analysis. Analyses examined the change in weight outcomes among control group participants.

RESULTS

For studies (N = 6) reporting body mass index (BMI) (kg/m² ) the overall standardized mean difference (SMD) from pre- to post-intervention was 0.085 (raw units 0.278 kg/m² ); for studies (N = 9) reporting zBMI, the SMD was 0.022 (0.020 z-scores), for studies (N = 2) reporting waist circumference (cm), the SMD was 0.149 (1.609 cm); for studies (N = 2) reporting BMI percentile, the SMD was 0.064 (0.985 percentiles); and for studies (N = 1) reporting percent body fat, the SMD was 0.031 (0.30 percentage).

CONCLUSIONS

Children assigned to control conditions (as part of school-based obesity-related interventions) experience, on average, minimal changes in weight outcomes during the school year. Therefore, routine practices of schools may protect against unhealthy weight gains.

Diet Quality Is Lower for Those Who Skip Lunch Among a Sample of Predominantly Black Adolescents

PURPOSE

To compare the dietary quality among adolescents who skip lunch and those who do not and explore associations between school-level variables, demographic variables and lunch skipping.

DESIGN

Cross-sectional.

SETTING

Public schools in New Orleans, Louisiana (n = 21).

PARTICIPANTS

718 adolescents.

METHODS

Adolescents participated in a 24-hour dietary recall using the Automated Self-Administered 24-Hour (ASA24) Dietary Assessment Tool early in 2013. Data were converted into Healthy Eating Index (HEI-2010) scores. Mean scores were compared between students who skipped lunch and those who did not. A multilevel analysis was conducted to assess relationships between school environment, demographics, and lunch skipping.

RESULTS

Of the 718 respondents, 88.3% were Black and 15.3% skipped lunch. Students who ate lunch had a mean HEI score of 46.6 compared to a mean score of 41.7 for students who skipped lunch (p < .001). Students who skipped lunch also had significantly lower intake of total vegetables (p = .02), whole fruits (p < .001), total dairy (p = .003), total protein (p < .001).

CONCLUSIONS

Skipping lunch was associated with lower quality diet, though diet quality was low among all students. Considering over 15% of the sample did not eat lunch in a closed-campus school setting, further research should consider how to encourage students to participate in the National School Lunch Program, which has the ability to increase diet quality in adolescents.

Barriers and facilitators to the implementation of nutrition standards for school food: a mixed methods systematic review protocol

Background: The importance of nutrition during childhood and the high prevalence of child and adolescence obesity has resulted in several countries implementing nutritional standards for school food as a way of providing healthy school food environments. Yet there has been less focus on the barriers and facilitators influencing the process of implementing school food standards. This mixed methods systematic review aims to address this evidence gap by synthesising the empirical evidence on the factors that may influence implementation of school food standards. Methods: This mixed methods systematic review will use qualitative, quantitative and mixed methods evidence from peer reviewed publications retrieved from the following databases; PubMed, CINAHL, Scopus, EMBASE, Medline, PsycINFO and Web of Science. Grey literature will be accessed through Google Scholar, Open Access Theses and Dissertations, OpenGrey, RIAN, EThOS, ProQuest, WorldCat, Networked Digital Library of Theses and Dissertations, and public health organisation websites will also be accessed. Screening reference lists and citation chaining of all included studies will also be undertaken. No restrictions on publication date or language will be applied, however, only primary research studies relevant to supply-side stakeholders will be eligible for inclusion. Study quality will be assessed using the Mixed Methods Appraisal Tool. Study titles and abstracts will be screened to decide whether the full text manuscript should be retrieved. For screening reliability, a second review author will assess a random sample of 20%. Kappa statistics will be used to assess inter-rater reliability, with values of 0.75 and higher representing high agreement. Two authors will independently extract data and factors reported to influence implementation. This will be synthesized using the Theoretical Domains Framework. Discussion: A comprehensive understanding of these factors can provide guidance to relevant stakeholders to enhance the adaption, implementation and sustainability of nutrition standards for school meals. Systematic review registration: PROSPERO CRD42019117904

Multi-Year Examination of School-Based Programs in Preventing Childhood Obesity: A Case of a State Policy in the U.S

This study examined the association between the obesogenic factors and the risk of suffering from weight excess in school-based state programs regarding physical activity, physical education, nutrition standards, and nutrition education in preventing childhood obesity. Data were drawn from the 1999–2011 Youth Risk Behavior Survey in the State of Mississippi (N = 8862; grades 9–12). Logistic regression with year-fixed effects was performed to capture the influence of the legislation on teenage obesity, controlling for demographics and nutrition- and physical activity-related behaviors. The age-, sex-, and ethnicity-adjusted mean of the body mass index had reduced since 2007 (year 1999: 23.52; year 2001: 23.53; year 2003: 23.76; year 2007: 24.26; year 2009: 24.29; and year 2011: 23.91). The legislation was significantly associated with a decreased likelihood of being overweight (year 2007, odds ratio (OR) = 0.686; year 2009, OR = 0.739; and year 2011, OR = 0.760; all p < 0.01). Children who were more sedentary, more frequently fasted to lose weight, and were less physically active and likelier to be overweight (OR = 1.05, 1.37, and 0.97, respectively; all p < 0.05), as were African-American children (OR = 0.64; p < 0.05) and female students (OR = 1.59; p < 0.05). In conclusion, schools are among the most easily modifiable settings for preventing childhood obesity and reducing its prevalence, with the implementation of physical activity and nutritional policies.

The Relationship between Flourishing and Depression in Children in the U.S. Using a Socioecological Perspective

Children's flourishing is likely to be associated with achieving a positive mental and physical quality of life, which is considered as an important factor for helping children to overcome psychological adversity during the critical stage of emotional development. This study examined the relationships between children's flourishing and childhood depression. This was a cross-sectional study using the 2011-2012 National Children's Health Survey in the U.S. The conceptual framework that guided this study was a modified ecological system theory model. Multiple regressions were performed to investigate the associations between flourishing and pediatric depression, controlling for demographics, physical activity-related behaviors, family and environmental conditions. A total of 45,309 children (representing 33,293,823 children at the population level) were identified in this study (mean age: 13.63 years; female: 48.7%). Children's childhood depression was highly related to direct parenting functions, individual needs and environmental availabilities and accessibilities from a socioecological perspective. This study revealed multiple dimensions of how sociological factors influence children's flourishing and mental health. Parents' involvement in children's physical activities and family and social support are crucial for children's flourishing and mental health status. More attention needs to be paid to provide children with family and social support to help them to overcome and reduce childhood depression.

Socioecological Predictors on Psychological Flourishing in the US Adolescence

This study examined the relationship between children’s flourishing and socioecological factors, including individual and family characteristics. A total of 45,309 children were drawn from the 2011–2012 National Survey of Children’s Health in the US (mean age = 13.6 years; male: 51.28%). An ordinary least square (OLS) regression was performed to examine the association between socioecological variables and flourishing. This study assessed children’s individual needs (such as health, education, and emotional and behavioral development), their parents’ parenting capacity (the ability to provide basic care and safety), and family factors (presence of community resources and family income). Children’s individual characteristics, parent’s capacities, and family functions were found to be significantly associated with children’s flourishing. In conclusion, multilevel socioecological factors appeared to be associated with children’s flourishing. Hence, parents’ involvement in their children’s physical activities, as well as family and social support, is crucial for children’s flourishing. This study makes a significant contribution to the literature as research is lacking a correlation between socioecological factors and children’s flourishing; in particular, very few studies have explored or investigated the manner by which children’s socioecological health indicators and factors are associated with their flourishing.

Using GIS and death records to inform statewide school-based diabetes prevention interventions in Michigan

Background: One of modifiable risk factors of diabetes is unhealthy diet which is related to obesity. Individuals with childhood obesity are at higher risk of adulthood obesity. School-based diabetes prevention programs are important to reduce childhood obesity. When resources are limited, evidence-based priority need to be undertaken. However, data related to childhood obesity was not widely available, the study used diabetes-related death records as the proxy of diabetes burden. This study aimed to map and identify geographic variation of diabetes-related mortality rate by school district level in Michigan to be used for policy-relevant information. Design and Methods: This study used death records in Michigan. Diabetes-related mortality rate and years potential life lost (YPLL) was calculated at the school district level. Spatial autocorrelation local Moran's I and geographically weighted regression were used to evaluate spatial pattern of age-adjusted diabetes-related mortality rate by school districts. Results: The age-adjusted diabetes-related mortality rate ranged from 17.0 (95% CI, 8.6-25.5) to 171.3 (95% CI, 135.9-206.7) deaths per 100,000 population. The YPLL per person ranged from 0 to 19.3 years (95% CI, 15.5-23.1). High rates of diabetes-related mortality rate and YPLL clustered in East central and Southeastern region of Lower Peninsula Michigan including Flint, Kearsley, Beecher, Westwood Heights, Detroit, Ecorse, River Rouge, Taylor, Allen Park and Lincoln Consolidated school districts. Conclusions: There was variation in diabetes burden examined by diabetes-related mortality rate and YPLL at the school district level within Michigan State. The high cluster can be prioritized for the intervention programs.

The Food and Nutrition Environment at Secondary Schools in the Eastern Cape, South Africa as Reported by Learners

Overweight and obesity are growing concerns in adolescents, particularly in females in South Africa. The aim of this study was to evaluate the food and nutrition environment in terms of government policy programs, nutrition education provided, and foods sold at secondary schools in the Eastern Cape province. Sixteen schools and grade 8-12 learners (N = 1360) were randomly selected from three health districts comprising poor disadvantaged communities. Based on age and sex specific body mass index (BMI) cut-off values, 13.3% of males and 5.5% of females were underweight, while 9.9% of males and 36.1% of females were overweight or obese. The main food items purchased at school were unhealthy energy-dense items such as fried flour dough balls, chocolates, candies, and crisps/chips. Nutrition knowledge scores based on the South African food-based dietary guidelines (FBDGs) were poor for 52% to 23.4% learners in Grades 8 to 12, respectively. Female learners generally had significantly higher nutrition knowledge scores compared to their male counterparts (p = 0.016). Questions poorly answered by more than 60% of learners, included the number of fruit and vegetable portions required daily, food to eat when overweight, foods containing fiber, and importance of legumes. It was noted that the majority of teachers who taught nutrition had no formal nutrition training and their responses to knowledge questions were poor indicating that they were not familiar with the FBDGs, which are part of the curriculum. Nutrition assessment as part of the Integrated School Health Program was done on few learners. Overall however, despite some challenges the government national school meal program provided meals daily to 96% of learners. In general, the school food and nutrition environment was not conducive for promoting healthy eating.

Middle School Students' Perceptions of the Lunchroom: Implications for Future Interventions

The National School Lunch Program provides nutritious and inexpensive lunches, but low participation and food waste are challenges in many schools. Interventions aim to improve participation in the program, but little is known about how students' perceptions affect their participation. This study explored how middle school students in a rural state perceive school food service staff, food served, and lunchroom atmosphere. An online survey was administered to middle school students at six schools participating in a larger lunchroom intervention. Mean perception scores were calculated for all measures. Multilevel logistic regression was used to examine the relationship between perceptions and consumption. Overall perceptions of staff, food, and atmosphere were positive, and students classified as school lunch eaters had more positive perceptions in all three areas than noneaters. Interventions to increase participation in school lunch programs and promote consumption of healthy food items should address multiple factors that contribute to school lunch participation.

Barriers and facilitators to the implementation of nutrition standards for school food: a mixed methods systematic review protocol

Background: The importance of nutrition during childhood and the high prevalence of child and adolescence obesity has resulted in several countries implementing nutritional standards for school food as a way of providing healthy school food environments. Yet there has been less focus on the barriers and facilitators influencing the process of implementing school food standards. This mixed methods systematic review aims to address this evidence gap by synthesising the empirical evidence on the factors that may influence implementation of school food standards. Methods: This mixed methods systematic review will use qualitative, quantitative and mixed methods evidence from peer reviewed publications retrieved from the following databases; PubMed, CINAHL, Scopus, EMBASE, PsycINFO and Web of Science. Grey literature will be accessed through Google Scholar, Open Access Theses and Dissertations, OpenGrey, RIAN, EThOS, ProQuest, WorldCat, Networked Digital Library of Theses and Dissertations, and public health organisation websites will also be accessed. Screening reference lists and citation chaining of all included studies will also be undertaken. No restrictions on publication date or language will be applied, however, only primary research studies relevant to supply-side stakeholders will be eligible for inclusion. Study quality will be assessed using the Mixed Methods Appraisal Tool. Study titles and abstracts will be screened to decide whether the full text manuscript should be retrieved. For screening reliability, a second review author will assess a random sample of 20%. Kappa statistics will be used to assess inter-rater reliability, with values of 0.75 and higher representing high agreement. Two authors will independently extract data and factors reported to influence implementation. This will be synthesized using the Theoretical Domains Framework. Discussion: A comprehensive understanding of these factors can provide guidance to relevant stakeholders to enhance the adaption, implementation and sustainability of nutrition standards for school meals. Systematic review registration: PROSPERO CRD42019117904

Measurement Methods Used to Assess the School Food Environment: A Systematic Review

Children consume approximately half of their total daily amount of energy at school. Foods consumed are often energy-dense, nutrient-poor. The school food environment represents an effective setting to influence children’s food choices when dietary habits are established and continue to track into adulthood. The aim of this review was to: (1) group methods used for assessing the school food environment according to four food environment dimensions: Physical, economic, socio-cultural and policy and (2) assess the quality of the methods according to four criteria: Comprehensiveness, relevance, generalizability and feasibility. Three databases were searched, and studies were used to assess food and beverages provided at school canteens, tuck shops or cafeterias were included. The review identified 38 global studies (including 49 methods of measuring the food environment). The physical environment was the primary focus for 47% of articles, aspects of policy environment was assessed by 37% articles and a small number of studies assessed the economic (8%) and socio cultural (8%) environment. Three methods were rated ‘high’ quality and seven methods received ‘medium’ quality ratings. The review revealed there are no standardized methods used to measure the school food environment. Robust methods to monitor the school food environment across a range of diverse country contexts is required to provide an understanding of obesogenic school environments.

Stronger State School Nutrition Laws Are Associated With Healthier Eating Behaviors and Optimal Weight Status in US Adolescents

PURPOSE

To investigate relationships of farm-to-school, school meal, and competitive food state laws with eating behaviors and weight status and to examine interaction between different types of state laws.

DESIGN

Observational cohort study.

SETTINGS

US adolescents.

PARTICIPANTS

The NEXT study is a nationally representative sample of adolescents assessed annually for 7 years. Data (N = 2751) from students attending public schools from the first (W1) and third (W3) assessment waves (2010 and 2012), occurring during grades 10 and 12, respectively, of the NEXT study were included.

MEASURES

Eating behaviors and weight status of adolescents were linked with Classification of Laws Associated with School Students scoring for state laws.

ANALYSIS

Regression analyses examined associations of laws with intake and weight status, accounting for complex survey design and school-level clustering.

RESULTS

Adolescents in states with strong farm-to-school laws had greater W1 whole fruit, lower soda, and snack intakes versus those in states with no laws. Strong school meal laws were associated with lower W1 soda intake. Adolescents in states with strong competitive food laws had lower soda intake and overweight/obesity odds than those in states with no laws in W3. Strong farm-to-school laws were inversely associated with W3 overweight/obesity odds only in states with strong competitive food laws.

CONCLUSIONS

Stronger laws governing school nutrition were related to healthier eating behaviors and optimal weight status in this nationally representative sample of adolescents. Further, farm-to-school laws may be more effective in reducing obesity when combined with strong competitive food legislation.

What's for lunch? The content and quality of lunches consumed by Dutch primary schoolchildren and the differences between lunches consumed at home and at school

Background

Lunch is an important part of a healthy diet, which is essential for the development, growth and academic performance of school-aged children. Currently there is an increasing number of Dutch primary schoolchildren who are transitioning from eating lunch at home to school. There is limited knowledge about the current quality of the lunches consumed by primary schoolchildren in the Netherlands and whether there are any differences between lunches consumed at home or at school. To investigate differences in content and quality of lunches consumed by Dutch primary schoolchildren at home and at school.

Methods

Cross-sectional study among 363 Dutch primary schoolchildren aged 4–12 years based on the first two years of the 2012–2016 Dutch National Food Consumption Survey. Demographic characteristics were obtained through a questionnaire. Diet was assessed with two non-consecutive 24-h dietary recalls. Quality of lunches was assessed on their nutritional quality whether they fitted the nutritional guidelines. ‘Nonparametric tests were used to examine the content and quality of the lunches between place of consumption and parental educational position.

Results

The most consumed lunch products among primary schoolchildren were bread, dairy products and sugar-sweetened beverages. Fruit and vegetable consumption was very low. Consumption of milk and other dairy products was higher among children who eat lunch at home than children who eat lunch at school (p < 0.01). Consumption of sugar-sweetened beverages was higher among children who eat lunch at school than children who eat lunch at home (p < 0.01), and at school a higher proportion of the drinks did not fit within the Dutch dietary recommendations (p < 0.01).

Conclusions

The current content of the lunches consumed by Dutch primary schoolchildren leaves room for improvement, especially regarding fruit and vegetables. The statistically significantly higher consumption of sugar-sweetened beverages and lower consumption of milk and dairy products at school vs. home is worrisome, as currently more children in the Netherlands are transitioning to having lunch at school.

Food literacy predictors and associations with physical and emergent literacy in pre-schoolers: results from the Training-to-Health Project

OBJECTIVE

Food literacy (FL) is a crucial need encompassing basic literacy and fundamental movement skills. The present study aimed to investigate the FL level in pre-schoolers and to evaluate the effect of potential predictors and the associations with gross motor and emergent literacy skills.

DESIGN

Cross-sectional study conducted within the Training-to-Health Project.

SETTING

Kindergartens (n 21) in the Palermo City Council, Italy.

PARTICIPANTS

Pre-school children aged 3-6 years (n 921) followed education sessions on nutritional topics, practical activities and compiled prearranged sheets. FL was assessed by the five-domain toolkit 'preschool-FLAT'; gross motor and emergent literacy skills were assessed by the Italian version of the gross motor development test and the PRCR-2/2009, respectively. Correlation and regression analyses were performed to assess relationships between FL scores and gender, age, weight, height, BMI, gross motor and emergent literacy skills.

RESULTS

Independent predictors (β, se) of higher FL were female gender (1·06, 0·315, P < 0·01), older age (0·08, 0·019, P < 0·001) and greater height (0·13, 0·03, P < 0·001). The adjusted coefficients were significant for quotient of gross motor development and in particular for the locomotor component (0·03, 0·01, P < 0·01 and 0·16, 0·046, P < 0·001, respectively). Almost all associations with the emergent literacy skills were significant (β = -0·02 to 0·47).

CONCLUSIONS

The study suggests that children raised in an environment where both cognitive and motor skills are enhanced can have better chances of increasing FL and success at school. Thus, the need for monitoring FL and its predictors since early age is highlighted.

Changes in Fast Food Outlet Availability Near Schools: Unequal Patterns by Income, Race/Ethnicity, and Urbanicity

INTRODUCTION

Previous research has observed income or racial/ethnic inequalities in fast food restaurant availability near schools. The purpose of this study was to investigate changes in fast food restaurant availability near schools between 2000 and 2010 by school neighborhood income, race/ethnicity, and urbanicity.

METHODS

Using data from 7,466 California public schools, negative binomial regression models estimated the relative ratios to evaluate the income gradient in fast food restaurant availability, examine differences in the income gradient in fast food restaurant availability between 2000 and 2010, and investigate if fast food restaurant availability changed in 2010 versus 2000, stratified by race/ethnicity and urbanicity. The analyses were conducted in 2018 and early 2019.

RESULTS

In urban areas, there was a negative school neighborhood income gradient in fast food restaurant availability in both 2000 and 2010, and across all race/ethnic groups, except majority African American schools. The income gradient in fast food restaurant availability was steeper in 2010 relative to 2000 among Latino majority urban schools. Fast food restaurant availability increased in 2010 relative to 2000 among majority African American, majority Latino, and majority Asian schools in the least affluent neighborhoods. Among majority white schools in similar neighborhoods the availability of fast food restaurants did not change but declined in the most affluent school neighborhoods. In nonurban areas, the income patterns in fast food restaurant availability were less clear, and fast food restaurant availability increased among majority white and Latino schools within the middle neighborhood income tertile.

CONCLUSIONS

These findings suggest the need for future interventions to target schools in low-income urban neighborhoods. Additionally, reducing child health disparities and improving health for all children requires monitoring changes in the food environment near schools.

The Impact of Local Food Expenditure on School Foodservice Revenues

BACKGROUND

Locally grown foods, through farm-to-school (FTS) activities, may be a key component to balancing foodservice budgets and alleviating financial constraints in school districts. Therefore, the purpose of this study is to examine the impact of local food expenditures on school foodservice revenues and earnings. We anticipated a positive impact of local food expenditures on foodservice revenues and earnings.

METHODS

Ordinary Least Squares (OLS) regression analysis was conducted using data from the 2013 US Department of Agriculture Farm to School Census. The questionnaire primarily asked all US public school districts about their FTS operations during 2011-2012 school year.

RESULTS

Although our results initially showed a negative impact of local milk and nonmilk expenditures on foodservice revenues from food sales, when combined with revenues from the federal government, the impact is positive. The positive effect seems to hold when adding foodservice revenues from both food sales and federal funds. Our study found a similar pattern for foodservice earnings.

CONCLUSIONS

This may indicate that competitive foods are still widely preferred in school districts. Revenue from the federal government is critical to maintain FTS activities viable to students and community members although federal funds and food sales may not cover total foodservice expenditures.

Exploring Student Food Behaviour in Relation to Food Retail over the Time of Implementing Ontario's School Food and Beverage Policy

Background: Canadian provincial policies, like Ontario’s School Food and Beverage Policy (P/PM 150), increasingly mandate standards for food and beverages offered for sale at school. Given concerns regarding students leaving school to purchase less healthy foods, we examined student behaviours and competitive food retail around schools in a large urban region of Southern Ontario. Methods: Using a geographic information system (GIS), we enumerated food outlets (convenience stores, fast-food restaurants, full-service restaurants) within 500, 1000 and 1500 m of all 389 regional schools spanning years of policy implementation. Consenting grade 6–10 students within 31 randomly selected schools completed a web-based 24-h diet recall (WEB-Q) and questionnaire. Results: Food outlet numbers increased over time (p < 0.01); post-policy, within 1000 m, they averaged 27.31 outlets, with a maximum of 65 fast-food restaurants around one school. Of WEB-Q respondents (n = 2075, mean age = 13.4 ± 1.6 years), those who ate lunch at a restaurant/take-out (n = 84, 4%) consumed significantly more energy (978 vs. 760 kcal), sodium (1556 vs. 1173 mg), and sugar (44.3 vs. 40.1 g). Of elementary and secondary school respondents, 22.1% and 52.4% reported ever eating at fast food outlets during school days. Conclusions: Students have easy access to food retail in school neighbourhoods. The higher energy, sodium and sugar of these options present a health risk.

Impact of State Laws Governing Physical Education on Attendance Among US High School Students, 2003 to 2017

PURPOSE

This study assessed the influence of state laws governing physical education (PE) on weekly PE class attendance among US high school students.

DESIGN

Cross-sectional.

SETTING

2003 to 2017 US national Youth Risk Behavior Survey (YRBS).

PARTICIPANTS

A total of 533 468 high school students.

MEASURES

Data on state laws governing PE came from National Cancer Institute's Classification of Laws Associated with School Students (CLASS). Eight distinct state PE policies were scored, with higher scores denoting stronger laws.

ANALYSIS

Individual-level YRBS data were merged with CLASS data based on students' residential state and survey year. State fixed-effect negative binomial regressions were performed, adjusting for individual-level characteristics and YRBS survey design.

RESULTS

A 1-score increase in state laws governing PE class time, staffing for PE, joint use agreement for physical activity, assessment of health-related fitness, and PE curriculum was associated with an increase in weekly PE attendance by 0.30, 0.28, 0.22, 0.20, and 0.13 days (P < .001), respectively. In contrast, a 1-score increase in state laws governing moderate-to-vigorous-intensity physical activity time in PE, PE proficiency, and recess time was associated with a reduction in weekly PE attendance by 0.25, 0.15, and 0.09 days (P < .001), respectively. The effects of most state PE policies on PE class attendance were larger among girls than boys.

CONCLUSION

State PE policies differentially impacted US high school students' PE class attendance, with larger effects on female students.

The perception of school food-service professionals on the implementation of the Healthy, Hunger-Free Kids Act of 2010: a mixed-methods study

OBJECTIVE

To: (i) understand the nutrition attitudes, self-efficacy, knowledge and practices of school food-service personnel (SFP) in Nebraska and (ii) identify potential barriers that schools face in offering healthy school meals that meet the US Department of Agriculture (USDA) nutrition standards.

DESIGN

Convergent parallel mixed-methods study.

SETTING

Kindergarten-12th grade schools in Nebraska, USA.ParticipantsSFP (260 survey participants; fifteen focus group participants) working at schools that participate in the USDA National School Lunch Program.

RESULTS

Mixed-methods themes identified include: (i) 'Mixed attitudes towards healthy meals', which captured a variety of conflicting positive and negative attitudes depending on the situation; (ii) 'Positive practices to promote healthy meals', which captured offering, serving and promotion practices; (iii) 'Mixed nutrition-related knowledge', which captured the variations in knowledge depending on the nutrition concept; and (iv) 'Complex barriers', which captured challenges with time, support and communication.

CONCLUSIONS

The study produced relevant findings to address the barriers identified by SFP. Implementing multicomponent interventions and providing training to SFP may help reduce some of the identified barriers of SFP.

A Systematic Review and Content Analysis of Classroom Teacher Professional Development in Nutrition Education Programs

Many nutrition programs include classroom-based education. Schoolteachers are relied upon to deliver these programs despite gaps in nutrition education motivation, knowledge, and self-efficacy. Teacher professional development (PD) for these nutrition education programs has been identified as a strategy for improving program effectiveness, yet many interventions do not include a PD component and still fewer describe it. A literature search was conducted between January and February 2017; articles were collected from PubMed, ERIC, and EBSCOhost. Article inclusion criteria were as follows: 1) published in an English-language peer-reviewed or scholarly journal, 2) published after 2000, 3) empirical research, 4) research conducted in a K-12 classroom, 5) research included nutrition education component, and 6) program delivered by a classroom teacher. Twenty-seven interventions were identified. A team of 2 researchers performed content analysis based on an evidence-based set of 7 PD components to assess if and how these components were incorporated before, during, or after program implementation. Little information was provided that described the role of teacher PD in the course of delivering nutrition education in classroom-based programs. The most common elements of PD described in the literature were the time spent in PD and follow-up with instructors during or after program implementation. There was a notable lack of methodologic description of teacher PD, and this limited reporting may decrease researchers' ability to work with teachers in a consistent and effective manner.

Inter-sectoral Transfer of the Food for Life Settings Framework in England

Organisational settings such as schools, workplaces and hospitals are well recognised as key environments for health promotion. Whilst there is extensive literature on specific types of settings, little empirical research has investigated the transfer of frameworks between sectors. This study analyses Food for Life, an England-wide healthy and sustainable food programme that evolved in schools and is being adapted for children's centres, universities, care homes, and hospital settings. Following a case study design, we interviewed 85 stakeholders in nine settings. Food for Life's systemic framework of 'food education, skills and experience' 'food and catering quality', 'community and partnerships' and 'leadership' carried salience in all types of settings. These were perceived to act both as principles and operational priorities for driving systemic change. However, each setting type differed in terms of the mix of facilitating factors and appropriate indicators for change. Barriers in common included the level of culture-shift required, cost perceptions and organisational complexity. For settings based health promotion practice, this study points to the importance of 'frame-working' (the systematic activity of scoping and categorising the field of change) alongside the development and application of benchmarks to stimulate change. These processes are critical in the transfer of learning from between sectors in a form that balances commonality with sufficient flexibility to adapt to specific settings. Synergy between types of settings is an under-recognised, but critical, part of action to address complex issues such as those emerging from the intersection between food, health and sustainability.

"Responses to the Chilean law of food labeling and advertising: exploring knowledge, perceptions and behaviors of mothers of young children"

Background

In line with calls for action from international health organizations, Chile implemented in June 2016 a set of regulations to tackle the obesity epidemic. The new regulation includes the mandatory use of front-of-package warning labels on packaged foods/beverages high in energy, sugars, saturated fats and sodium. Additionally, such foods cannot be sold nor offered in daycares/schools and cannot be promoted to children under 14yo. The law is targeted to children; thus, this study examined mothers’ understanding, perceptions, and behaviors associated with the regulation one year after its implementation, using a qualitative approach.

Methods

Nine focus groups of mothers (7–10 people each) of children (2-14yo) were conducted in July 2017 in Santiago-Chile. They were stratified by socioeconomic status (SES) and children’s age. Macrocodes were developed by three researchers, combining an iterative process of deductive and inductive thematic analyses. Quotations representing each category were selected.

Results

Mothers understood the new regulation as a policy to fight child obesity and were aware that products with more labels were less healthy than products with fewer labels. Attention and use of labels in the buying decision-making process ranged from participants who did not pay attention to others who relied on them as a quick shortcut (mostly from middle and upper-SES); many mothers indicated changing their purchase habits only when buying new products. Mothers declared that young children accepted school environment changes while teens/preteens resisted them more. Many mothers agreed that schools have become key promoters of food behavioral change. Mothers were less aware about the food marketing regulations. Mothers declared that they perceived that the regulation was changing the perceptions, attitudes and behaviors toward healthier eating patterns.

Conclusion

After the first year of implementation, the regulation was well known by mothers of diverse SES and different children ages. The degree of use of warning labels was heterogeneous among participants, but most of them agreed that their children, particularly the youngest have positive attitudes toward the regulation and have become promoters of change in their families. Many mothers also expressed that they perceived an important shift toward healthier eating, which may lead to a change in eating social norms. This information contributes to better understand how regulatory actions may influence people’s consumer behaviors.