An environmental intervention to promote lower-fat food choices in secondary schools: outcomes of the TACOS Study

Long-Term Effectiveness of a Multi-Strategy Choice Architecture Intervention in Increasing Healthy Food Choices of High-School Students From Online Canteens (Click & Crunch High Schools): Cluster Randomized Controlled Trial

BACKGROUND

School canteens are a recommended setting to influence adolescent nutrition due to their scope to improve student food choices. Online lunch ordering systems ("online canteens") are increasingly used and represent attractive infrastructure to implement choice architecture interventions that nudge users toward healthier food choices. A recent cluster randomized controlled trial demonstrated the short-term effectiveness (2-month follow-up) of a choice architecture intervention to increase the healthiness of foods purchased by high school students from online canteens. However, there is little evidence regarding the long-term effectiveness of choice architecture interventions targeting adolescent food purchases, particularly those delivered online.

OBJECTIVE

This study aimed to determine the long-term effectiveness of a multi-strategy choice architecture intervention embedded within online canteen infrastructure in high schools at a 15-month follow-up.

METHODS

A cluster randomized controlled trial was undertaken with 1331 students (from 9 high schools) in New South Wales, Australia. Schools were randomized to receive the automated choice architecture intervention (including menu labeling, positioning, feedback, and prompting strategies) or the control (standard online ordering). The foods purchased were classified according to the New South Wales Healthy Canteen strategy as either "everyday," "occasional," or "should not be sold." Primary outcomes were the average proportion of "everyday," "occasional," and "should not be sold" items purchased per student. Secondary outcomes were the mean energy, saturated fat, sugar, and sodium content of purchases. Outcomes were assessed using routine data collected by the online canteen.

RESULTS

From baseline to 15-month follow-up, on average, students in the intervention group ordered significantly more "everyday" items (+11.5%, 95% CI 7.3% to 15.6%; P<.001), and significantly fewer "occasional" (-5.4%, 95% CI -9.4% to -1.5%; P=.007) and "should not be sold" items (-6%, 95% CI -9.1% to -2.9%; P<.001), relative to controls. There were no between-group differences over time in the mean energy, saturated fat, sugar, or sodium content of lunch orders.

CONCLUSIONS

Given their longer-term effectiveness, choice architecture interventions delivered via online canteens may represent a promising option for policy makers to support healthy eating among high school students.

TRIAL REGISTRATION

Australian Clinical Trials ACTRN12620001338954, https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380546 ; Open Science Framework osf.io/h8zfr, https://osf.io/h8zfr/.

Implementation and effectiveness of a school-based intervention to increase adherence to national school meal guidelines: a non-randomised controlled trial

OBJECTIVE

Implementation of school meal guidelines is often inadequate, and evidence for effective implementation strategies for school-based nutrition interventions is limited. The aim of the present study was to examine the implementation and effectiveness of a multi-strategy implementation intervention to increase adherence to the Norwegian national school meal guideline.

DESIGN

The study was a school-based hybrid implementation effectiveness trial with a pre-post non-equivalent control group design, testing three implementation strategies: internal facilitation, training and an educational meeting.

SETTING

Primary schools and after-school services in two counties in south-east Norway.

PARTICIPANTS

School principals, after-school leaders and class teachers from thirty-three schools in the intervention county and principals and after-school leaders from thirty-four schools in a comparison county.

RESULTS

There was a significant difference of 4 percentage points in change scores between the intervention and the comparison groups at follow-up, after adjusting for baseline adherence (B = 0·04, seB = 0·01, t = 3·10, P = 0·003). The intervention effect was not associated with the school's socio-economic profile. School-level fidelity was the implementation dimension that was most strongly correlated (r s = 0·48) with the change scores in the intervention group, indicating that principals' support is important for gaining the largest intervention effects.

CONCLUSIONS

A school-based intervention with low intensity, based on trained teachers as internal facilitators, can increase adherence to the national school meal guideline among Norwegian primary schools, irrespective of local socio-economic conditions. Implementation fidelity, at an organisational level, may be a useful predictor for intervention outcomes in schools.

Youth and Peer Mentor Led Interventions to Improve Biometric-, Nutrition, Physical Activity, and Psychosocial-Related Outcomes in Children and Adolescents: A Systematic Review

The utilization of youth (older) and peer (same age) mentor-led interventions to improve nutrition and physical activity has been an emerging trend in recent years. This systematic review is intended to synthesize the effectiveness of these intervention programs on participants and mentors based on biometric, nutrition, physical activity, and psychosocial outcomes of youth and peer mentor-led interventions among children and adolescents. Online databases, including PubMed, ScienceDirect, EBSCOhost and Google Scholar, were searched, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. A three-step screening process was used to meet the proposed eligibility criteria, and the risk-of-bias tool for randomized trials (RoB 2) was used to assess bias for the included studies. Nineteen unique intervention programs and twenty-five total studies were deemed eligible when considering the criteria required for review. Multiple studies demonstrated positive evidence of the biometric and physical activity outcomes that were considered significant. The findings regarding the nutritional outcomes across the included studies were mixed, as some studies reported significant changes in eating habits while others did not find a significant change. Overall, the utilization of youth and peer mentor-led models in nutrition- and physical-activity-related interventions may be successful in overweight and obesity prevention efforts for those children and adolescents receiving the intervention and the youths and peers leading the interventions. More research is needed to explore the impact on the youths and peers leading the interventions and disseminating more detailed implementation strategies, e.g., training mentors would allow for advancements in the field and the replicability of approaches. Terminology: In the current youth- and peer-led nutrition and physical activity intervention literature, a varying age differential exists between the targeted sample and the peers, and varying terminology with regards to how to name or refer to the youth. In some instances, the youth mentors were individuals of the same grade as the target sample who either volunteered to serve in the peer role or were selected by their fellow students or school staff. In other cases, the youth mentors were slightly older individuals, either in high school or college, who were selected based upon their experience, leadership skills, passion for the project, or demonstration of healthy lifestyle behaviors.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Perceptions and Impact of a Youth-led Childhood Obesity Prevention Intervention among Youth-leaders

Objective

To evaluate the impact of a youth-led nutrition intervention on youth-leaders themselves.

Design

Mixed methods, including: in-depth interviews and a quasi-experimental quantitative study comparing youth-leaders and nonparticipant comparison youth.

Analysis

Qualitative analysis using direct content analysis. Difference-in-differences analyses assessing quantitative program impact.

Results

Youth-leaders perceived that the intervention impacted themselves, the youth-participants, and their respective social networks. Youth-leaders experienced greater increases in intentions to eat healthfully (p=0.04), and greater decreases in support for healthy eating from their friends (p=0.01), than the comparison group.

Conclusions/Implications

Youth-leaders reported multiple levels of intervention impact, and increased intentions for healthy eating; however, additional research is needed to enhance impact on behavioral outcomes.

Improving implementation of school-based healthy eating and physical activity policies, practices, and programs: a systematic review

Although best practice recommendations exist regarding school-based healthy eating and physical activity policies, practices, and programs, research indicates that implementation is poor. As the field of implementation science is rapidly evolving, an update of the recent review of strategies to improve the implementation of healthy eating and physical activity interventions in schools published in the Cochrane Library in 2017 was required. The primary aim of this review was to examine the effectiveness of strategies that aim to improve the implementation of school-based policies, practices, or programs to address child diet, physical activity, or obesity. A systematic review of articles published between August 31, 2016 and April 10, 2019 utilizing Cochrane methodology was conducted. In addition to the 22 studies included in the original review, eight further studies were identified as eligible. The 30 studies sought to improve the implementation of healthy eating (n = 16), physical activity (n = 11), or both healthy eating and physical activity (n = 3). The narrative synthesis indicated that effect sizes of strategies to improve implementation were highly variable across studies. For example, among 10 studies reporting the proportion of schools implementing a targeted policy, practice, or program versus a minimal or usual practice control, the median unadjusted effect size was 16.2%, ranging from -0.2% to 66.6%. Findings provide some evidence to support the effectiveness of strategies in enhancing the nutritional quality of foods served at schools, the implementation of canteen policies, and the time scheduled for physical education.

Perceptions of eating practices and physical activity among Malaysian adolescents in secondary schools: a qualitative study with multi-stakeholders

OBJECTIVE

To conduct formative research using qualitative methods among stakeholders of secondary schools to explore their perceptions, barriers and facilitators related to healthy eating and physical activity (PA) among Malaysian adolescents.

DESIGN

A qualitative study involving eight focus groups and twelve in-depth interviews. Focus groups and interviews were recorded and transcribed verbatim. An inductive thematic analysis approach was used to analyse the data.

SETTING

Four secondary schools in Perak and Selangor states (two urban and two rural schools) in Malaysia.

PARTICIPANTS

Focus groups were conducted with seventy-six adolescents aged 13-14 years, and in-depth interviews were conducted with four headmasters, four PA education teachers and four food canteen operators.

RESULTS

Stakeholders thought that adolescents' misperceptions, limited availability of healthy options, unhealthy food preferences and affordability were important challenges preventing healthy eating at school. Low-quality physical education (PE) classes, limited adolescent participation and teachers' commitment during lessons were perceived as barriers to adolescents being active at school. Affordability was the main challenge for adolescents from rural schools. Stakeholders perceived that a future school-based intervention should improve the availability and subsidies for healthy foods, provide health education/training for both adolescents and PE teachers, enhance active adolescent participation in PE and develop social support mechanisms to facilitate engagement with PA.

CONCLUSIONS

These findings provide important insights into developing school-based lifestyle interventions to improve healthy eating and strengthening PA of Malaysian adolescents.

Poised for Change: University Students Are Positively Disposed toward Food Waste Diversion and Decrease Individual Food Waste after Programming

Eaters (consumers of food) are responsible for 60% of waste along the food cycle in developed countries. Programs that target individual and household food waste behavior change are essential to addressing such waste. School cafeterias worldwide offer an opportune microcosm in which to educate on food and nutrition skills and change related behavior. No Scrap Left Behind, a cafeteria food waste diversion program, was developed, piloted, and assessed based on measures of both direct and indirect food waste behavior, and attitudes, knowledge, and emotions related to food waste. Participants had positive attitudes towards food waste reduction, engaged in food waste diversion actions, had some knowledge of the impacts of wasted food, and considered their actions important to waste reduction generally. Food waste per student was decreased by 28% over the course of the first year of programming (p = 0.000967), and by 26% in the following year when measured a week before and a week after programming occurred (p = 0.0218). Results indicate that students were poised for food behavior change and that related programming did impact behavior in the short term. Programming may, therefore, help improve student attitudes and skills to develop long-term change as well, although future research should explore this specifically. In comparison with other research on cafeteria programming, results suggest that food waste diversion programming can positively impact students’ dispositions and behaviors, and may be more effective when tailored to the specific population.

Cost-Effectiveness of 2 Support Models for a Healthy School Initiative

BACKGROUND

In school year (SY) 2014-2015, 128 schools in 24 districts and 14 states were randomly assigned to receive either onsite or online support to implement a school-based wellness program. The objective of this study was to assess the cost-effectiveness (CE) of the 2 models of implementation support: onsite and online.

METHODS

We adapted the "ingredients method" for the CE analysis. Using expenditure data, we tabulated the costs of relevant expense categories and allocated the appropriate proportion to determine the total costs of providing each type of support for 4 years (SY 2014-2015 through SY 2017-2018). We divided the average cost per school by the average change in school wellness policies and practices, using assessment data provided by the program provider, to calculate a CE ratio for schools in each group.

RESULTS

Findings indicate that when the program is implemented as intended, online support is, on average, approximately 1.3 times more cost-effective than onsite support at the end of 4 years.

CONCLUSIONS

By demonstrating the relative CE of 2 approaches to supporting the implementation of a school health program, this study provides further insight on more efficient interventions for improving overall school wellness.

Altering the availability or proximity of food, alcohol, and tobacco products to change their selection and consumption

BACKGROUND

Overconsumption of food, alcohol, and tobacco products increases the risk of non-communicable diseases. Interventions to change characteristics of physical micro-environments where people may select or consume these products - including shops, restaurants, workplaces, and schools - are of considerable public health policy and research interest. This review addresses two types of intervention within such environments: altering the availability (the range and/or amount of options) of these products, or their proximity (the distance at which they are positioned) to potential consumers.

OBJECTIVES

1. To assess the impact on selection and consumption of altering the availability or proximity of (a) food (including non-alcoholic beverages), (b) alcohol, and (c) tobacco products.2. To assess the extent to which the impact of these interventions is modified by characteristics of: i. studies, ii. interventions, and iii.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, and seven other published or grey literature databases, as well as trial registries and key websites, up to 23 July 2018, followed by citation searches.

SELECTION CRITERIA

We included randomised controlled trials with between-participants (parallel group) or within-participants (cross-over) designs. Eligible studies compared effects of exposure to at least two different levels of availability of a product or its proximity, and included a measure of selection or consumption of the manipulated product.

DATA COLLECTION AND ANALYSIS

We used a novel semi-automated screening workflow and applied standard Cochrane methods to select eligible studies, collect data, and assess risk of bias. In separate analyses for availability interventions and proximity interventions, we combined results using random-effects meta-analysis and meta-regression models to estimate summary effect sizes (as standardised mean differences (SMDs)) and to investigate associations between summary effect sizes and selected study, intervention, or participant characteristics. We rated the certainty of evidence for each outcome using GRADE.

MAIN RESULTS

We included 24 studies, with the majority (20/24) giving concerns about risk of bias. All of the included studies investigated food products; none investigated alcohol or tobacco. The majority were conducted in laboratory settings (14/24), with adult participants (17/24), and used between-participants designs (19/24). All studies were conducted in high-income countries, predominantly in the USA (14/24).Six studies investigated availability interventions, of which two changed the absolute number of different options available, and four altered the relative proportion of less-healthy (to healthier) options. Most studies (4/6) manipulated snack foods or drinks. For selection outcomes, meta-analysis of three comparisons from three studies (n = 154) found that exposure to fewer options resulted in a large reduction in selection of the targeted food(s): SMD -1.13 (95% confidence interval (CI) -1.90 to -0.37) (low certainty evidence). For consumption outcomes, meta-analysis of three comparisons from two studies (n = 150) found that exposure to fewer options resulted in a moderate reduction in consumption of those foods, but with considerable uncertainty: SMD -0.55 (95% CI -1.27 to 0.18) (low certainty evidence).Eighteen studies investigated proximity interventions. Most (14/18) changed the distance at which a snack food or drink was placed from the participants, whilst four studies changed the order of meal components encountered along a line. For selection outcomes, only one study with one comparison (n = 41) was identified, which found that food placed farther away resulted in a moderate reduction in its selection: SMD -0.65 (95% CI -1.29 to -0.01) (very low certainty evidence). For consumption outcomes, meta-analysis of 15 comparisons from 12 studies (n = 1098) found that exposure to food placed farther away resulted in a moderate reduction in its consumption: SMD -0.60 (95% CI -0.84 to -0.36) (low certainty evidence). Meta-regression analyses indicated that this effect was greater: the farther away the product was placed; when only the targeted product(s) was available; when participants were of low deprivation status; and when the study was at high risk of bias.

AUTHORS' CONCLUSIONS

The current evidence suggests that changing the number of available food options or altering the positioning of foods could contribute to meaningful changes in behaviour, justifying policy actions to promote such changes within food environments. However, the certainty of this evidence as assessed by GRADE is low or very low. To enable more certain and generalisable conclusions about these potentially important effects, further research is warranted in real-world settings, intervening across a wider range of foods - as well as alcohol and tobacco products - and over sustained time periods.

Altering the availability or proximity of food, alcohol, and tobacco products to change their selection and consumption

BACKGROUND

Overconsumption of food, alcohol, and tobacco products increases the risk of non-communicable diseases. Interventions to change characteristics of physical micro-environments where people may select or consume these products - including shops, restaurants, workplaces, and schools - are of considerable public health policy and research interest. This review addresses two types of intervention within such environments: altering the availability (the range and/or amount of options) of these products, or their proximity (the distance at which they are positioned) to potential consumers.

OBJECTIVES

1. To assess the impact on selection and consumption of altering the availability or proximity of (a) food (including non-alcoholic beverages), (b) alcohol, and (c) tobacco products.2. To assess the extent to which the impact of these interventions is modified by characteristics of: i. studies, ii. interventions, and iii.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, and seven other published or grey literature databases, as well as trial registries and key websites, up to 23 July 2018, followed by citation searches.

SELECTION CRITERIA

We included randomised controlled trials with between-participants (parallel group) or within-participants (cross-over) designs. Eligible studies compared effects of exposure to at least two different levels of availability of a product or its proximity, and included a measure of selection or consumption of the manipulated product.

DATA COLLECTION AND ANALYSIS

We used a novel semi-automated screening workflow and applied standard Cochrane methods to select eligible studies, collect data, and assess risk of bias. In separate analyses for availability interventions and proximity interventions, we combined results using random-effects meta-analysis and meta-regression models to estimate summary effect sizes (as standardised mean differences (SMDs)) and to investigate associations between summary effect sizes and selected study, intervention, or participant characteristics. We rated the certainty of evidence for each outcome using GRADE.

MAIN RESULTS

We included 24 studies, with the majority (20/24) giving concerns about risk of bias. All of the included studies investigated food products; none investigated alcohol or tobacco. The majority were conducted in laboratory settings (14/24), with adult participants (17/24), and used between-participants designs (19/24). All studies were conducted in high-income countries, predominantly in the USA (14/24).Six studies investigated availability interventions, of which two changed the absolute number of different options available, and four altered the relative proportion of less-healthy (to healthier) options. Most studies (4/6) manipulated snack foods or drinks. For selection outcomes, meta-analysis of three comparisons from three studies (n = 154) found that exposure to fewer options resulted in a large reduction in selection of the targeted food(s): SMD -1.13 (95% confidence interval (CI) -1.90 to -0.37) (low certainty evidence). For consumption outcomes, meta-analysis of three comparisons from two studies (n = 150) found that exposure to fewer options resulted in a moderate reduction in consumption of those foods, but with considerable uncertainty: SMD -0.55 (95% CI -1.27 to 0.18) (low certainty evidence).Eighteen studies investigated proximity interventions. Most (14/18) changed the distance at which a snack food or drink was placed from the participants, whilst four studies changed the order of meal components encountered along a line. For selection outcomes, only one study with one comparison (n = 41) was identified, which found that food placed farther away resulted in a moderate reduction in its selection: SMD -0.65 (95% CI -1.29 to -0.01) (very low certainty evidence). For consumption outcomes, meta-analysis of 15 comparisons from 12 studies (n = 1098) found that exposure to food placed farther away resulted in a moderate reduction in its consumption: SMD -0.60 (95% CI -0.84 to -0.36) (low certainty evidence). Meta-regression analyses indicated that this effect was greater: the farther away the product was placed; when only the targeted product(s) was available; when participants were of low deprivation status; and when the study was at high risk of bias.

AUTHORS' CONCLUSIONS

The current evidence suggests that changing the number of available food options or altering the positioning of foods could contribute to meaningful changes in behaviour, justifying policy actions to promote such changes within food environments. However, the certainty of this evidence as assessed by GRADE is low or very low. To enable more certain and generalisable conclusions about these potentially important effects, further research is warranted in real-world settings, intervening across a wider range of foods - as well as alcohol and tobacco products - and over sustained time periods.

Comprehensive Approaches to Improving Nutrition: Future Prospects

When it comes to nutrition, nearly everyone has an opinion. In the past, nutrition was considered to be an individual's responsibility, however, more recently governments have been expected (by some) to share that responsibility by helping to ensure that marketing is responsible, and that food chains offer healthy meal choices in addition to their standard fare, for example. In some countries, governments have gone as far as to remove tax from unprocessed foods or to introduce taxes, such as that imposed on sugary soft drinks in the UK, Mexico, France and Norway. Following on from the sugar tax, chocolate might be next! Is this the answer to our burgeoning calorie intake and increasing poor nutritional status, or is there another approach? In this narrative we will focus on some of the approaches taken by communities and governments to address excess calorie intake and improve nutritional status, as well as some of the conflicts of interest and challenges faced with implementation. It is clear that in order to achieve meaningful change in the quality of nutritional intake and to reduce the long-term prevalence of obesity, a comprehensive approach is required wherein governments and communities work in genuine partnership. To take no or little action will doom much of today's youth to a poor quality of life in later years, and a shorter life expectancy than their grandparents.

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.

Youth Mentor Dietary Outcomes and Waist Circumference Improvement: Camp NERF Study Findings

Background. The health impact of youth mentors serving in the delivery of child nutrition and physical activity (PA) interventions on youth mentors themselves has been understudied. Objective. The primary objective of the current study was to examine the impact of engaging youth mentors in the delivery of a summertime childhood obesity prevention intervention on youth mentors' behavioral health. Method. Data were collected at baseline and postintervention. A survey of validated nutrition, mental health, PA, and psychosocial questionnaires was administered. Diet was assessed via 24-hour recall. Height, weight, and waist circumference (WC) were measured. In-depth interviews were conducted with youth mentors. Results. Eleven youth mentors enrolled: 60% were female, mean age was 16.1 ± 0.38 years, and 100% were Black. Mean kilocalories (p = .05), sugar-sweetened beverage intake (p = .08), and waist circumference (p = .04) decreased. In-depth interviews were conducted with 11 youth mentors, and three themes emerged: perceived improvement in nutrition, PA, and mental health-related behaviors; formation of a positive role modeling relationship with the child campers; and strengthening of higher education goals and future career aspirations. Conclusions. Youth mentor staffing may be an important intervention strategy for changing health behaviors among youth mentors. Results from this study can be used to inform utilization of youth mentors in the delivery of this and similar health behavior interventions in the future.

Consumption habits of school canteen and non-canteen users among Norwegian young adolescents: a mixed method analysis

BACKGROUND

Food/drinks available to adolescents in schools can influence their dietary behaviours, which once established in adolescence, tend to remain over time. Food outlets' influence near schools, known to provide access to unhealthy food/drinks, may also have lasting effects on consumption behaviours. This study aimed to gain a better understanding of the consumption habits of adolescents in the school arena by comparing different personal characteristics and purchasing behaviours of infrequent and regular school canteen users to those never or seldom using the canteen.

METHODS

A convergent mixed methods design collected qualitative and quantitative data in parallel. A cross-sectional quantitative study including 742 adolescents was conducted, with data collected at schools via an online questionnaire. Focus group interviews with students and interviews with school administrators formed the qualitative data content. Quantitative data were analysed using descriptive statistics and logistic regression; thematic content analysis was used to analyse qualitative data.

RESULTS

Sixty-seven percent of adolescents reported never/rarely using the school canteen (NEV), whereas 13% used it ≥2 times per week (OFT). When the two groups were compared, we found a significantly higher proportion of the NEV group were female, having parents with a high education, and with a high self-efficacy, whilst a significantly higher proportion of the OFT group consumed salty snacks, baked sweets, and soft-drinks ≥3 times per week, and breakfast at home < 5 days in the school week. The OFT group had significantly higher odds of purchasing food/drink from shops near school during school breaks and before/after school compared to the NEV group (adjusted odds ratio (aOR) = 1.80, 95% CI 1.07-3.01, and aOR = 3.61, 95% CI 2.17-6.01, respectively). The interviews revealed most students ate a home packed lunch, with the remainder purchasing either at the school canteen or at local shops.

CONCLUSIONS

Students using the canteen often are frequently purchasing snacks and sugar-soft drinks from shops near school, most likely owing to availability of pocket money and an emerging independence. School authorities must focus upon satisfying canteen users by providing desirable, healthy, and affordable items in order to compete with the appeal of local shops.

Sugar-Sweetened Beverage, Obesity, and Type 2 Diabetes in Children and Adolescents: Policies, Taxation, and Programs

PURPOSE OF REVIEW

Obesity has grown at an alarming rate in children and adolescents. Concurrently, consumption on sugar-sweetened beverages (SSBs) also rose significantly. This review provides an overview of obesity and type 2 diabetes mellitus (T2DM) related to SSBs and current policies restricting SSBs in schools, school-based interventions, and taxation on reducing SSB intake and obesity. We also discuss challenges of and future steps for these initiatives.

RECENT FINDINGS

Clinical and epidemiological studies suggest a strong association between SSB intake and obesity and T2DM. School food policies have been initiated at federal, state, and local levels. School-based interventions have shown positive effects on SSB intake and obesity reduction. Taxation on SSBs is promising in combating obesity and in generating revenue. Challenges towards compliance and implementation of the policies and programs exist. The relationship between SSB and obesity and T2DM is a complex problem which requires comprehensive solutions. Continued efforts in restricting SSBs in schools are needed. Intervention programs should be tailored to age, gender, language, and culture and involve participation from families and local communities. Taxation can reduce SSB consumption by direct economic incentive, earmarking revenues to support healthy foods, and sending negative message. However, a higher tax rate may be necessary to have a measurable effect on weight.

Effectiveness of school food environment policies on children's dietary behaviors: A systematic review and meta-analysis

Background

School food environment policies may be a critical tool to promote healthy diets in children, yet their effectiveness remains unclear.

Objective

To systematically review and quantify the impact of school food environment policies on dietary habits, adiposity, and metabolic risk in children.

Methods

We systematically searched online databases for randomized or quasi-experimental interventions assessing effects of school food environment policies on children’s dietary habits, adiposity, or metabolic risk factors. Data were extracted independently and in duplicate, and pooled using inverse-variance random-effects meta-analysis. Habitual (within+outside school) dietary intakes were the primary outcome. Heterogeneity was explored using meta-regression and subgroup analysis. Funnel plots, Begg’s and Egger’s test evaluated potential publication bias.

Results

From 6,636 abstracts, 91 interventions (55 in US/Canada, 36 in Europe/New Zealand) were included, on direct provision of healthful foods/beverages (N = 39 studies), competitive food/beverage standards (N = 29), and school meal standards (N = 39) (some interventions assessed multiple policies). Direct provision policies, which largely targeted fruits and vegetables, increased consumption of fruits by 0.27 servings/d (n = 15 estimates (95%CI: 0.17, 0.36)) and combined fruits and vegetables by 0.28 servings/d (n = 16 (0.17, 0.40)); with a slight impact on vegetables (n = 11; 0.04 (0.01, 0.08)), and no effects on total calories (n = 6; -56 kcal/d (-174, 62)). In interventions targeting water, habitual intake was unchanged (n = 3; 0.33 glasses/d (-0.27, 0.93)). Competitive food/beverage standards reduced sugar-sweetened beverage intake by 0.18 servings/d (n = 3 (-0.31, -0.05)); and unhealthy snacks by 0.17 servings/d (n = 2 (-0.22, -0.13)), without effects on total calories (n = 5; -79 kcal/d (-179, 21)). School meal standards (mainly lunch) increased fruit intake (n = 2; 0.76 servings/d (0.37, 1.16)) and reduced total fat (-1.49%energy; n = 6 (-2.42, -0.57)), saturated fat (n = 4; -0.93%energy (-1.15, -0.70)) and sodium (n = 4; -170 mg/d (-242, -98)); but not total calories (n = 8; -38 kcal/d (-137, 62)). In 17 studies evaluating adiposity, significant decreases were generally not identified; few studies assessed metabolic factors (blood lipids/glucose/pressure), with mixed findings. Significant sources of heterogeneity or publication bias were not identified.

Conclusions

Specific school food environment policies can improve targeted dietary behaviors; effects on adiposity and metabolic risk require further investigation. These findings inform ongoing policy discussions and debates on best practices to improve childhood dietary habits and health.

Are school meals a viable and sustainable tool to improve the healthiness and sustainability of children´s diet and food consumption? A cross-national comparative perspective

There is little agreement among governments, institutions, scientists and food activists as to how to best tackle the challenging issues of health and sustainability in the food sector. This essay discusses the potential of school meals as a platform to promote healthy and sustainable food behavior. School meal programs are of particular interest for improving public diet because they reach children at a population scale across socio-economic classes and for over a decade of their lives, and because food habits of children are more malleable than those of adults. Current research on the history and health implications of school meal programs is reviewed in a cross-national comparative framework, and arguments explored that speak for the need of a new developmental phase of school meals as an integrative learning platform for healthy and sustainable food behavior. Nutritional, social, practical, educational, economical, political, and cultural perspectives and challenges linked to the implementation of healthy and sustainable school meals are discussed. Finally, the need for long-term interventions and evaluations is highlighted and new research directions are proposed.

Healthy food procurement and nutrition standards in public facilities: evidence synthesis and consensus policy recommendations

INTRODUCTION

Unhealthy foods are widely available in public settings across Canada, contributing to diet-related chronic diseases, such as obesity. This is a concern given that public facilities often provide a significant amount of food for consumption by vulnerable groups, including children and seniors. Healthy food procurement policies, which support procuring, distributing, selling, and/or serving healthier foods, have recently emerged as a promising strategy to counter this public health issue by increasing access to healthier foods. Although numerous Canadian health and scientific organizations have recommended such policies, they have not yet been broadly implemented in Canada.

METHODS

To inform further policy action on healthy food procurement in a Canadian context, we: (1) conducted an evidence synthesis to assess the impact of healthy food procurement policies on health outcomes and sales, intake, and availability of healthier food, and (2) hosted a consensus conference in September 2014. The consensus conference invited experts with public health/nutrition policy research expertise, as well as health services and food services practitioner experience, to review evidence, share experiences, and develop a consensus statement/recommendations on healthy food procurement in Canada.

RESULTS

Findings from the evidence synthesis and consensus recommendations for healthy food procurement in Canada are described. Specifically, we outline recommendations for governments, publicly funded institutions, decision-makers and professionals, citizens, and researchers.

CONCLUSION

Implementation of healthy food procurement policies can increase Canadians' access to healthier foods as part of a broader vision for food policy in Canada.

Early Outcomes of State Public Health Actions' School Nutrition Strategies

INTRODUCTION

Since 2013, the State Public Health Actions to Prevent and Control Diabetes, Heart Disease, Obesity and Associated Risk Factors and Promote School Health (State Public Health Actions) program has been implemented to support and reinforce healthy choices and healthy behaviors among the US population. The Centers for Disease Control and Prevention's Division of Population Health's School Health Branch has been a critical component, ensuring that state health departments support schools in adopting nutrition standards and creating a supportive nutrition environment. The objective of this article was to describe early outcomes of the school nutrition strategies of State Public Health Actions.

METHODS

We examined the extent of progress for short-term performance measures and for school nutrition evaluation questions, using data secured from 51 grantees through the performance measures database and state evaluation reports.

RESULTS

During the first 4 years of the cooperative agreement, grantees demonstrated significant progress compared with year 2 for school nutrition performance measures. Collectively, grantees provided professional development and technical assistance to staff in 7,672 local education agencies and reached more than 29 million students. Success was also noted for several nutrition practices in schools.

CONCLUSION

These early outcomes suggest that State Public Health Actions has had a positive impact on the nutrition environment of US schools. Systematically addressing areas for improvement could further expand the reach of these efforts during the remainder of the cooperative agreement.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Pricing Strategies to Encourage Availability, Purchase, and Consumption of Healthy Foods and Beverages: A Systematic Review

Introduction

Food pricing policies to promote healthy diets, such as taxes, price manipulations, and food subsidies, have been tested in different settings. However, little consensus exists about the effect of these policies on the availability of healthy and unhealthy foods, on what foods consumers buy, or on the impact of food purchases on consumer health outcomes. We conducted a systematic review of studies of the effect of food-pricing interventions on retail sales and on consumer purchasing and consumption of healthy foods and beverages.

Methods

We used MEDLINE, Embase, PsycINFO, Web of Science, ClinicalTrials.gov, and the Cochrane Library to conduct a systematic search for peer-reviewed articles related to studies of food pricing policies. We selected articles that were published in English from January 2000 through December 2016 on the following types of studies: 1) real-world experimental studies (randomized controlled trials, quasi-experimental studies, and natural experiments); 2) population studies of people or retail stores in middle-income and high-income countries; 3) pricing interventions alone or in combination with other strategies (price promotions, coupons, taxes, or cash-back rebates), excluding studies of vending-machine or online sales; and 4) outcomes studies at the retail (stocking, sales) and consumer (purchasing, consumption) levels. We selected 65 articles representing 30 studies for review.

Results

Sixteen pricing intervention studies that sought to improve access to healthy food and beverage options reported increased stocking and sales of promoted food items. Most studies (n = 23) reported improvement in the purchasing and consumption of healthy foods or beverages or decreased purchasing and consumption of unhealthy foods or beverages. Most studies assessed promotions of fresh fruits and vegetables (n = 20); however, these foods may be hard to source, have high perishability, and raise concerns about safety and handling. Few of the pricing studies we reviewed discouraged purchasing and consumption of unhealthy foods (n = 6). Many studies we reviewed had limitations, including lack of formative research, process evaluation, or psychosocial and health assessments of the intervention’s impact; short intervention duration; or no assessment of food substitutions or the effects of pricing interventions on food purchasing and diets.

Conclusion

Pricing interventions generally increased stocking, sales, purchasing, and consumption of promoted foods and beverages. Additional studies are needed to differentiate the potential impact of selected pricing strategies and policies over others.

Food environment and policies in private schools in Kolkata, India

School food policies and services have the potential to influence the food practices and eating behaviours of adolescents which in turn may affect their lifestyles and health in adulthood. The aim of this qualitative investigation was to describe the opinions of adolescents, their parents, nutrition educators and school principals about the prevailing food environment and canteen policies in Indian schools. Fifteen adolescents aged 14-15 years, 15 parents, 12 teachers and 10 principals from 10 private schools in Kolkata, India participated in semi-structured interviews. The interview questions were primarily based on the existing literature related to school food environments and policies. Audio recordings were transcribed verbatim and assessed thematically. Throughout the 52 interviews, a number of inadequacies of the school food environment and policies were revealed. These included the absence of written food policies, the widespread supply of unhealthy foods, inadequate provision of healthy foods, misleading messages about food communicated by school authorities, lack of cleanliness in the school canteen and the high cost of canteen food. Current school food environments do not appear to promote healthy eating among adolescents. Therefore, it is important to upgrade the quality of food services in Indian schools through adoption of healthy eating policies.

Creating a school nutrition environment index and pilot testing it in elementary and middle schools in urban South Korea

BACKGROUND/OBJECTIVES

The role of a school's nutrition environment in explaining students' eating behaviors and weight status has not been examined in an Asian setting. The purpose of this study was to create a school nutrition environment index and to pilot test the index in elementary and middle schools in urban South Korea.

SUBJECTS/METHODS

This study used a mixed-methods approach. Environment assessment tools were developed based on formative research, which comprised literature reviews, in-depth interviews, and focus group discussions. Key elements from the formative research were included in the assessment tool, which consisted of a structured survey questionnaire for school dietitians. Fifteen school dietitians from 7 elementary and 8 middle schools in Seoul completed the questionnaire.

RESULTS

The formative research revealed four main sections that guided a summary index to assess a school's nutrition environment: resource availability, education and programs, dietitians' perceptions and characteristics, and school lunch menu. Based on the literature reviews and interviews, an index scoring system was developed. The total possible score from the combined four index sections was 40 points. From the 15 schools participating in the pilot survey, the mean school nutrition-environment index was 22.5 (standard deviation ± 3.2; range 17-28). The majority of the schools did not offer classroom-based nutrition education or nutrition counseling for students and parents. The popular modes of nutrition education were school websites, posters, and newsletters.

CONCLUSIONS

This paper illustrates the process used to develop an instrument to assess a school's nutrition environment. Moreover, it presents the steps used to develop a scoring system for creation of a school nutrition environment index. As pilot testing indicated the total index score has some variation across schools, we suggest applying this instrument in future studies involving a larger number of schools. Future studies with larger samples will allow investigation of the validity and reliability of this newly developed tool.

Impact of school policies on non-communicable disease risk factors - a systematic review

BACKGROUND

Globally, non-communicable diseases (NCDs) are identified as one of the leading causes of mortality. NCDs have several modifiable risk factors including unhealthy diet, physical inactivity, tobacco use and alcohol abuse. Schools provide ideal settings for health promotion, but the effectiveness of school policies in the reduction of risk factors for NCD is not clear. This study reviewed the literature on the impact of school policies on major NCD risk factors.

METHODS

A systematic review was conducted to identify, collate and synthesize evidence on the effectiveness of school policies on reduction of NCD risk factors. A search strategy was developed to identify the relevant studies on effectiveness of NCD policies in schools for children between the age of 6 to 18 years in Ovid Medline, EMBASE, and Web of Science. Data extraction was conducted using pre-piloted forms. Studies included in the review were assessed for methodological quality using the Effective Public Health Practice Project (EPHPP) quality assessment tool. A narrative synthesis according to the types of outcomes was conducted to present the evidence on the effectiveness of school policies.

RESULTS

Overall, 27 out of 2633 identified studies were included in the review. School policies were comparatively more effective in reducing unhealthy diet, tobacco use, physical inactivity and inflammatory biomarkers as opposed to anthropometric measures, overweight/obesity, and alcohol use. In total, for 103 outcomes independently evaluated within these studies, 48 outcomes (46%) had significant desirable changes when exposed to the school policies. Based on the quality assessment, 18 studies were categorized as weak, six as moderate and three as having strong methodological quality.

CONCLUSION

Mixed findings were observed concerning effectiveness of school policies in reducing NCD risk factors. The findings demonstrate that schools can be a good setting for initiating positive changes in reducing NCD risk factors, but more research is required with long-term follow up to study the sustainability of such changes.

Healthy Concessions: High School Students' Responses to Healthy Concession Stand Changes

BACKGROUND

A previous sales data analysis demonstrated success in selling healthier items at a concession stand. Questions remained regarding student satisfaction and whether the intervention reached non-health-conscious students.

METHODS

Cross-sectional anonymous samples of students at a large midwestern high school were surveyed before and after an intervention improved the number of healthier items available at the concession stand.

RESULTS

The survey was completed by 301 students preintervention and 314 students postintervention. Satisfaction remained good (3.7 preintervention and 3.6 postintervention). Satisfaction with the variety and taste of foods increased. We compared students who felt having healthy items were important at the concessions to those who did not. Overall satisfaction with concessions did not differ between groups. The latter group (healthy items not important) reported improved satisfaction with food variety (2.8 to 3.1, p = .02) and the former reported improved satisfaction with healthy foods (2.5 to 2.9, p = .03) and overall taste (3.2 to 3.4, p = .02). Of the healthy items not important students 76% reported purchasing at least 1 new healthier food.

CONCLUSIONS

Adding healthier foods to school concession stands has positive effects on student satisfaction, sales, and reaches all students whether or not they care about having healthy items available.

Child and youth participatory interventions for addressing lifestyle-related childhood obesity: a systematic review

A growing number of childhood obesity interventions involve children and youth in participatory roles, but these types of interventions have not been systematically reviewed. We aimed to identify child and youth participatory interventions in the peer-reviewed literature in order to characterize the approaches and examine their impact on obesity and obesity-related lifestyle behaviours. We searched PubMed/Medline, psychINFO and ERIC for quasi-experimental and randomized trials conducted from date of database initiation through May 2015 that engaged children or youth in implementing healthy eating, physical activity or weight management strategies. Eighteen studies met our eligibility criteria. Most (n = 14) trained youth to implement pre-defined strategies targeting their peers. A few (n = 4) assisted youth to plan and implement interventions that addressed environmental changes. Thirteen studies reported at least one statistically significant weight, physical activity or dietary change outcome. Participatory approaches have potential, but variation in strategies and outcomes leave questions unanswered about the mechanisms through which child and youth engagement impact childhood obesity. Future research should compare child-delivered or youth-delivered to adult-delivered health promotion interventions and more rigorously evaluate natural experiments that engage youth to implement environmental changes. With careful attention to theoretical frameworks, process and outcome measures, these studies could strengthen the effectiveness of child and youth participatory approaches.

Informing Best Practice With Community Practice: The Community Change Chronicle Method for Program Documentation and Evaluation

Health promotion professionals are increasingly encouraged to implement evidence-based programs in health departments, communities, and schools. Yet translating evidence-based research into practice is challenging, especially for complex initiatives that emphasize environmental strategies to create community change. The purpose of this article is to provide health promotion practitioners with a method to evaluate the community change process and document successful applications of environmental strategies. The community change chronicle method uses a five-step process: first, develop a logic model; second, select outcomes of interest; third, review programmatic data for these outcomes; fourth, collect and analyze relevant materials; and, fifth, disseminate stories. From 2001 to 2003, the authors validated the use of a youth empowerment model and developed eight community change chronicles that documented the creation of tobacco-free schools policies (n = 2), voluntary policies to reduce secondhand smoke in youth hangouts (n = 3), and policy and program changes in diverse communities (n = 3).

How do we actually put smarter snacks in schools? NOURISH (Nutrition Opportunities to Understand Reforms Involving Student Health) conversations with food-service directors

OBJECTIVE

In autumn 2012, Massachusetts schools implemented comprehensive competitive food and beverage standards similar to the US Department of Agriculture's Smart Snacks in School standards. We explored major themes raised by food-service directors (FSD) regarding their school-district-wide implementation of the standards.

DESIGN

For this qualitative study, part of a larger mixed-methods study, compliance was measured via direct observation of foods and beverages during school site visits in spring 2013 and 2014, calculated to ascertain the percentage of compliant products available to students. Semi-structured interviews with school FSD conducted in each year were analysed for major implementation themes; those raised by more than two-thirds of participating school districts were explored in relationship to compliance.

SETTING

Massachusetts school districts (2013: n 26; 2014: n 21).

SUBJECTS

Data collected from FSD.

RESULTS

Seven major themes were raised by more than two-thirds of participating school districts (range 69-100 %): taking measures for successful transition; communicating with vendors/manufacturers; using tools to identify compliant foods and beverages; receiving support from leadership; grappling with issues not covered by the law; anticipating changes in sales of competitive foods and beverages; and anticipating changes in sales of school meals. Each theme was mentioned by the majority of more-compliant school districts (65-81 %), with themes being raised more frequently after the second year of implementation (range increase 4-14 %).

CONCLUSIONS

FSD in more-compliant districts were more likely to talk about themes than those in less-compliant districts. Identified themes suggest best-practice recommendations likely useful for school districts implementing the final Smart Snacks in School standards, effective July 2016.

Acceptance and satisfaction of parents and students about a school-based dietary intervention in Isfahan, 2012-2013

OBJECTIVE

Snacks play an important role in child health and nutritional status. Schools are considered as the preferred place to encourage healthy eating among children. The aim of this study was to evaluate the effect of buffet school-based intervention on acceptance and satisfaction of parents and students in Iran.

MATERIALS AND METHODS

Primary school students (n = 1120, 68.83% girls) from first to third grade, with one of their parents, participated in this prospective field trial study conducted in Isfahan, Iran. The study was consisted of three phases; schools selection, kitchen selection, implementation including two different parts, getting order and distribution. We provided hot snacks as traditional and healthy fast food according to taste and food preferences of children. Acceptance and satisfaction of parents and students were evaluated via a researcher made questionnaire before and after the intervention in one-third of participants as a representative sample of students who ordered the snacks.

RESULTS

Most of the students usually ate snack in the break-time at school, the eagerness of provided snacks was 98.8% and 63.6% in girls and boys, respectively. The most interesting tastes were Ashe Reshteh and Tahchin, (45.1% girls vs. 36.8% boys), while bean (among girls) and Ashe Jo (among boys) were ranked as the lowest. More than half of parents (66.7%) evaluated the price of snacks as "acceptable," showing their satisfaction.

CONCLUSION

Results of this study indicate that school-based interventions accompanied with parental and principals' support is considered as a practical approach to promote healthful eating at an early age. Developing effective interventions for youth might, therefore, help to prevent unhealthy dietary choices becoming habitual.

CVD Prevention Through Policy: a Review of Mass Media, Food/Menu Labeling, Taxation/Subsidies, Built Environment, School Procurement, Worksite Wellness, and Marketing Standards to Improve Diet

Poor diet is the leading cause of cardiovascular disease in the USA and globally. Evidence-based policies are crucial to improve diet and population health. We reviewed the effectiveness for a range of policy levers to alter diet and diet-related risk factors. We identified evidence to support benefits of focused mass media campaigns (especially for fruits, vegetables, salt), food pricing strategies (both subsidies and taxation, with stronger effects at lower income levels), school procurement policies (for increasing healthful or reducing unhealthful choices), and worksite wellness programs (especially when comprehensive and multicomponent). Evidence was inconclusive for food and menu labeling (for consumer or industry behavior) and changes in local built environment (e.g., availability or accessibility of supermarkets, fast food outlets). We found little empiric evidence evaluating marketing restrictions, although broad principles and large resources spent on marketing suggest utility. Widespread implementation and evaluation of evidence-based policy strategies, with further research on other strategies with mixed/limited evidence, are essential “population medicine” to reduce health and economic burdens and inequities of diet-related illness worldwide.

Systematic Review of School-Based Interventions to Modify Dietary Behavior: Does Intervention Intensity Impact Effectiveness?

BACKGROUND

Owing to the associations between diet and health, it is important that effective health promotion strategies establish healthful eating behaviors from an early age. We reviewed the intensity of school-based interventions aimed to modify dietary behavior in preadolescent and adolescents and related intervention characteristics to effectiveness.

METHODS

Our systematic literature search of 8 databases sought to identify interventions measuring dietary intake in school settings to students aged 9 to 18. We evaluated these studies for effectiveness, intensity, intervention category, and follow-up measures.

RESULTS

Of the 105 interventions 81 were found to be effective immediately postintervention, irrespective of intensity. Studies that were 6 weeks to 5 months in duration, targeted students' environment or group (alone or in combination), and reached students only in schools were more effective. Only one-fifth of interventions conducted a follow-up measure, and a majority showed a loss of effectiveness from postintervention to follow-up.

CONCLUSIONS

We identified characteristics of effective interventions. These findings may inform the development of future interventions targeting dietary behavior in preadolescents and adolescents in the school-based setting.

Impact of Nutrition Standards on Competitive Food Quality in Massachusetts Middle and High Schools

OBJECTIVES

To examine changes in competitive foods (items sold in à la carte lines, vending machines, and school stores that "compete" with school meals) in Massachusetts middle and high schools before and after implementation of a statewide nutrition law in 2012.

METHODS

We photographed n = 10 782 competitive foods and beverages in 36 Massachusetts school districts and 7 control state districts to determine availability and compliance with the law at baseline (2012), 1 year (2013), and 2 years (2014) after the policy (overall enrollment: 71 202 students). We examined availability and compliance trends over time.

RESULTS

By 2014, 60% of competitive foods and 79% of competitive beverages were compliant. Multilevel models showed an absolute 46.2% increase for foods (95% confidence interval = 36.2, 56.3) and 46.8% increase for beverages (95% confidence interval = 39.2, 54.4) in schools' alignment with updated standards from 2012 to 2014.

CONCLUSIONS

The law's implementation resulted in major improvements in the availability and nutritional quality of competitive foods and beverages, but schools did not reach 100% compliance. This law closely mirrors US Department of Agriculture Smart Snacks in School standards, suggesting that complying with strict nutrition standards is feasible, and schools may experience challenges and improvements over time.

Simple interventions to improve healthy eating behaviors in the school cafeteria

The National School Lunch Program in the United States provides an important opportunity to improve nutrition for the 30 million children who participate every school day. The purpose of this narrative review is to present and evaluate simple, evidence-based strategies to improve healthy eating behaviors at school. Healthy eating behaviors are defined as increased selection/consumption of fruits and/or vegetables, increased selection of nutrient-dense foods, or decreased selection of low-nutrient, energy-dense foods. Data were collected from sales records, 24-hour food recalls, direct observation, and estimation of plate waste. The review is limited to simple, discrete interventions that are easy to implement. Sixteen original, peer-reviewed articles are included. Interventions are divided into 5 categories: modification of choice, behavior modification, marketing strategies, time-efficiency strategies, and fruit slicing. All interventions resulted in improved eating behaviors, but not all interventions are applicable or feasible in all settings. Because these studies were performed prior to the implementation of the new federally mandated school meal standards, it is unknown if these interventions would yield similar results if repeated now.

Peer-led nutrition education programs for school-aged youth: a systematic review of the literature

To date, the impacts of school-based, peer-led nutrition education initiatives have not been summarized or assessed collectively. This review presents the current evidence, identifies knowledge gaps, and provides recommendations for future research. PubMed, Scopus, ERIC and Google Scholar were searched for refereed Canadian and American primary studies published between January 2000 and November 2013, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Seventeen articles (11 programs) from Canada (24%) and the United States (76%) were identified. The results were summarized in terms of the study population, program design and main outcomes. Common outcome measures included healthy eating knowledge (n = 5), self-efficacy or attitudes towards healthy eating (n = 13), dietary measures (n = 9) and body mass index (n = 4), all of which tended to improve as a result of the programs. More research is needed to ascertain the effect of improvements in knowledge, self-efficacy and attitudes towards healthy eating on food behaviors. When evaluated, programs were generally well received, while the long-term maintenance of positive impacts was a challenge. Studies of sustainability and feasibility to promote long-term impact are a logical next step.

Apple or Chocolate – Intentional and Social-Reactive Processes in Eating Behavior Among Adolescents

Abstract. Two studies examined the main assumption of the Prototype/Willingness Model for eating behavior. Accordingly, health-behavior in adolescents results from intentional and social-reactive processes, namely behavioral intentions and behavioral willingness. The hypothesis was that willingness explains eating behavior over and above intentions with respect to eating behavior in general and in the peer context. This was tested in a cross-sectional (N = 286) and a longitudinal (N = 335) study. Intentions and willingness were assessed for healthy and unhealthy eating, eating behavior using an eating pattern index, and observed food consumption in the peer context. Willingness explained variance in eating behavior over and above intentions. Intentional as well as social-reactive processes contribute to adolescents’ eating behavior. Implications for practice are discussed.

Public health policies to encourage healthy eating habits: recent perspectives

There is an urgent need to address unhealthy dietary patterns at the population level. Poor diet and physical inactivity are key drivers of the obesity pandemic, and they are among the leading causes of preventable death and disability in nearly every country in the world. As countries grapple with the growing obesity prevalence, many innovative policy options to reduce overeating and improve diet quality remain largely unexplored. We describe recent trends in eating habits and consequences for public health, vulnerabilities to unhealthy eating, and the role for public health policies. We reviewed recent public health policies to promote healthier diet patterns, including mandates, restrictions, economic incentives, marketing limits, information provision, and environmental defaults.

Food Service Perspectives on National School Lunch Program Implementation

OBJECTIVES

Explore barriers and facilitators to implementation of the new National School Lunch Program (NSLP) policy guidelines.

METHODS

Interviews with eight food service directors using an interview guide informed by the Consolidated Framework for Implementation Research.

RESULTS

Food service personnel; parents, teachers, school staff; and students were important stakeholders. Characteristics of the new NSLP policy guidelines were reported to create increased demands; resources alleviated some barriers. Directors reported increased food and labor costs, food sourcing challenges, decreased student participation, and organizational constraints as barriers to implementation. Creativity in menu planning facilitated success.

CONCLUSIONS

Factors within the food service department, characteristics of implementing individuals and the new NSLP policy guidelines, and stakeholder involvement in the implementation process relate to successful implementation.

Vending Assessment and Program Implementation in Four Iowa Worksites

The worksite food environment, including vending options, has been explored as an important contributor to dietary decisions made every day. The current study describes the vending environment, and efforts to change it, in four Iowa worksites using a series of case studies. Data were gathered by local coordinators as part of the Iowa Community Transformation Grant project. Data were collected from three sources. First, the Nutrition Environment Measures Survey-Vending was used to assess healthy vending options in worksite machines before and after the intervention. Second, employee vending behavior was evaluated with a pre-, post-intervention survey. Items assessed attitudes and behaviors regarding vending, plus awareness and reaction to intervention activities. Third, program coordinators documented vending machine intervention strategies used, such as social marketing materials and product labels. The Nutrition Environment Measures Survey-Vending documented that the majority of vending options did not meet criteria for healthfulness. The vending survey found that employees were generally satisfied with the healthier items offered. Some differences were noted over time at the four worksites related to employee behavior and attitudes concerning healthy options. There were also differences in intervention implementation and the extent of changes made by vending companies. Overall, findings demonstrate that a large percentage of employees are constrained in their ability to access healthy foods due to limited worksite vending options. There also remain challenges to making changes in this environment. Findings have implications for public health practitioners to consider when designing healthy vending interventions in worksites.

Youth peers put the "invent" into NutriBee's online intervention

BACKGROUND

Early adolescents perceive peers as credible and relatable. Peers therefore have a unique conduit to engage early adolescents in positive health behaviors through nutrition learning such as that recommended by the U.S. Institute of Medicine (IOM).

PURPOSE

We developed an online, peer leader component to an existing in-person preventive nutrition intervention called NutriBee. We reasoned that youth ages 13-18 could create intervention materials that could remain engaging, credible and relatable to younger peers ages 10-12 online. Peer leaders could potentially derive health benefits from their service-learning experience.

METHODS

From 2013-2014 youth could apply online to relate a personal interest to nutrition, an opportunity promoted at NutriBee pilot sites and through social media. The peer leaders with diverse backgrounds honed original ideas into tangible projects with the support of adult subject-matter experts chosen by the youth. Nutrition expertise was provided by NutriBee staff who then also converted the youth-invented projects from various media into an online curriculum.

RESULTS

19 of 27 (70%) of selected youth from 12 states and diverse backgrounds, created an online curriculum comprising 10% of NutriBee's 20-hour intervention. All 19 online projects modeled 1 or more of NutriBee's 10 positive health behaviors; 8 evoked the chemosenses; 6 conveyed food texture; and 13 provided social context. Peer leaders perceived career advancement and service learning benefits. The dose, pedagogic approach, and project content align with the IOM recommendation.

CONCLUSIONS

Youth created intervention materials which communicate positive health behaviors online in ways peers can adopt. In a customarily sight-sound digital platform, youth leveraged the senses of smell, taste and touch and social context important for food selection. Peer leaders derived health benefit, as indirectly assessed by IOM criteria.

Understanding self-reported staging of dietary behavior in low-income women

This study examined self-reported staging for the goal of eating a low-fat diet and several specific dietary consumption behaviors to understand better readiness for dieting. Self-assessed motivation, food frequency measures, and psychosocial variables were obtained from 2057 low-income women enrolled in the Maryland Food for Life Program. Results indicated that staging of specific dietary consumption behaviors was significantly related to staging for the global goal of eating a low-fat diet. Women evaluate their motivation about eating low-fat diets based on perceived efforts and specific activities related to dietary consumption with important implications for dietary behavior change measurement and interventions.

Influence of school architecture and design on healthy eating: a review of the evidence

We examined evidence regarding the influence of school physical environment on healthy-eating outcomes. We applied a systems perspective to examine multiple disciplines' theoretical frameworks and used a mixed-methods systematic narrative review method, considering both qualitative and quantitative sources (published through March 2014) for inclusion. We developed a causal loop diagram from 102 sources identified. We found evidence of the influence of many aspects of a school's physical environment on healthy-eating outcomes. The causal loop diagram highlights multilevel and interrelated factors and elucidates the specific roles of design and architecture in encouraging healthy eating within schools. Our review highlighted the gaps in current evidence and identified areas of research needed to refine and expand school architecture and design strategies for addressing healthy eating.

The Michigan Healthy School Action Tools process generates improvements in school nutrition policies and practices, and student dietary intake

The Michigan Healthy School Action Tools (HSAT) is an online self-assessment and action planning process for schools seeking to improve their health policies and practices. The School Nutrition Advances Kids study, a 2-year quasi-experimental intervention with low-income middle schools, evaluated whether completing the HSAT with a facilitator assistance and small grant funding resulted in (1) improvements in school nutrition practices and policies and (2) improvements in student dietary intake. A total of 65 low-income Michigan middle schools participated in the study. The Block Youth Food Frequency Questionnaire was completed by 1,176 seventh-grade students at baseline and in eighth grade (during intervention). Schools reported nutrition-related policies and practices/education using the School Environment and Policy Survey. Schools completing the HSAT were compared to schools that did not complete the HSAT with regard to number of policy and practice changes and student dietary intake. Schools that completed the HSAT made significantly more nutrition practice/education changes than schools that did not complete the HSAT, and students in those schools made dietary improvements in fruit, fiber, and cholesterol intake. The Michigan HSAT process is an effective strategy to initiate improvements in nutrition policies and practices within schools, and to improve student dietary intake.

School nutrition guidelines: overview of the implementation and evaluation

Objective

To holistically evaluate the extent of implementation of dietary guidelines in schools and present various monitoring systems.

Design

The study comprises three methods: (i) a cross-sectional survey (process evaluation); (ii) an indicator-based evaluation (menu quality); and (iii) a 5 d weighed food record of school lunches (output evaluation).

Setting

Slovenian primary schools.

Subjects

A total 234 food-service managers from 488 schools completed a self-administrated questionnaire for process evaluation; 177 out of 194 randomly selected schools provided menus for menu quality evaluation; and 120 school lunches from twenty-four schools were measured and nutritionally analysed for output evaluation.

Results

The survey among food-service managers revealed high levels of implementation at almost all process evaluation areas of the guidelines. An even more successful implementation of these guidelines was found in relation to organization cultural issues as compared with technical issues. Differences found in some process evaluation areas were related to location, size and socio-economic characteristics of schools. Evaluation of school menu quality demonstrated that score values followed a normal distribution. Higher (better) nutrition scores were found in larger-sized schools and corresponding municipalities with higher socio-economic status. School lunches did not meet minimum recommendations for energy, carbohydrates or dietary fibre intake, nor for six vitamins and three (macro, micro and trace) elements.

Conclusions

The implementation of the guidelines was achieved differently at distinct levels. The presented multilevel evaluation suggests that different success in implementation might be attributed to different characteristics of individual schools. System changes might also be needed to support and improve implementation of the guidelines.

School-level factors associated with increased fruit and vegetable consumption among students in California middle and high schools

BACKGROUND

This study assessed associations between selective school-level factors and students' consumption of fruits and vegetables at school. Better understanding of school factors associated with increased produce consumption is especially important, as students are served more produce items at school.

METHODS

This cross-sectional study included 5439 seventh- and ninth-grade students from 31 schools in California in 2010. Multilevel regression models estimated whether the odds of consuming fruits or vegetables at school among students eating the school lunch were associated with the length of the lunch period, quality/variety of produce options, or other factors.

RESULTS

A longer lunch period was associated with increased odds of a student eating fruits (odds ratio [OR] = 1.40) and vegetables (OR = 1.54) at school. Better fruit quality increased the odds of a student consuming fruit (OR = 1.44). Including a salad bar and involving students in food service decisions increased a student's odds of consuming vegetables (OR = 1.48 and OR = 1.34, respectively).

CONCLUSIONS

This study suggests that institutional factors in schools are positively associated with middle and high school students' consumption of produce items at school. Additional efforts to structure school meal environments to enhance students' consumption of produce items can benefit students' nutrition and health.

A randomized controlled trial of students for nutrition and eXercise: a community-based participatory research study

PURPOSE

To conduct a randomized controlled trial of Students for Nutrition and eXercise, a 5-week middle school-based obesity-prevention intervention combining school-wide environmental changes, multimedia, encouragement to eat healthy school cafeteria foods, and peer-led education.

METHODS

We randomly selected schools (five intervention, five waitlist control) from the Los Angeles Unified School District. School records were obtained for number of fruits and vegetables served, students served lunch, and snacks sold per attending student, representing an average of 1,515 students (SD = 323) per intervention school and 1,524 students (SD = 266) per control school. A total of 2,997 seventh-graders (75% of seventh-graders across schools) completed pre- and postintervention surveys assessing psychosocial variables. Consistent with community-based participatory research principles, the school district was an equal partner, and a community advisory board provided critical input.

RESULTS

Relative to control schools, intervention schools showed significant increases in the proportion of students served fruit and lunch and a significant decrease in the proportion of students buying snacks at school. Specifically, the intervention was associated with relative increases of 15.3% more fruits served (p = .006), 10.4% more lunches served (p < .001), and 11.9% fewer snacks sold (p < .001) than would have been expected in its absence. Pre-to-post intervention, intervention school students reported more positive attitudes about cafeteria food (p = .02) and tap water (p = .03), greater obesity-prevention knowledge (p = .006), increased intentions to drink water from the tap (p = .04) or a refillable bottle (p = .02), and greater tap water consumption (p = .04) compared with control school students.

CONCLUSIONS

Multilevel school-based interventions may promote healthy adolescent dietary behaviors.

Healthy food procurement policies and their impact

Unhealthy eating is the leading risk for death and disability globally. As a result, the World Health Organization (WHO) has called for population health interventions. One of the proposed interventions is to ensure healthy foods are available by implementing healthy food procurement policies. The objective of this systematic review was to evaluate the evidence base assessing the impact of such policies. A comprehensive review was conducted by searching PubMed and Medline for policies that had been implemented and evaluated the impact of food purchases, food consumption, and behaviors towards healthy foods. Thirty-four studies were identified and found to be effective at increasing the availability and purchases of healthy food and decreasing purchases of unhealthy food. Most policies also had other components such as education, price reductions, and health interventions. The multiple gaps in research identified by this review suggest that additional research and ongoing evaluation of food procurement programs is required. Implementation of healthy food procurement policies in schools, worksites, hospitals, care homes, correctional facilities, government institutions, and remote communities increase markers of healthy eating. Prior or simultaneous implementation of ancillary education about healthy eating, and rationale for the policy may be critical success factors and additional research is needed.