ArticleLiterature Review

Do school based food and nutrition policies improve diet and reduce obesity?

December 2008
Preventive Medicine 48(1):45-53

DOI:10.1016/j.ypmed.2008.10.018

Source
PubMed

Authors:

Patricia Jaime

University of São Paulo

Karen Lock

London School of Hygiene and Tropical Medicine

To review the effectiveness of school food and nutrition policies world wide in improving the school food environment, student's dietary intake, and decreasing overweight and obesity. Systematic review of published and unpublished literature up to November 2007 of three categories of nutrition policy; nutrition guidelines, regulation of food and/or beverage availability, and price interventions applied in preschools, primary and secondary schools. 18 studies met the inclusion criteria. Most evidence of effectiveness was found for the impact of both nutrition guidelines and price interventions on intake and availability of food and drinks, with less conclusive research on product regulation. Despite the introduction of school food policies worldwide few large scale or national policies have been evaluated, and all included studies were from the USA and Europe. Some current school policies have been effective in improving the food environment and dietary intake in schools, but there is little evaluation of their impact on BMI. As schools have been proposed worldwide as a major setting for tackling childhood obesity it is essential that future policy evaluations measure the long term effectiveness of a range of school food policies in tackling both dietary intake and overweight and obesity.

The impact of primary school nutrition policy on the school food environment: a systematic review

Article

Full-text available

Sep 2022

School nutrition policies that aim to address unhealthy diets have been introduced in many countries. This systematic review aimed to synthesize the international literature to determine the impact (overall and by socioeconomic position [SEP]) of primary school nutrition policies on the availability of foods and beverages in schools. Seven databases were searched using keywords and medical subject headings related to nutrition policies and schools. Studies that reported on the impact of implemented school nutrition policies on food and beverage availability within primary schools were included. Eighteen studies (reported across 20 papers) were included. Fifteen of the included studies reported some positive impacts of policies, including increased availability of healthier foods and decreased availability of less healthy foods. Five studies focused specifically on schools in low-income communities and a further three specifically compared schools by SEP, with mixed findings. Two studies reported on factors influencing policy implementation, reporting a lack of financial resources as a barrier to schools offering a wider selection of healthy foods and additional school resources as increasing the likelihood of offering healthy foods. School nutrition policies appear to be effective at improving the healthiness of foods and beverages available at schools. Furthermore, the results suggest that well-implemented school nutrition policies that improve the healthiness of foods available are unlikely to exacerbate the socioeconomic gradient of poor nutrition. However, the number of studies that reported results by SEP limits drawing strong conclusions regarding equity impacts and we strongly recommend further studies analyze their findings according to SEP.

Evaluation of school food policies for secondary schools in Europe: Results for health, acceptance, and affordability from a scoping review

Article

Full-text available

Feb 2025
OBES REV

Introduction All European Union (EU) countries have established national school food policies. However, evaluations of those policies for secondary schools remain limited. This scoping review aims to synthesize the evidence of school food policies in secondary schools on child health, acceptance, and affordability in the EU, UK, Switzerland, Norway, and Iceland. Methods The scoping review adheres to the PRISMA‐ScR guideline. Searches were conducted in four databases from 2000 to September 2023 without language and methods restrictions following a published protocol. After a two‐stage screening process, reviewers extracted data using a standardized and predefined coding scheme. Results The search identified 185 records with N = 10 articles meeting the inclusion criteria ( n = 7 UK, n = 1 each in Norway, Sweden, and Portugal). Among the included articles, n = 7 addressed school meal acceptance, n = 6 addressed health impacts, and n = 3 addressed affordability. Findings indicate low acceptance rates of school meals. Results of several studies showed that the reformulated menus did not meet nutritional standards and were not accepted because of taste, quality, and pupils' different food preferences. Affordability was reported as a barrier across the three articles addressing this topic. Conclusion The existing literature highlights challenges in interpreting the impact of school food policies on health, acceptance, and affordability. Further research is needed to strengthen the methodological approaches and increase the evidence to inform policy development and implementation.

The Importance of Obesity and its Role in Education

Article

Dec 2024

Improving peer review of systematic reviews and related review types by involving librarians and information specialists as methodological peer reviewers: a randomized controlled trial

Preprint

Sep 2024

Objective: To evaluate the impact of adding librarians and information specialists (LIS) as methodological peer reviewers to the formal journal peer review process on the quality of search reporting and risk of bias in systematic review searches in the medical literature.Methods: A pragmatic two-group parallel randomized controlled trial of systematic reviews and related evidence synthesis manuscripts submitted to The BMJ, BMJ Open, and BMJ Medicine and sent out for peer review from January 3, 2023 to September 1, 2023. Randomization (allocation ratio, 1:1) was stratified by journal and used permuted blocks (block size = 4). All manuscripts followed usual journal practice for peer review, but those in the intervention group had an additional (LIS) peer reviewer invited. The primary outcomes are the differences in first revision manuscripts between intervention and control groups in the quality of reporting and risk of bias. Quality of reporting was measured using four pre-specified PRISMA-S items. Risk of bias was measured using ROBIS Domain 2. Assessments were done in duplicate and assessors were blinded to group allocation. We performed intention to treat and per protocol analyses. As secondary outcomes, we analyzed differences between groups for each individual PRISMA-S and ROBIS Domain 2 item. We also assessed differences in the proportion of manuscripts rejected as the first decision between the intervention and control groups. The study protocol was registered (https://doi.org/10.17605/OSF.IO/W4CK2) and the protocol published (https://dx.doi.org/10.1186/s13063-021-05738-z).Results: Of 2,670 manuscripts sent to peer review during study enrollment, 400 met inclusion criteria and were randomized (62 The BMJ, 334 BMJ Open, 4 BMJ Medicine). By study close, 76 first revisions were submitted in the intervention group and 90 in the control group. Differences in the proportion of adequately reported searches (4.4% difference, 95% CI: -2.0%, 10.7%) and risk of bias in searches (0.5% difference, 95% CI: -13.7%, 14.6%) showed no statistically significant differences between groups. Inviting an LIS peer reviewer showed a difference (16.0%, 95% CI: 0.96%, 31.0%) on adequately reporting one individual item, PRISMA-S Item 13 (dates of search). By four months post-study, 98 intervention and 70 control group manuscripts had been rejected after peer review (13.8% difference, 95% CI: 3.9%, 23.8%). Conclusions: Inviting LIS peer reviewers did not impact adequate reporting or risk of bias of searches in first revision manuscripts of biomedical systematic reviews and related review types, though LIS peer reviewers may have contributed to a higher rate of rejection after peer review.

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

Article

Full-text available

Jan 2024
PUBLIC HEALTH NUTR

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 nonequivalent 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 33 schools in the intervention county and principals and after-school leaders from 34 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, standard error (s.e.) B = 0.01, t = 3.10, P = 0·003). The intervention effect was not associated with the school’s socioeconomic profile. School-level fidelity was the implementation dimension that was most strongly correlated ( r s = .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 socioeconomic conditions. Implementation fidelity, at an organizational level, may be a useful predictor for intervention outcomes in schools.

Parents' and teachers' perceptions of the Australian primary school food provision venues and food-related policies

Article

Sep 2023
BRIT FOOD J

Purpose This study aims to gain an understanding from parents and teachers about the types of food provision practices and venues, and the food-related policies and rules in primary schools in Australia; and investigate any differences in the presence of policies and rules based on the school location and school type. Design/methodology/approach Data were collected via two online surveys from August 2019 to March 2020. Descriptive statistics were employed to analyse quantitative responses. Respondents' written responses to food-related policies were categorised into groups. Findings The two most common food provision services were canteen and lunch order services (mentioned by 72 and 55% of respondents, respectively). Of the 425 respondents whose schools had a canteen (parents and teachers together), 62% reported their school implements a healthy school canteen policy. Significantly more parents compared to teachers, and more respondents from government schools compared to non-government schools stated that their school had implemented such a policy. Approximately half of the respondents (47%) stated their school had implemented other food-related policies and/or rules. These policies or rules belonged to four categories: avoiding certain foods, avoiding food sharing, avoiding food packages and promoting healthy eating. Originality/value This study shows the disparities exist in implementing food-related policies among primary schools in Australia. Nutrition promoters and policy planners should consider these results and find the best mechanisms to minimise the gaps in policy implementation.

THE NUTRITIONAL CONTENT OF THE FOOD SUPPLIED BY FOOD VENDORS TO STUDENTS IN A SOUTH AFRICAN UNIVERSITY

Article

Full-text available

Feb 2022

University students often overlook the nutritional content of the food supplied by food vendors, either due to lack of knowledge or being unable to afford the variety of nutritious foods. With the relentless threat of the corona virus (Covid-19) lurking over South Africa and the ongoing search for a vaccine postulating that underlying health risks including diabetes and obesity may be an impediment in the fight of this pandemic, good nutrition is now essential. There is, therefore, a need to provide insight on food consumption and purchasing behaviours in South Africa with particular reference to the youth. Food vendors provide convenient access to affordable meals for university students. Whether the food provided is balanced or not is unknown. This study was, therefore, carried out to examine the nutritional value of the foods sold to university students by food vendors that were contracted to the four campuses of the Durban University of Technology (DUT). Utilising the qualitative approach, technical information was sourced using an observation technique and a structured menu recording sheet. Thus, data was collected by weighing the cooked and pre-cooked items individually to provide accurate nutrient assessment using an electronic food scale. Whilst this study only focused on the macronutrients, it was found that the nutritional value of foods served by these vendors was not balanced due to the fact that the top 15 meals contained more than the World Health Organisation's (WHO) recommended fat 15-30% contributing to energy. Furthermore, the contribution of carbohydrates (CHO) was less than the recommended percentage of 55-75%. Notably, the students who consumed two or three of the top 15 meals in a day exceeded the recommended intake of fat and energy for that day revealing a high probability that university students can be overweight. This study recommends a menu improvement and a strong collaboration between the food vendors and the university's Department of Food and Nutrition to develop healthier menu options and assist students in making informed decisions regarding their health and consumption behaviours. The main limitation of this study is that it only focused on the macronutrients as recommended by WHO of the most popular meals, this study still provides valuable insight into student nutrition and contributes to food consumption patterns by university students.

National school food standards in England: a cross-sectional study to explore compliance in secondary schools and impact on pupil nutritional intake

Article

Full-text available

Oct 2024
INT J BEHAV NUTR PHY

Background Many countries have introduced school food standards to improve the dietary intakes of school-aged children. England has school food standards (SFS) legislation in place but little is known about how well secondary schools comply with this. We aimed to assess compliance with the SFS legislation in English secondary schools and explore the impact of the SFS on pupils’ nutritional intake. Methods We conducted a cross-sectional study with English secondary schools from 2019 to 2022. We compared SFS compliance and pupil nutritional intake in schools mandated or not mandated to comply with the SFS legislation, and explored the association between school compliance and pupil nutritional intake. We assessed the percentage of SFS (%SFS) complied with by reviewing school food menus and observing food served in school canteens. We assessed pupil nutritional intake using a 24-hour dietary recall measure (Intake24) and estimated intakes of free sugar (primary outcome) and other nutrients/foods. We used adjusted multilevel models to compare pupil intakes in the SFS-mandated and SFS-non-mandated schools, and to explore the association between school SFS compliance and pupil intakes. Results 36 schools (23 not mandated and 13 mandated to comply with the SFS) and 2,273 pupils participated. The median %SFS complied with was 63.9% (interquartile range 60.0–70.0%). This was similar for SFS-non-mandated (64.5%) and SFS-mandated schools (63.3%). Compliance was highest for standards applying to lunchtime (median = 81.3%) and lowest for those applying across the whole school day (median = 41.7%). It was also lower for standards restricting high fat, sugar and energy-dense items (median = 26.1%) than for standards aiming to increase dietary variety (median = 92.3%). Pupils from SFS-mandated schools had a lower mean lunchtime intake of free sugar (g) (adjusted mean difference: -2.78g; 95% CI: -4.66g to -0.90g). There were few significant associations between %SFS complied with and pupil nutritional intake. Conclusions English secondary schools do not fully comply with SFS legislation regardless of whether they are mandated to comply. Schools and caterers may require monitoring and support to fully comply. There is little evidence that SFS compliance is associated with better pupil nutritional intake. Food environments outside of school also need to be considered. Study registration ISRCTN68757496 (17-10-2019).

Home-based cooking intervention with a smartphone app to improve eating behaviors in children aged 7-9 years: a feasibility study

Article

Full-text available

Jul 2024

Objective To develop and evaluate the feasibility of a mobile application in Swiss households and assess its impact on dietary behavior and food acceptability between children who cooked with limited parental support (intervention group) with children who were not involved in cooking (control group). Methods A ten-week randomized controlled trial was conducted online in 2020. Parents were given access to a mobileapp with ten recipes. Each recipe emphasized one of two generally disliked foods (Brussels sprouts or whole-meal pasta). Parents photographed and weighed the food components from the child’s plate and reported whether their child liked the meal and target food. The main outcome measures were target food intake and acceptability analyzed through descriptive analysis for pre-post changes. Results Of 24 parents who completed the baseline questionnaires, 18 parents and their children (median age: 8 years) completed the evaluation phase. Mean child baseline Brussel sprouts and whole-meal pasta intakes were 19.0 ± 24.2 g and 86.0 ± 69.7 g per meal, respectively. No meaningful differences in intake were found post-intervention or between groups. More children reported a neutral or positive liking towards the whole-meal pasta in the intervention group compared to those in the control group. No change was found for liking of Brussel sprouts. Conclusions for practice The intervention was found to be feasible however more studies on larger samples are needed to validate feasibility. Integrating digital interventions in the home and promoting meal preparation may improve child reported acceptance of some healthy foods. Using such technology may save time for parents and engage families in consuming healthier meals.

School Food Policy through a Project Financing

Article

Full-text available

Apr 2024

In recent years, the scientific community has focused more on urban food policies adopted by big cities and less on the local food policies adopted by small municipalities. Furthermore, the empirical evidence on school food policy initiatives is quite fragmented, and the management of the canteen service is not directly addressed by the studies carried out. In this work, the school food policy implemented in a small municipality (Corciano in the province of Perugia, Centre Italy) of about 22,000 inhabitants, through the application of project financing with the participation of local social cooperatives is presented and discussed. This paper aims to reflect on the capability of the alternative food networks developed through the project financing mechanism to identify and implement the uses of the resources concerning the local food policy objectives and the project capacity of the network. The analysis is conducted using a methodological approach based on agricultural economics and anthropology. Results from economic data analysis, collective interviews, and participant observation show that: the financial balance of the project financing is positive but quite precarious and very sensitive to market variations, both regarding the overall demand for canteen meals, and the procurement of raw materials and workforce; the project’s organizational model through a local network not only can combine the environmental, social, and health dimensions of food, but it can also reshape the local concept of community, as well as new opportunities for the circulation of food products.

State school catering in Italy during the COVID-19 pandemic: a qualitative study

Article

Full-text available

May 2024

Elena Pagliarino

The complex value of school meals for children and families is well documented. In Italy, school cafeterias have been an instrument of social policy since the end of the Second World War. Thereafter, school cafeterias have acquired several functions in the areas of children's health and wellbeing, education, social inclusion, support to local and quality agriculture, and environmental sustainability. In particular, the goal of a nutritious and balanced diet has been emphasized in recent decades, since malnutrition and food insecurity have been increasing in Italian society. During the pandemic, Italy was the first European country to implement a nationwide lockdown and one of the high-income countries where schools closed for the longest period. In this work, we use in-depth interviews with representatives of the school catering service, both from the major catering companies and the biggest municipalities, to analyze what happened in the management of the Italian school catering service during the pandemic crisis. In addition, a review of public recommendations issued during the pandemic has made it possible to analyze their compliance with the state guidelines for school catering and food education. The results highlight how the system reacted extremely slowly to the crisis and how the measures taken led to a deterioration of the value that has always been attributed to state school cafeterias, especially in terms of children's food security and environmental sustainability.

Impacts of the National Nutrition Plan 2017–2030 on Listed Agrifood Enterprises: A Financial Statement Perspective

Article

Full-text available

Apr 2024

The Chinese government promulgated the National Nutrition Plan 2017–2030 to provide scientific guidance for agrifood consumption and enhance nutrition intake. We categorized the sample into pre-2018 and post-2018 periods. By evaluating the effects of the National Nutrition Plan 2017–2030 through economic theory and a translog revenue function model based on financial statement data from 2015 to 2022, our findings indicate that the National Nutrition Plan 2017–2030 has increased the overall agrifood sales of listed agrifood enterprises, but the increase in agrifood sales produced by large listed agrifood enterprises has been slight. Finally, we offer policy recommendations for regulatory authorities and develop strategies for agrifood firms to encourage local food procurement. This study also contributes to our understanding of China’s agrifood industry dynamics and underscores the significance of the National Nutrition Plan 2017–2030 in enhancing nutritional intake and fostering sustainable growth in China’s agriculture industry.

Spatial barriers to the effective delivery of school food policy in UK primary schools: Findings from an Institutional Ethnography

Article

Full-text available

Oct 2023

Anna Hawkins

Gender differences and climate zones in overweight and obesity prevalence in European elementary school children from 2000 to 2020: a systematic review and meta-analysis

Article

Full-text available

Sep 2023

Introduction After 2000, there are more obese than underweight people in the world. We face a rapid increase in average global warming of 1.5°C, reported as a syndemic problem of three interconnected epidemics: obesity, global warming, and undernutrition. We aimed to analyze the impact and association between global warming and obesity in children and differences by gender across Europe after 2000. Methods We searched PubMed, MEDLINE, Google Scholar, ScienceDirect, and Embase databases. The considered population were children aged 6–14. Only cross-sectional studies that defined obesity by the IOTF cutoffs and the subjects’ place of residence, used to determine precise climate zones, were included. We assessed the prevalence of obesity and overweight using a random-effects and the Mantel–Haenszel fixed-effect method when heterogeneity was greater/lower than 50%. We did a subgroup analysis for prevalence across gender, obesity, and overweight, two decades, regions, countries, and the Köppen–Geiger climate zones. Random effects of the meta-regression were used to study the global warming impact and differences in trends across European countries by gender for both conditions separately. Results We identified 114 studies that included 985,971 children from 39 European countries. A significant difference between genders was in favor of obese girls 4.78 (95% CI: 3.85–5.93) versus boys 5.76% (95% CI: 5.11–6.48, p = 0.03), respectively, but not for overweight children. Most of the obese girls were in South Europe 7.51% (95% CI: 6.61–8.51) versus East Europe 2.86% (95% CI: 23–3.12), versus boys in South Europe 8.66% (95% CI: 7.68–9.74) and North Europe 3.49% (95% CI: 2.90–4.19), respectively. The “cold” Köppen–Geiger climate zone, with lowest temperatures, has the largest trend rise between two decades of 2.8% and 1.53% for obese girls and boys, and 5.31% and 1.81% for overweight girls and boys, respectively, followed by the smallest number of obese girls 3.28% (95% CI: 2.17–4.92) and boys 3.58% (95% CI: 2.39–5.33), versus the zone with the highest temperatures “hot” for girls 7.02% (95% CI: 6.30–7.82) and for boys 8.23% (95% CI: 7.55–8.96), respectively. The meta-regression proved global warming has a significant impact on the distribution of obesity and overweight across climate zones, R² = 0.52 and R² = 0.22. No significant gender differences, or significant interaction, was noted. Conclusion Our meta-analysis provides a comprehensive overview of the association between and impact of global warming on obesity. This impact increases obesity among children in Europe throughout all climate zones, and emphasizes an urgent call for further preventive methods in schools, since obesity differences continue their trend of disappearing into the future. Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021282127, identifier: CRD42021282127.

How (Un-)Healthy are Austrian school food environments? Evidence from focus groups and citizen science

Article

Full-text available

Jun 2023
APPETITE

Background: Adolescents face high-choice school food environments that offer plenty of highly processed foods. Processed food producers target young people in their marketing, but there is limited data on the actual food supply inside and in the vicinity of Austrian schools and its impact on adolescent food choices. This study employs an innovative mixed-methods approach to explore adolescents' food choices. Methods: In Study 1, we conducted a citizen science study, with students as volunteer scientists. The students examined the food supply in and around their schools according to the Austrian food pyramid and categorized 953 food items in 144 food suppliers using photographs and descriptions. In Study 2, we explored students' food preferences in focus groups. We conducted four focus groups at four different schools in Tyrol, with 25 students (11 male, 14 female) between the ages of 12 and 15. We then linked the findings on individual preferences with the documented supply. Results: Study 1 found that the food supply in the investigated schools was predominantly categorized as unhealthy. The students categorized 46% as "unhealthy", 32% as "intermediate", and only 22% as "healthy". Study 2 identified three influential factors in students' food choices: 1) individual factors (such as taste and preferences), 2) social factors (such as mingling with peers), and 3) structural factors (such as physical environment and accessibility). Conclusion: The study shows that unhealthy products cater to unhealthy preferences among adolescents and dominate current school food environments. Policies need to address unhealthy school food environments to address this issue. For instance, food supplies should be presented in an attractive ways, in fun places where students can mingle and express their identities.

Home-based cooking intervention with a smartphone app to improve eating behaviors in children aged 7–9 years: a feasibility study

Article

Full-text available

Jun 2023

Objective To develop and evaluate the feasibility of a mobile application in Swiss households and assess its impact on dietary behavior and food acceptability between children who cooked with limited parental support (intervention group) with children who were not involved in cooking (control group). Methods A ten-week randomized controlled trial was conducted online in 2020. Parents were given access to a mobile-app with ten recipes. Each recipe emphasized one of two generally disliked foods (Brussels sprouts or whole-meal pasta). Parents photographed and weighed the food components from the child’s plate and reported whether their child liked the meal and target food. The main outcome measures were target food intake and acceptability analyzed through descriptive analysis for pre-post changes. Results Of 24 parents who completed the baseline questionnaires, 18 parents and their children (median age: 8 years) completed the evaluation phase. Mean child baseline Brussel sprouts and whole-meal pasta intakes were 19.0 ± 24.2 g and 86.0 ± 69.7 g per meal, respectively. No meaningful differences in intake were found post-intervention or between groups. More children reported a neutral or positive liking towards the whole-meal pasta in the intervention group compared to those in the control group. No change was found for liking of Brussel sprouts. Conclusions for practice The intervention was found to be feasible however more studies on larger samples are needed to validate feasibility. Integrating digital interventions in the home and promoting meal preparation may improve child reported acceptance of some healthy foods. Using such technology may save time for parents and engage families in consuming healthier meals.

The School Food Solution: Creating a healthy school food environment with Canada's Food Guide

Article

Full-text available

Dec 2022

In 2021, Canada’s federal government made a historic commitment to develop a national school food policy. Among overlapping challenges of increasing food insecurity, rising food costs, and the impact on food systems from climate change, there is now an opportunity to create a school food environment that ensures universal access to nutritious foods and supports sustainability in food systems. A universal school food program can ensure that all children, regardless of income, access the recommended nutritious foods and can promote climate-friendly diets. Such school food programs can also support local farmers and regional economies. In this paper, we outline the policy context for the new Canada’s Food Guide and the researched benefits of school food. We argue that Canada’s Food Guide can support a healthy school environment that is equitable and that promotes sustainability in the food system by embracing founding principles of diet equity and sustainability. Our concluding discussion outlines issues to be addressed in implementation.

How French children food representations and tastes vary according to their social backgrounds: a study of disparities in food habitus

Article

Oct 2022

The diet of individuals is influenced by social and cultural factors. Children’s food tastes and representations, being principally transmitted by their parents, are likely to depend on their social backgrounds. As it is known that parents’ feeding strategies and food education differ depending on their social positions, this study aimed at examining how food representations and tastes vary among children. A qualitative sociological study, based on semi-structured interviews, was conducted with forty children, aged from 9 years to 11 years, within four French elementary schools. Results showed that children from disadvantaged social backgrounds mentioned less foods, seemed to have a less varied diet, to consume less vegetables, and to enjoy eating ultra-processed foods more than other children. Different food habitus were found, that can be put into perspective with Bourdieu’s distinction theory, including different preoccupations regarding health and necessity among social groups. Disparities in children food habitus could be theoretically linked with observed and growing social inequalities in health, when taking into consideration the potential practises that these habitus imply, and their probable effects on health. Participative food education classes at school could be a relevant perspective, although some concerns and limits must be addressed.

Unwrapping school lunch: Examining the social dynamics and caring relationships that play out during school lunch

Article

Full-text available

Jul 2022

Students are important stakeholders in school food programs. Yet children’s daily experiences and voices are often overlooked in advocacy around school food. In Canada, where the federal government recently expressed interest in creating a National School Food Program, nearly no research has documented the first-hand experiences of children during lunch. This ethnographic study draws on data collected during 36 lunchtimes in three Canadian schools during a transitional period in a school district’s lunch program. The findings unwrap the powerful role of students’ perceptions of and relationships to food in shaping their social interactions, and their sense of care, connection, and identity. Classroom observations coupled with photos of school lunches demonstrate the wide diversity of foods eaten at school and the nuanced, complex, and sometimes divergent meanings children give to food, school lunch and the people involved in preparing, serving, supervising, and sharing lunchtime experiences. Students demonstrated in-depth knowledge of the food choices and attitudes of their peers and actively marked out their identities vis-à-vis food. Students frequently talked about food as a site of care and support, and both the social relationships and care work that played out were a major part of school lunch experiences. Understanding the intricacies of children’s school lunch experiences, including the relationships, meanings, and values that shape school lunch, will be critical for creating robust school food programs and policies in Canada that better serve the needs of children and reduce rather than reproduce existing health and social inequalities.

Observational study: determinants for vegetable consumption among elementary school students in Indonesia

Article

Full-text available

Sep 2022

Background : The prevalence of obesity in school children has been increasing worldwide, including in developing countries such as Indonesia. Childhood obesity is associated with an unbalanced diet, especially the lack of fruit and vegetable consumption. This study aimed to determine the factors that influence vegetable consumption behavior in school children in Indonesia. Methods : The cross-sectional study was conducted in eight public elementary schools in a suburban area of Bogor Regency involving 433 students from the fifth grade. Data collection was conducted from November to December 2018. Data on the students’ characteristics, knowledge, and attitude as well as availability of vegetables at home and at school were collected using a structured questionnaire. While, a 24-hour food recall was utilized to obtain information on vegetable consumption and overall diet. Data analysis was done using Chi-squared test and logistic regression. Results : The average daily intake of vegetables was 47.11 g, far below the recommend amount (250 g). Female students had significantly better vegetables intake compared with their male counterparts. The availability of vegetables at home and students’ positive attitude toward vegetables were also significantly associated with better vegetable intake. Logistic regression analysis showed that availability of vegetables at home almost tripled the likelihood of better vegetable consumption (OR 2.822, 95% CI 1.822–4.372). Additionally, availability of vegetables at school and positive attitude toward vegetables doubled the odd for better vegetable consumption, OR 2.2 and 2.1 respectively (p<0.005). Conclusions : Vegetable consumption among schoolchildren was very low compared with the recommended portion. Better vegetable consumption was significantly associated with sex, availability, and students’ attitudes. Vegetable availability at home was the strongest determinant influencing vegetable consumption among elementary school students involved in the study. Hence, parental support or home food environment is key in improving their diet quality to prevent obesity.

Benchmarking policy goals and actions for healthy food environments in Ethiopia to prevent malnutrition in all its forms using document analysis

Article

Full-text available

Aug 2022

Objective Unhealthy diets resulting in overweight and obesity and diet-related non-communicable diseases are of increasing concern in Ethiopia, alongside persistent undernutrition, and have been linked to unhealthy food environments. Little is known about the policy response to unhealthy food environments in Ethiopia. The objective of this study was to assess how different food environment domains have been addressed in Ethiopian policy goals and action over time and how this compares with global good practice benchmarks. Setting Ethiopia. Primary and secondary outcome measures We analysed intentions and plans of the government to act, using policy documents (outputs of decision-making in the form of published strategies, plans or policies) related to improving diets and nutritional status through healthy food environments in Ethiopia between 2008 and 2020. Our coding framework was guided by the policy component (n=7 domains) of the Healthy Food-Environment Policy Index, which was modified to include food quality and safety as an eighth domain. Results From the 127 policy outputs identified, 38 were retained, published by 9 different government ministries and institutions. Our results show that eight food environment domains have been addressed to some extent, but gaps remain compared with global best practice, especially in food promotion, processing, retail, price and trade. From 2018, policy began to embrace the wider food system, with more explicit food environment interventions becoming apparent. Conclusions Policy efforts achieved in food safety, food processing, marketing and labelling are important stepping stones to building future policy actions addressing the food environment domains of food retail, food provision and food trade. Benchmarking of food environment policy actions should also consider actions on food fortification, agro-processing and informal markets in the context of multiple forms of malnutrition.

Outcome Evaluation on Impact of the Nutrition Intervention among Adolescents: A Feasibility, Randomised Control Study from Myheart Beat (Malaysian Health and Adolescents Longitudinal Research Team—Behavioural Epidemiology and Trial)

Article

Full-text available

Jun 2022

A healthy eating environment in the school setting is crucial to nurture the healthy eating pattern for youth. Thus, it helps to combat the obesity issue. However, the impact of healthy school environment on healthy eating habits among Asian adolescents is scarce and less clear. This clustered randomised-control study has two objectives. The first objective was to evaluate the changes in adolescents’ dietary intake after the interventions for all arms (control; healthy cooking training only; subsidization with healthy cooking training). The second objective was to compare the effect of subsidization with healthy cooking training and healthy cooking training only with the control arm on adolescents’ dietary intakes. This study consisted of 340 secondary school students aged 14 years in rural and urban Malaysia. A total of two arms of intervention and one arm of control were included. Intervention one focused on healthy cooking preparation for the canteen and convenience shop operators. Intervention two included subsidization for fruits and vegetables with a healthy cooking preparation training for the canteen and suggestions on providing healthy options to the convenience shop operators. The outcome measured was changes to dietary intake. It was measured using a three-day dietary history pre- and post-intervention. A paired-t test was used to evaluate the outcome of intervention programmes on dietary changes for all arms (control, intervention one and two). An ANCOVA test was used to investigate the effect of providing subsidization and healthy cooking preparation training to the canteen and convenience shop operators on adolescents’ dietary intakes as compared to the control arm. Overall, the reduction in energy and carbohydrates for all arms were observed. Interestingly, fat intake was significantly increased after the four-week intervention programme under healthy cooking intervention but not in the food subsidization group. When comparing between control, healthy cooking training only and subsidization with the healthy cooking training arm, there was no significant changes between arms. A robust intervention to include subsidization of healthy foods for intervention programmes at schools in a larger scale study is needed to confirm this finding.

Using Economics to Impact Local Obesity Policy: Introducing the UK Centre for Economics of Obesity (CEO)

Article

Full-text available

Jun 2022
Appl Health Econ Health Pol

Worldwide, population obesity levels are at their highest recorded levels, having nearly tripled between 1975 and 2016. This leads to substantial pressure on health systems, a negative impact on economic development, and results in adverse physical and mental health outcomes. There are many economic reasons why reducing population obesity should be a priority, and global targets have been set with many governments pledging to reduce obesity levels by 2030. To achieve these targets, a 'system-wide' approach has been widely advocated in direct recognition of the wide-ranging complex interacting determinants of the disease. This system approach requires action at all levels, including at the local government level, to use all fiscal and non-fiscal levers to bring about local system change that promotes healthier population behaviours. Like many country contexts, in England, local resources for achieving this system change have been drastically reduced in recent years. Economic evaluation offers a formal explicit framework to support local decision making but, to date, there has been a disconnect between national guidance on cost-effectiveness and how that informs local action. A new Centre for Economics of Obesity has been purposively developed to work closely with local government to adapt methods to help achieve efficiency and equity gains. By working across six workstreams to begin with, this Centre will use economics to inform policy action on different but interrelated parts of the obesity system and act as a training hub for health economists working in obesity policy.

Interventions for Health and Well-Being in School-Aged Children and Adolescents: A Way Forward

Article

May 2022

The health and well-being of school-aged children has received little attention compared with younger children aged < 5 years and adolescents. In this final article in a supplement of reviews that have assessed the effectiveness of interventions for school-aged children across a variety of health-related domains (including infectious diseases, noncommunicable diseases, healthy lifestyle, mental health, unintentional injuries, and sexual and reproductive health), we summarize the main findings and offer a way forward for future research, policy, and implementation. We complement this evidence base on interventions with a summary of the literature related to enabling policies and intersectoral actions supporting school-aged child health. The school represents an important platform for both the delivery of preventive interventions and the collection of data related to child health and academic achievement, and several frameworks exist that help to facilitate the creation of a health-promoting environment at school.

Food commercialization in schools: analysis of the regulatory process in Brazil

Article

Full-text available

Apr 2022
REV NUTR

Objective To identify and to describe the legal provisions that regulate the sale of food in Brazilian schools. Method Documentary analysis carried out in 2019, on the websites of the State, capital and Federal District Legislative Assemblies, via e-mail and/or telephone contact and publications on the subject review. The data were grouped by geographic region and a descriptive analysis was carried out. Results Data were obtained from 96% of the federative units (25 States and the Federal District). 62 legal provisions were found: 60% current, 11% revoked and 29% draft bills. Current legislation was found in 67% of States: 100% of the States in the South, Southeast and Center-West regions, 56% in the Northeast and 43% in the North. Most of the legal provisions prohibit the sale of ultra-processed foods and encourage the sale of fruits and fresh foods in the public and private school network. Conclusion Progress is observed in the school food regulatory process in this country, considering its coverage in the States and in the public and private school network, but still restricted to the South, Southeast and Midwest regions. Keywords Food legislation; Health policies; Legal standards; Nutrition

Dietary disparities among adolescents according to individual and school socioeconomic status: a multilevel analysis

Article

Jan 2022

This study aimed to estimate disparities in dietary habits according to the individual and contextual socioeconomic status (SES), while taking into account school nutrition-related characteristics. Data came from the 2018 cross-sectional "Health Behaviour in School-aged Children" (HBSC) survey. Multilevel multiple logistic regressions were performed. Over two-thirds of the observed variance was explained by individual and school characteristics, with SES being the main contributors. For example, 76.9% of the variance in daily sugar-sweetened beverage (SSB) intake was explained by individual and school characteristics. Adolescents of a secondary or lower parental education level were more likely to consume SSB daily than those of a post-secondary level (aOR = 1.46 (1.29-1.66)). Compared to those in a high SES school, the odds to consume SSB daily was higher for adolescents in low SES schools (aOR = 2.37(1.90-2.96)). These findings support the need for schools to pursue a consistent nutrition policy, with an increased support in low socioeconomic populations.

Effectiveness of Nutritional Strategies on Improving the Quality of Diet of Children from 6 to 12 Years Old: A Systematic Review

Article

Full-text available

Jan 2022

Dietary habits, that are formed during childhood and consolidated in adulthood, are known to influence the development of future chronic diseases such as metabolic syndrome or type 2 diabetes. The aim of this review was to evaluate the effectiveness of nutritional interventions carried out in recent years focused on improving the quality of the diet of the child population. A systematic search of the PubMed and Scopus databases was performed from January 2011 until September 2021. A total of 910 articles were identified and screened based on their title, abstract and full text. Finally, 12 articles were included in the current systematic review. Of those, in six studies the intervention was based on the provision of healthy meals and in the other six studies the intervention focused on modifying the school environment. Six of the studies selected included other components in their intervention such as nutritional education sessions, physical activity and/or families. A wide variety of methods were used for diet assessments, from direct method to questionnaires. The results suggest that interventions that modify the school environment or provide different meals or snacks may be effective in improving children’s dietary patterns, both in the short and long term. Further research is necessary to evaluate the real effectiveness of strategies with multidisciplinary approach (nutritional sessions, physical activity and family’s involvement).

Characteristics of Brazilian school food and physical activity environments: PeNSE 2015

Article

Full-text available

Dec 2021
REV SAUDE PUBL

Objective: To characterize the food and physical activity environments in Brazilian public and private schools, and develop indicators to evaluate them. Methods: This is a cross-sectional study conducted with data from a questionnaire on school characteristics of the 2015 National Adolescent School-based Health Survey, answered by principals or coordinators, referring to 3040 public and private schools throughout the country. The variables related to food and physical activity environments were described in isolation, and an indicator was developed for each environment, with scores ranging from 0 to 100. The frequency and mean score of each variable were described according to the administrative sphere (public or private). Results: The public sector showed a predominance of school meals offer (97.8%), whereas the private sector, of canteens (89.8%). Both had a similar frequency of alternative food outlets in the surroundings. Private schools provided all markers of healthy and unhealthy eating in canteens more frequently. Public schools scored higher in "Food and beverage availability" (64.9) than private schools (55.8). The characteristics of physical activity environments showed that sports courts and sports or games equipment were common in public (69.2% and 90.7%, respectively) and private schools (94.1% and 99.8%, respectively), though at a significantly higher frequency in the second group. Private schools scored higher in "Structures and materials availability" than public schools (63.3 and 41.6, respectively). Conclusions: Public schools provide a more favorable food environment, whereas private schools, a physical activity environment.

Public Acceptability of Policy Interventions to Reduce Sugary Drink Consumption in Urban Vietnam

Article

Full-text available

Dec 2021

This study aims to assess the public acceptability of interventions to reduce sugary drinks in Vietnam, identify the key determinants, and develop a classification of consumers. A cross-sectional survey with 263 urban consumers evaluated perceptions of four potential interventions: restricting choice, taxation, nudging, and labeling. Thereby, specific attention was devoted to perceived intrusiveness and (personal and societal) effectiveness, as well personal characteristics, including Confucius values. Results showed that “hard” interventions like taxation are less acceptable to consumers than “soft” measures such as labeling. Acceptability is generally affected by perceived intrusiveness and effectiveness (especially on other people in the society), while other factors (sugary drink behavior, trust in government’s competence, personal values, age, education) only matter for some of the interventions. Cluster analysis revealed three consumer segments, depicted as anti-taxation (28%), pro-intervention (20%) and pro-labeling (52%), which further underpins the heterogeneity of intervention acceptability.

The Food and Health Environment in Junior Secondary Schools in Urban Burkina Faso: A Cross-Sectional Study of Administrators, Food Vendors and Early Adolescents

Article

Full-text available

Dec 2021
Int J Environ Res Publ Health

School enrolment rates have increased globally, making the school environment a unique setting to promote healthy nutrition and eating outcomes among early adolescents. In this cross-sectional study, we describe the food and health environment of junior secondary schools in Ouagadougou (Burkina Faso, West Africa). We evaluated the food and health environment using three components: (1) the implementation of health-related policies or guidelines in the schools, (2) the provision of health, nutrition and water, sanitation & hygiene (WASH) services in the schools, and (3) the quality of the school food environment, including foods sold by vendors. We used stratified random sampling to recruit 22 junior secondary schools from the five Ouagadougou districts in 2020. Trained fieldworkers collected standardized questionnaire data from 19 school administrators, 18 food vendors, and 1059 in-school adolescents. We report that only 7 out of 19 school administrators were aware of existing health-related policies and guidelines at their school and only 3 schools had a school health and nutrition curriculum in place. The overall provision of health, nutrition and WASH services was low or inadequate. Likely because of the lack of school canteens, 69% of the students bought snacks and unhealthy foods from food vendors. There is a critical need to improve the food and health environment of junior secondary schools in urban Burkina Faso.

Strengthening sector polices for better food security and nutrition result: Food systems for healthy diets

Technical Report

Full-text available

Jan 2018

Stakeholder perceptions of strategies to reduce fast food consumption in Cambodian adults

Article

Sep 2021

Background: Fast food consumption is one of the major contributing factors effecting overweightness and obesity, leading to many non-communicable diseases. Therefore, the purpose of this study was to determine strategies for reducing the fast-food consumption of Cambodian adults. Methods: This qualitative study was conducted among adults in Phnom Penh city, Cambodia, in 2018. 10 stakeholders were included from different institutions in Cambodia, mostly health institutions. The tools used in this study were a multidisciplinary meeting with stakeholders and the completion of observation forms. Using a semi-structured questionnaire, data were collected, and a thematic analysis was used. Results: Stakeholders’ viewpoints followed three identifiable themes with regard to approaches to reduce fast-food consumption among Cambodian adults. These comprised: (1) health education and health promotion (focusing on educational institutions), (2) reducing the availability and marketing impact of fast-food, and (3) implementing government policy. Conclusions: Knowing the important contributors to reduce the consumption of the fast food among Cambodia adults was the first priorities for all policy makers and other stakeholders to take action. This study provided essential findings for improving the decision-making abilities of those preparing strategy and policy for reducing fast-food consumption.

The food environment in schools and their immediate vicinities associated with excess weight in adolescence: A systematic review and meta-analysis

Article

Sep 2021
HEALTH PLACE

Aim The present study systematically reviewed the characteristics of the food environment in schools and their immediate vicinities associated with excess weight in adolescents. Methods We searched for relevant articles in seven databases. No restrictions were applied on language, publication date, and status of publication. The study selection process and data extraction were conducted by two authors independently. For meta-analyses, the random-effects model and the maximum-likelihood method were applied. Results A total of 9327 publications were identified from the initial search. Of these, 20 studies met the inclusion criteria and were included in the systematic review. The sale of food in school or immediate vicinity was associated with high BMI [Odds ratio (OR)= 1.14, 95% confidence interval (CI) 1.01, 2.06]. The availability of healthy food provided by school significantly decreased the odds of obesity [OR= 0.89, 95%CI 0.82, 0.96]. However, the presence of nutrition policies or programs at school was not associated with obesity (OR= 0.81, 95%CI 0.57, 1.16). Conclusions This study highlights the need for improvement in school food environment, including restricting students' exposure to unhealthy foods. The quality of food (healthy vs unhealthy) provided or made available to adolescents in the school food environment influences their weight status. Therefore, promotion of healthy food programs and availability of healthy food at school would limit the prevalence of excess weight in adolescents.

The Impact of the National Nutrition Program 2017–2030 on People’s Food Purchases: A Revenue-Based Perspective

Article

Full-text available

Aug 2021

The General Office of the State Council of China promulgated the National Nutrition Program 2017–2030 in 2017 to guide the people to improve their food supply and nutritional intake. This study uses qualitative and quantitative information which are analyzed to estimate the change in people’s food purchases following the implementation of the National Nutrition Program 2017–2030, and puts forward measures that should be taken by the competent authorities and stakeholders. We use the translog revenue function of the food industry, and based on the data of listed companies of Chinese food enterprises from 2015 to 2020, and this study find that the National Nutrition Program 2017–2030 has had a positive impact on people’s food purchases, and the impact is more obvious in people’s food purchases from large food manufacturers. Finally, we also provide regulators with public policy implications, and provide food manufacturers with development suggestions.

Scrutinize of healthy school canteen policy in Iran’s primary schools: a mixed method study

Article

Full-text available

Aug 2021
BMC PUBLIC HEALTH

Background Schools provide an opportunity for developing strategies to create healthy food environments for children. The present study aimed to analyze the Healthy School Canteen (HSC) policy and identify challenges of its implementation to improve the school food environment in Iran. Methods This mixed method study included two qualitative and quantitative phases. In the qualitative phase, triangulation approach was applied by using semi-structured interviews with key informants, documents review and direct observation. Data content analysis was conducted through policy analysis triangle framework. In the quantitative phase, food items available in 64 canteens of primary schools of Tehran province were gathered. The food’s nutrient data were evaluated using their nutrition facts label. The number and proportion of foods that met the criteria based on Iran’s HSC guideline and the World Health Organization nutrient profile model for the Eastern Mediterranean Region (WHO-EMR) were determined. Results The main contextual factors that affected adoption of HSC policy included health (nutritional transition, high prevalence of non-communicable diseases and unhealthy food environment in and around the schools), political (upstream supportive policies and joint memorandums about health children between the Ministry of Health and Medical Education and Ministry of Education), structural (the lack of unified stewardship, inadequate human resource capacity, poor inter-sectional cooperation), economic (school financial problems, poor fiscal supportive of food policies), and socio-cultural (mothers working outside the home, the role of children’s peer group, low nutrition knowledge of school principals) factors. Assessment of the school canteens showed that a large proportion of available foods did not comply with the national guidelines (54.7 ± 2.54%) and WHO-EMR model (85.6 ± 2.34%). The main reasons identified for incomplete implementation of the policy were inadequate physical and economic infrastructure to set up standard school canteens, lack of scientific criteria for food categorization, poor monitoring, high price of healthy foods, and conflict of interest among the actors. Conclusion The majority of foods and beverages available in the school canteens did not comply with national and regional standards. Iran HSC policy needs to be improved by using an evidence-based approach and active interaction between all key actors.

Cosa mangiano i nostri bambini: come far male a se stessi e anche all’ambiente: Consapevolezza dei genitori, ruolo del sistema scolastico e del pediatra nella transizione verso diete sane e sostenibili

Article

May 2025

Background. The growth of the human population and expanding consumption patterns are among the primary causes of climate change and its health effects. The food system significantly contributes to the climate change, as it is responsible for 26% of CO2 emissions, uses 50% of habitable land and 70% of water resources and causes biodiversity loss. Animal-based and processed foods have a greater environmental impact and the widespread adoption of a western diet is unsustainable for both the planet and human health. Materials and methods. This study examined the dietary habits of a paediatric sample (aged: 6 months-14 years) to assess adherence to guidelines by focusing on the consumption of high-impact foods. It also analysed whether school canteens promote a sustainable and healthy diet and assessed parents’ awareness of these issues and the role of paediatricians in disseminating this information, as well. Results. The results showed an excessive consumption of meat (68%) and dairy products (49%), making the diet unsustainable for both human and planetary health. The school system, while promoting overall healthy eating, increases the consumption of high-impact foods already excessively consumed at home. There is a lack of parental awareness about what a healthy diet and its environmental impact are, topics that are also under-addressed by paediatricians. The paper highlights the need for a better training for paediatricians to promote healthy and sustainable diets.

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

Article

Dec 2024

Background: A range of school-based interventions are effective in improving student diet and physical activity (e.g. school food policy interventions and classroom physical activity interventions), and reducing obesity, tobacco use and/or alcohol use (e.g. tobacco control programmes and alcohol education programmes). However, schools are frequently unsuccessful in implementing such evidence-based interventions. Objectives: The primary review objective is to evaluate the effectiveness of strategies aiming to improve school implementation of interventions to address students' (aged 5 to 18 years) diet, physical activity, obesity, tobacco use and/or alcohol use. The secondary objectives are to: 1. determine whether the effects are different based on the characteristics of the intervention including school type and the health behaviour or risk factor targeted by the intervention; 2. describe any unintended consequences and adverse effects of strategies on schools, school staff or students; and 3. describe the cost or cost-effectiveness of strategies. Search methods: We searched CENTRAL, MEDLINE (Ovid), Embase (Ovid), five additional databases, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), and the US National Institutes of Health registry (clinicaltrials.gov). The latest search was between 1 May 2021 and 30 June 2023 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 randomised controlled trial (RCT) or cluster-RCT conducted on any scale, in a school setting, with a parallel control group that compared a strategy to improve the implementation of policies or practices to address diet, physical activity, obesity, tobacco use and/or alcohol use by students (aged 5 to 18 years) to no active implementation strategy (i.e. no intervention, inclusive of usual practice, minimal support) 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 outcome using a decision hierarchy (i.e. continuous over dichotomous, most valid, total score over subscore). Where possible, we calculated standardised mean differences (SMDs) to account for variable outcome measures with 95% confidence intervals (CI). We conducted meta-analyses using a random-effects model. Where we could not combine data in meta-analysis, we followed recommended Cochrane methods and reported results in accordance with 'Synthesis without meta-analysis' (SWiM) guidelines. We conducted assessments of risk of bias and evaluated the certainty of evidence (GRADE approach) using Cochrane procedures. Main results: We included an additional 14 trials in this update, bringing the total number of included trials in the review to 39 trials with 83 trial arms and 6489 participants. Of these, the majority were conducted in Australia and the USA (n = 15 each). Nine were RCTs and 30 were cluster-RCTs. Twelve trials tested strategies to implement healthy eating practices; 17 physical activity, two tobacco, one alcohol, and seven a combination of risk factors. All trials used multiple implementation strategies, the most common being educational materials, educational meetings, and education outreach visits, or academic detailing. Of the 39 included trials, we judged 26 as having high risks of bias, 11 as having some concerns, and two as having low risk of bias across all domains. Pooled analyses found, relative to a control (no active implementation strategy), the use of implementation strategies probably results in a large increase in the implementation of interventions in schools (SMD 0.95, 95% CI 0.71, 1.19; I2 = 78%; 30 trials, 4912 participants; moderate-certainty evidence). This is equivalent to a 0.76 increase in the implementation of seven physical activity intervention components when the SMD is re-expressed using an implementation measure from a selected included trial. Subgroup analyses by school type and targeted health behaviour or risk factor did not identify any differential effects, and only one study was included that was implemented at scale. Compared to a control (no active implementation strategy), no unintended consequences or adverse effects of interventions were identified in the 11 trials that reported assessing them (1595 participants; moderate-certainty evidence). Nine trials compared costs between groups with and without an implementation strategy and the results of these comparisons were mixed (2136 participants; low-certainty evidence). A lack of consistent terminology describing implementation strategies was an important limitation of the review. Authors' conclusions: We found the use of implementation strategies probably results in large increases in implementation of interventions targeting healthy eating, physical activity, tobacco and/or alcohol use. While the effectiveness of individual implementation strategies could not be determined, such examination will likely be possible in future updates as data from new trials can be synthesised. Such research will further guide efforts to facilitate the translation of evidence into practice in this setting. The review will be maintained as a living systematic review.

School food policy in secondary schools in England and its impact on adolescents’ diets and dental health: the FUEL multiple-methods study

Article

Nov 2024

Background School food standards are a legal requirement for state-funded schools in England and are designed to promote healthy eating in pupils. However, state-funded academies/free schools established between 2010 and 2014 are exempt from this legislation. To complement the school food standards, the government launched the School Food Plan in 2013, which outlines voluntary actions that schools can take to support healthy eating and increase school meal uptake. There has been little evaluation of the school food standards and School Food Plan in secondary schools. Objectives To compare implementation and costs of the school food standards and School Food Plan, and pupil dietary and dental outcomes in two groups of secondary schools: those mandated and those not mandated to comply with the school food standards legislation. Methods An observational, multiple-methods study. We sampled state-funded secondary school academies/free schools, pupils aged 11–15 years, and school staff/governors with a role in food provision/education from the Midlands. We collected qualitative data in four schools. The primary outcome was pupil free sugar intake at lunch; across the school day; and during 24-hours. Secondary outcomes were additional nutritional outcomes and dental caries measures. We assessed school food standards/School Food Plan implementation and costs using researcher observation, document analysis, and surveys with staff/governors, schools and pupils. Dietary intake and dental outcomes were measured online using 24-hour dietary recall and surveys, respectively. In the qualitative study we conducted staff/governor interviews and pupil focus groups in a subsample of schools. We used multilevel analyses to explore variation in pupil outcomes across the school food standards-mandated and school food standards-non-mandated school groups. Data were analysed using the Framework approach. Results Thirty-six schools (13 school food standards-mandated, 23 school food standards-non-mandated), 2453 pupils and 151 staff/governors participated. On average, schools were compliant with 64% of school food standards and implemented 41% of School Food Plan actions, with no differences across school food standards-mandated/non-mandated schools. There was a wide variation in annual costs of the school food standards and School Food Plan reported by schools (mean of £195 per pupil). Pupils in school food standards-mandated schools had lower lunch intakes of free sugar than those in school food standards-non-mandated schools (adjusted mean difference = –2.78 g, 95% confidence interval –4.66 to –0.90 g). After further adjustment for total energy intake, there was no significant difference in free sugar intake, but the school food standards-mandated group had lower fruit and vegetable intake at all time points, and higher consumption of confectionery during the school day and sugar-sweetened beverages over 24 hours. There were no differences in dental outcomes between the two groups. Twenty-one staff/governors and 137 pupils participated in the qualitative study. Staff described balancing school food standards compliance with conflicting priorities related to financial viability. Some pupils felt that school food did not meet their needs for convenience, speed, value for money and taste, and disliked the lunchtime experience. Little time was afforded to healthy-eating education within the curriculum. Limitations There were large numbers of missing data for some study elements, including assessment of some School Food Plan actions and cost data. Conclusions In the secondary school context, the current school food standards are difficult to comply with and the School Food Plan has not achieved the desired outcomes. We found no evidence to show that school food standards legislation has positively influenced nutritional intake. Future research We need to develop healthy secondary-school food provision models that meet pupils’ preferences, and better understand how to situate the food and healthy-eating agenda in secondary schools. Trial registration This trial is registered as ISRCTN68757496. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: 17/92/39) and is published in full in Public Health Research ; Vol. 12, No. 12. See the NIHR Funding and Awards website for further award information.

Mapa de Evidências - Estratégias efetivas em programas e políticas de alimentação e nutrição

Technical Report

Full-text available

Apr 2024

Realizou-se o mapeamento das evidências sobre a efetividade das ações de programas e políticas públicas de alimentação e nutrição sobre as condições de saúde, alimentação e nutrição da população. Foram analisadas 101 revisões sistemáticas.

Mengatasi tingginya konsumsi minuman berpemanis di indonesia

Research

Full-text available

Jan 2024

Relmbuss Biljers Fanda

Using Non-Violent Discipline Tools: Evidence Suggesting the Importance of Attunement

Article

Full-text available

Dec 2023
Int J Environ Res Publ Health

Training in non-violent discipline is important to prevent violence against children and ensure that their caregivers remain a safe base for them. This paper aims to deepen understanding of non-violent discipline by exploring attunement as a mechanism in the effectiveness of non-violent discipline tools. Attunement describes the sensitive responsiveness of caregivers towards their children and has been found to be central to the formation of secure attachment bonds and development of self-regulation. It includes understanding or being “in tune with” the child’s needs and signals, matching these with appropriate responses. The objective of this paper is to explore attunement in relation to non-violent discipline. Peer-reviewed systematic reviews previously included in a systematic overview of evidence on non-violent discipline options were screened for information relevant to attunement. All reviews were published in English between 1999 and 2018 and offered evidence on at least one non-violent discipline tool. Although no reviews explicitly addressed attunement, evidence was found suggesting its importance in the use and effectiveness of discipline methods. Research directly investigating attunement in discipline is needed.

CAPTURING SUGAR-PROMOTING ENVIRONMENTS AND UNDERSTANDING THE LINK WITH CHILD DENTAL HEALTH OUTCOMES THROUGH THE CREATION OF A MULTIDIMENSIONAL INDEX

Thesis

Jan 2023

Suruchi G Ganbavale

Background: Geographical inequalities in children’s dental health, associated with area-level deprivation, could be explained by variation in sugar-promotion in local environments. Investigating the nature and variation of such local-level sugar-promoting environments can inform public health planning. Aim: To investigate local-level socio-environmental contributors to sugar intake in 5-to-11-year-olds and develop a reliable index that quantifies sugar-promotion in small-areas of England and explains geographical inequalities associated with dental caries in children. Methods: The research design had three interlinked phases: 1. Development of a testable framework of sugar-promoting socio-environmental factors through two structured reviews of the systematic reviews of dental caries and obesity literature. 2. Development and validation of a multidimensional index using large national datasets and quantitative techniques to collectively measure factors across Middle-layer Super Output Areas (MSOAs), and lower- and upper-tier local authorities (LAs) in England. 3. Predictive analyses to assess the relative importance of the index in explaining excessive sugar intake, dental caries prevalence, and tooth extractions in 5-11-year-olds. Results: Study-1: Socio-environmental factors in neighbourhood-, school-, and family-environments, qualitatively contribute to sugar intake, dental health, and weight status in children. Study-2: A newly-developed MSOA-level index included 30 indicators within 3 environmental domains; and indicated higher sugar-promotion in cities, inner London, and coastal areas. At LA-level, indices showed higher sugar-promotion in deprived, urban, and northern parts of England. Study-3: In logistic regression controlling age, gender, and ethnicity, the upper-tier LA-level index remained positively associated with excessive sugar intake. In simple linear regression, an increased index score was significantly associated with 4.7% increase in the percentage of severely decayed teeth in lower-tier LAs. In multilevel logistic regression, MSOA-level index and age were positively associated with tooth extraction. School- and family-environment domains predicted 380% increase and 37% decrease in chances of tooth extraction, respectively. Conclusion and key contribution: The qualitative predictors of sugar-promotion can be quantified using an index within small geographies. This could inform targeted and locally-relevant dental health promotion activities.

School nutrition policy and diet quality of children and youth: a quasi-experimental study from Canada

Article

Mar 2023
CAN J PUBLIC HEALTH

Objective: We investigated the impact of mandatory school nutrition policy on diet quality of Canadian school children using a quasi-experimental study design. Methods: Using 24-h dietary recall data from the 2004 Canadian Community Health Survey (CCHS) Cycle 2.2 and 2015 CCHS - Nutrition, we constructed the Diet Quality Index (DQI). We used multivariable difference-in-differences regressions to quantify the DQI scores associated with school nutrition policy. We conducted stratified analyses by sex, school grade, household income, and food security status to gain additional insights into the impact of nutrition policy. Results: We found that mandatory school nutrition policy was associated with an increased DQI score by 3.44 points (95% CI: 1.1, 5.8) during school-hours in intervention provinces relative to control provinces. DQI score was higher among males (3.8 points, 95% CI: 0.6, 7.1) than among females (2.9 points, 95% CI: -0.5, 6.3), and the score among students in elementary schools was higher (5.1 points, 95% CI: 2.3, 8.0) than that among high school students (0.4 points, 95% CI: -3.6, 4.5). We also found that DQI scores were higher for middle-high income and food secure households. Conclusion: Provincial mandatory school nutrition policy was associated with better diet quality among children and youth in Canada. Our findings suggest that other jurisdictions may consider implementing mandatory school nutrition policy.

Avaliação de indivíduos diabéticos quanto ao autocuidado e ao estágio de mudança de comportamento segundo o Modelo Transteórico na Atenção Secundária do Distrito Federal

Article

Jan 2022

Changes in Meal and Menu Quality at Early Care and Education Programs after Training with Food Service Staff: the FRESH Study

Article

Feb 2023

Background: Prevalence of obesity in Native American (NA) children is disproportionately high, indicating a higher risk of health disparities. Many children attend early care and education (ECE) programs, presenting an opportune environment to improve meal and menu quality as the intake of healthy foods is associated with lowered risk of childhood obesity. Objectives: We aimed to examine the effectiveness of food service staff training on meals and menu quality across NA ECEs. Methods: Food service staff from 9 participating ECE programs attended a 3-h training focused on Child and Adult Care Food Program (CACFP) best practices, and received a tailored, best-practice menu, and healthy recipes. Meals and menus prepared across 1 wk were examined per CACFP serving size assumptions at baseline, 4 mos, 6 mos, and 12 mos for all 9 programs. Healthy Eating Index (HEI), CACFP requirements and best practices achievement, and food substitutions quality (classified into superior, equivalent, and inferior based on the nutritional quality) were calculated. A repeated measures ANOVA model was used to determine the differences across time points. Results: The total meal HEI score increased significantly from baseline to 4 mos (71.1 ± 2.1; 78.6 ± 5.0; P = 0.004), but did not differ from baseline to 12 mos. Menu CACFP requirements and best practices achievement did not differ across time points, although achievement with CACFP requirements was already high at baseline. Superior nutrition quality substitutions declined from baseline to 6 mos (32.4 ± 8.9; 19.5 ± 10.9; P = 0.007); however, it did not differ from baseline to 12 mos. Equivalent and inferior quality substitutions did not differ across time points. Conclusions: Implementing a best-practice menu with healthy recipes showed immediate improvements in meal quality. Although the change did not sustain, this study showed evidence of an opportunity to educate and train food service staff. Robust efforts are needed for improving both meals and menus.This trial was registered ClinicalTrials.gov as NCT03251950 (https://clinicaltrials.gov/ct2/show/NCT03251950?cond=food+resource+equity&draw=2&rank=1).

Effectiveness of a Teaching Kitchen Intervention on Dietary Intake, Cooking Self-Efficacy, and Psychosocial Health

Article

Dec 2022

Background The consumption of fruits, vegetables, and whole grains (FVWG) has been associated with decreased risk of chronic disease, yet over 80% of U.S. adults do not meet dietary recommendations for FVWG. Purpose This study explored the effectiveness of a teaching kitchen intervention upon consumption of FVWG and overall dietary patterns. Cooking self-efficacy, comfort in the kitchen, and elements of psychosocial health were also assessed. Methods Participants were recruited to the 5-week Complete Health Improvement Program–Teaching Kitchen (CHIP-TK) through a worksite wellness initiative. The program, based upon elements of the social cognitive theory, included cooking classes, health education, and horticulture activities. Pre- and post-surveys were administered and evaluated. Results CHIP-TK led to significant increases in FVWG intake. Cooking self-efficacy, comfort in the kitchen, and general well-being scores also improved, with medium-to-large effect sizes. Participant feedback indicated weekly meetings, hands-on cooking classes, facilitator expertise, and group camaraderie were keys to success in the program. Discussion Teaching kitchens are well-received within a worksite setting and have the potential to improve dietary intake patterns and psychosocial health.Translation to Health Education Practice: Health educators should design and implement integrative, theory-driven programs to improve nutritional status, well-being, and overall health.

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

Article

Aug 2022
COCHRANE DB SYST REV

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.

“We should be able to decide” : Obesogenic factors influencing dietary behaviours of women and adolescents in Ethiopia

Thesis

Jan 2022

Ursula Trübswasser

Nutrition guidelines and standards: A report from 33 low and middle-income countries

Technical Report

Full-text available

Sep 2019

Melissa Vargas

Setting nutrition guidelines and standards has been recommended internationally to ensure that school meals are in line with children’s nutrition needs and adequate to their context. This report provides a descriptive overview of the situation of school meal nutrition guidelines and standards in 33 low and middle-income countries as reported through a global survey. The report identifies key aspects to consider for stakeholders who are planning to develop or update their guidelines and standards in the context of school meal programmes.

Beslenme Eğitiminin Çocukların Beslenme Kararları ve Akıl Yürütme Örüntüleri Üzerindeki Etkisinin İncelenmesi

Article

Full-text available

Sep 2021

Bu araştırmanın amacı, beslenme eğitiminin çocukların beslenme kararlarını ve akıl yürütme örüntülerini nasıl etkilediğini keşfetmektir. Bu durum çalışması, 2020-2021 eğitim öğretim yılı Elazığ ilinde bir anaokulunda öğrenim gören 60-72 aylık sekiz çocuğun katılımı ile gerçekleştirilmiştir. Araştırma kapsamında örnek menü seçenekleri, haftalık etkinlikler ve video kayıtlar aracılığıyla veriler toplanmıştır. Çocuklar, haftada iki gün olacak şekilde toplamda altı haftalık beslenme eğitimine dâhil edilmişlerdir. Eğitimin b1şında ve sonunda çocuklara sağlıklı, sağlıklı gibi görünen ve sağlıksız olacak şekilde beslenme uzmanı tarafından hazırlanmış olan kahvaltı, öğlen ve akşam yemeği menüleri sunulmuştur. Çocukların üç alternatifli menülerden birini seçmeleri istenmiştir. Eğitim öncesi ve sonrasında çocukların kararları -1, 0, 1 şeklinde puanlandırılırken akıl yürütme örüntülerini analitik rubrik aracılığıyla değerlendirilmiştir. Sonuçlar, beslenme eğitiminin çocukların menü seçimlerini olumlu etkilediğini ve onların daha mantıksal akıl yürütmeler yapmalarını sağladığını göstermiştir. Bu sonuçlar, literatür temelli olarak derinlemesine tartışılmış ve pedagojik önerilerde bulunulmuştur.

Randomised controlled trial of primary school based intervention to reduce risk factors for obesity

Article

Full-text available

Nov 2001

Objective: To assess if a school based intervention was effective in reducing risk factors for obesity. Design: Group randomised controlled trial. Setting: 10 primary schools in Leeds. Participants: 634 children aged 7-11 years. Intervention: Teacher training, modification of school meals, and the development of school action plans targeting the curriculum, physical education, tuck shops, and playground activities. Main outcome measures: Body mass index, diet, physical activity, and psychological state. Results: Vegetable consumption by 24 hour recall was higher in children in the intervention group than the control group (weighted mean difference 0.3 portions/day, 95% confidence interval 0.2 to 0.4), representing a difference equivalent to 50% of baseline consumption. Fruit consumption was lower in obese children in the intervention group (-1.0, -1.8 to -0.2) than those in the control group. The three day diary showed higher consumption of high sugar foods (0.8, 0.1 to 1.6)) among overweight children in the intervention group than the control group. Sedentary behaviour was higher in overweight children in the intervention group (0.3, 0.0 to 0.7). Global self worth was higher in obese children in the intervention group (0.3, 0.3 to 0.6). There was no difference in body mass index, other psychological measures, or dieting behaviour between the groups. Focus groups indicated higher levels of self reported behaviour change, understanding, and knowledge among children who had received the intervention. Conclusion: Although it was successful in producing changes at school level, the programme had little effect on children's behaviour other than a modest increase in consumption of vegetables.

Evaluation of implementation and effect of primary school based intervention to reduce risk factors for obesity

Article

Full-text available

Dec 2001

Objectives: To implement a school based health promotion programme aimed at reducing risk factors for obesity and to evaluate the implementation process and its effect on the school. Design: Data from 10 schools participating in a group randomised controlled crossover trial were pooled and analysed. Setting: 10 primary schools in Leeds. Participants: 634 children (350 boys and 284 girls) aged 7-11 years. Main outcome measures: Response rates to questionnaires, teachers' evaluation of training and input, success of school action plans, content of school meals, and children's knowledge of healthy living and self reported behaviour. Results: All 10 schools participated throughout the study. 76 (89%) of the action points determined by schools in their school action plans were achieved, along with positive changes in school meals. A high level of support for nutrition education and promotion of physical activity was expressed by both teachers and parents. 410 (64%) parents responded to the questionnaire concerning changes they would like to see implemented in school. 19 out of 20 teachers attended the training, and all reported satisfaction with the training, resources, and support. Intervention children showed a higher score for knowledge, attitudes, and self reported behaviour for healthy eating and physical activity. Conclusion: This programme was successfully implemented and produced changes at school level that tackled risk factors for obesity.

Promoting physical activity and a healthful diet among children: Results of a school-based intervention study

Article

Full-text available

Sep 1991

National health objectives call for improved diet and more regular physical activity among children. We tested the effects of a school-based program to improve students' diet and physical activity behavior at school. Two of the four elementary schools in one Texas school district were assigned to intervention and two to control conditions. The three intervention components were classroom health education, vigorous physical education, and lower fat, lower sodium school lunches. Nutrients from school lunches and the total day and the amount of physical activity students obtained during physical education were assessed as outcome. Analysis of school lunches showed declines from base line to posttest in the two intervention schools of 15.5% and 10.4% for total fat, 31.7% and 18.8% for saturated fat, and 40.2% and 53.6% for sodium; posttest values were lower in the intervention schools. Observation of physical activity during physical education classes indicated an increase in the intervention schools from baseline to posttest in the percent of time children engaged in moderate-to-vigorous physical activity from less than 10% of class time at baseline to about 40% of class time at posttest; posttest values were higher in the intervention schools than in the control schools. This efficacy study demonstrates the feasibility of substantially modifying school lunches and school physical education to improve children's diet and physical activity behavior at school.

Soft drink "pouring rights": Marketing empty calories

Article

Full-text available

Jul 2000

Marion Nestle

Healthy People 2010 objectives call for meals and snacks served in schools to contribute to overall diets that meet federal dietary guidelines. Sales in schools of foods and drinks high in calories and low in nutrients undermine this health objective, as well as participation in the more nutritious, federally sponsored, school lunch programs. Competitive foods also undermine nutrition information taught in the classroom. Lucrative contracts between school districts and soft drink companies for exclusive rights to sell one brand are the latest development in the increasing commercialization of school food. These contracts, intended to elicit brand loyalty among young children who have a lifetime of purchases ahead of them, are especially questionable because they place schools in the position of "pushing" soft drink consumption. "Pouring rights" contracts deserve attention from public health professionals concerned about the nutritional quality of children's diets.

Effect of a fruit and vegetable subscription in Danish schools

Article

Full-text available

Mar 2003

To measure the effect of a school fruit and vegetable subscription on children's intake of fruit and vegetables after 5 weeks of intervention. Seven primary schools in Denmark. Intervention schools (n=4) were offered a fruit and vegetable subscription comprising one piece per day. Control schools situated in another municipality were not offered the subscription. Intake of fruit and vegetables was measured at baseline and 5 weeks after the start of the subscription. Two methods were used for dietary assessment: a pre-coded 24-hour recall form including total food intake and a food-frequency questionnaire (FFQ) including only fruit and vegetables. Children aged 6-10 years (n=804 from intervention schools and n=689 from control schools). Response rate in the dietary assessment was 31%. At intervention schools 45% of the children enrolled in the subscription. After 5 weeks of intervention, both subscribers and non-subscribers had increased their intake of fruit by 0.4 (P=0.019) and 0.3 (P=0.008) pieces per school day, respectively, but no change was observed in vegetable intake. Total intake increased only for non-subscribers by 0.4 piece/school day (P=0.008) mainly due to the consistent increase in fruit intake. No change in intake was measured at control schools. Only the 24-hour recall questionnaire was sensitive enough to pick up the changes of the subscription, whereas the FFQ was not. Five weeks with the subscription affected both subscribers and non-subscribers to increase intake of fruit. This may indicate that the subscription had an additional effect of stimulating parents of non-subscribers to supply their children with fruit. The results stress the importance of evaluating the effect of this type of programme, and the carefulness needed in designing the evaluation study.

Environmental Interventions for Eating and Physical Activity A Randomized Controlled Trial in Middle Schools

Article

Full-text available

Apr 2003
AM J PREV MED

Our objective was to evaluate the effects of environmental, policy, and social marketing interventions on physical activity and fat intake of middle school students on campus. Twenty-four middle schools were randomly assigned to intervention or control conditions. Baseline measures were collected in spring 1997, and interventions were conducted during the 1997-1998 and 1998-1999 school years SETTING/PARTICIPATION: The schools had mean enrollments of 1109, with 44.5% nonwhite students. Over 2 years, physical activity interventions were designed to increase physical activity in physical education classes and throughout the school day. Nutrition interventions were designed to provide and market low-fat foods at all school food sources, including cafeteria breakfasts and lunches, a la carte sources, school stores, and bag lunches. School staff and students were engaged in policy change efforts, but there was no classroom health education. Primary outcomes were measured by direct observation and existing records. Randomized regression models (N =24 schools) revealed a significant intervention effect for physical activity for the total group (p <0.009) and boys (p <0.001), but not girls (p <0.40). The intervention was not effective for total fat (p <0.91) or saturated fat (p <0.79). Survey data indicated that the interventions reduced reported body mass index for boys (p <0.05). Environmental and policy interventions were effective in increasing physical activity at school among boys but not girls. The interventions were not effective in reducing fat intake at school. School environmental and policy interventions have the potential to improve health behavior of the student population, but barriers to full implementation need to be better understood and overcome.

The Association of the School Food Environment With Dietary Behaviors of Young Adolescents

Article

Full-text available

Aug 2003

We examined the association between young adolescents' dietary behaviors and school vending machines, à la carte programs, and fried potatoes' being served at school lunch. Using a cross-sectional study design, we measured à la carte availability and the number of school stores, vending machines, and amounts of fried potatoes served to students at school lunch in 16 schools. Grade 7 students (n = 598) completed 24-hour dietary recall interviews. A la carte availability was inversely associated with fruit and fruit/vegetable consumption and positively associated with total and saturated fat intake. Snack vending machines were negatively correlated with fruit consumption. Fried potatoes' being served at school lunch was positively associated with vegetable and fruit/vegetable intake. School-based programs that aim to promote healthy eating among youths should target school-level environmental factors.

Food Environment in Secondary Schools: À La Carte, Vending Machines, and Food Policies and Practices

Article

Full-text available

Jul 2003

This study described the food environment in 20 Minnesota secondary schools. Data were collected on school food policies and the availability and nutritional content of foods in school à la carte (ALC) areas and vending machines (VMs). Approximately 36% and 35% of foods in ALC areas and in VMs, respectively, met the lower-fat criterion (< or = 5.5 fat grams/serving). The chips/crackers category constituted the largest share of ALC foods (11.5%). The median number of VMs per school was 12 (4 soft drink, 2 snack, 5 other). Few school food policies were reported. The availability of healthful foods and beverages in schools as well as school food policies that foster healthful food choices among students needs greater attention.

A Randomized School Trial of Environmental Strategies to Encourage Fruit and Vegetable Consumption among Children

Article

Full-text available

Mar 2004

The Cafeteria Power Plus project examined whether a cafeteria-based intervention would increase the fruit and vegetable (FV) consumption of children. Twenty-six schools were randomly assigned to either an intervention or control condition. Baseline lunch observations of a sample (N = 1668) of first- and third-grade students occurred in the spring of 2000; follow-up was in the spring of 2002. The intervention took place during two consecutive school years beginning in the fall of 2000 and consisted of daily activities (increasing the availability, attractiveness, and encouragement for FV) and special events (kick-offs, samplings, challenge weeks, theater production, and finale meal). Training of food-service staff and cook managers was ongoing throughout the intervention phase. Students in the intervention schools significantly increased their total fruit intake. Process measures indicated that verbal encouragement by food-service staff was associated with outcomes. The outcomes suggest that multicomponent interventions are more powerful than cafeteria programs alone with this age group.

Diet, nutrition and the prevention of excess weight gain and obesity

Article

Full-text available

Mar 2004

To review the evidence on the diet and nutrition causes of obesity and to recommend strategies to reduce obesity prevalence. The evidence for potential aetiological factors and strategies to reduce obesity prevalence was reviewed, and recommendations for public health action, population nutrition goals and further research were made. Protective factors against obesity were considered to be: regular physical activity (convincing); a high intake of dietary non-starch polysaccharides (NSP)/fibre (convincing); supportive home and school environments for children (probable); and breastfeeding (probable). Risk factors for obesity were considered to be sedentary lifestyles (convincing); a high intake of energy-dense, micronutrient-poor foods (convincing); heavy marketing of energy-dense foods and fast food outlets (probable); sugar-sweetened soft drinks and fruit juices (probable); adverse social and economic conditions-developed countries, especially in women (probable). A broad range of strategies were recommended to reduce obesity prevalence including: influencing the food supply to make healthy choices easier; reducing the marketing of energy dense foods and beverages to children; influencing urban environments and transport systems to promote physical activity; developing community-wide programmes in multiple settings; increased communications about healthy eating and physical activity; and improved health services to promote breastfeeding and manage currently overweight or obese people. The increasing prevalence of obesity is a major health threat in both low- and high income countries. Comprehensive programmes will be needed to turn the epidemic around.

The National School Fruit Scheme produces short-term but not longer-term increases in fruit consumption in primary school children

Article

Full-text available

May 2005

The National School Fruit Scheme (NSFS) provides one free piece of fruit each school day to children, aged 4 to 6 years, attending state schools in England. The aims of the present study were to determine if NSFS was associated with a higher fruit consumption in infant school children (4-6 years old), and to assess whether fruit consumption was higher in junior school children (7-8 years old) who had received free fruit as infants compared with those who had not. The present cross-sectional study involved seventeen schools, eight in the NSFS (study schools) and nine not in the NSFS (control schools). Study and control schools were selected in areas of similar levels of deprivation. All schools were on the outskirts of London in Southeast England. A retrospective 24 h food tick list was given to each pupil in Reception to Year 4 to take home for their parents to complete and return. Response rate was 51%. Median total fruit consumption (excluding fruit juice) in infants receiving free fruit was 117 g/d compared with 67 g/d in infants not receiving free fruit (P<0.001). Median consumption in juniors who had received free fruit at school as infants did not differ from those who had not (83 g/d v. 86 g/d). The NSFS has increased fruit consumption in infant school children. It does not appear to have longer-term effects in junior school children. If the scheme is to affect dietary habits and improve health in the long term, further interventions will be needed.

Interventions for Preventing Obesity in Children (Review)

Article

Full-text available

Feb 2005

The current evidence suggests that many diet and exercise interventions to prevent obesity in children are not effective in preventing weight gain, but can be effective in promoting a healthy diet and increased physical activity levels. Being very overweight (obese) can cause health, psychological and social problems for children. Children who are obese are more likely to have weight and health problems as adults. Programmes designed to prevent obesity focus on modifying one or more of the factors considered to promote obesity. This review included 22 studies that tested a variety of intervention programmes, which involved increased physical activity and dietary changes, singly or in combination. Participants were under 18 and living in Asia, South America, Europe or North America. There is not enough evidence from trials to prove that any one particular programme can prevent obesity in children, although comprehensive strategies to address dietary and physical activity change, together with psycho-social support and environmental change may help. There was a trend for newer interventions to involve their respective communities and to include evaluations. Future research might usefully assess changes made on behalf of entire populations, such as improvements in the types of foods available at schools and in the availability of safe places to run and play, and should assess health effects and costs over several years. The programmes in this review used different strategies to prevent obesity so direct comparisons were difficult. Also, the duration of the studies ranged from 12 weeks to three years, but most lasted less than a year.

School lunch and snacking patterns among high school students: Associations with school food environment and policies

Article

Full-text available

Oct 2005
INT J BEHAV NUTR PHY

This study examined associations between high school students' lunch patterns and vending machine purchases and the school food environment and policies. A randomly selected sample of 1088 high school students from 20 schools completed surveys about their lunch practices and vending machine purchases. School food policies were assessed by principal and food director surveys. The number of vending machines and their hours of operation were assessed by trained research staff. Students at schools with open campus policies during lunchtime were significantly more likely to eat lunch at a fast food restaurant than students at schools with closed campus policies (0.7 days/week vs. 0.2 days/week, p < .001). Student snack food purchases at school were significantly associated with the number of snack machines at schools (p < .001) and policies about the types of food that can be sold. In schools with policies, students reported making snack food purchases an average of 0.5 +/- 1.1 days/week as compared to an average of 0.9 +/- 1.3 days/week in schools without policies (p < .001). In schools in which soft drink machines were turned off during lunch time, students purchased soft drinks from vending machines 1.4 +/- 1.6 days/week as compared to 1.9 +/- 1.8 days/week in schools in which soft drink machines were turned on during lunch (p = .040). School food policies that decrease access to foods high in fats and sugars are associated with less frequent purchase of these items in school among high school students. Schools should examine their food-related policies and decrease access to foods that are low in nutrients and high in fats and sugars.

Law as a Tool to Facilitate Healthier Lifestyles and Prevent Obesity

Article

Full-text available

Feb 2007
J Am Med Assoc

Lawrence Gostin

Public health agencies face considerable challenges trying to prevent overweight and obesity in society, primarily because a person's own behavior is often the root cause of the disease. Individuals make personal choices about their diet, exercise, and lifestyle, so disease is often thought of as a matter of personal, not governmental, responsibility. This Commentary shows how law can be used as a tool to prevent overweight and obesity (see Table). The tools discussed in this article include: - Disclosure - e.g., labels and consumer information - Tort liability - e.g., inadequate disclosure of risks, misleading advertisements, and targeting children - Surveillance - e.g., reporting of glycosylated hemoglobin for diabetes management - Targeting children and adolescents - e.g., restricting food advertising during children's programs; counter advertising to promote good nutrition and physical activity; limiting the use of cartoon characters; and restricting web-based games and promotions - Taxation of unhealthy food - e.g., "junk food," "snack," or "Twinkie" tax provides disincentive for purchasing calorie-dense, nutrient-poor foods; tax revenue could also be used to promote healthy nutrition - School policies - e.g., require schools to adhere to dietary guidelines and portion size; increase opportunities for nutrition education and physical activities - Built Environment - e.g., limit fast food restaurants, build recreational parks and bike paths, expand mass transportation, and provide lighting and playgrounds in housing developments - Food Prohibitions - e.g., ban trans fat from restaurants Despite the undoubted political risks, should public health agencies push for strong measures to control obesity, perhaps even banning hazardous foods? The justification lies with the epidemic rates of overweight and obesity, the preventable morbidity and mortality, and the stark health disparities based on race and socioeconomic status. Although the public dislikes paternalism, it is at least worth considering whether such an approach is ever justified to regulate harms that are apparently self-imposed, but which are deeply socially embedded and pervasively harmful to the public.

International school-based interventions for preventing obesity in children

Article

Full-text available

Apr 2007

Manoj Sharma

The purpose of this article was to review international (excluding the United States) school-based interventions for preventing obesity in children published between 1999 and 2005. A total of 21 such interventions were found from Australia (1), Austria (1), Canada (1), Chile (1), France (1), Germany (3), Greece (1), New Zealand (1), Norway (1), Singapore (1) and the United Kingdom (9). The grade range of these interventions was from pre-school to high school with the majority (17) from elementary schools. Nine of these interventions targeted nutrition behaviours followed by seven aiming to modify both physical activity and nutrition behaviours. Only five interventions in international settings were based on any explicit behavioural theory which is different than the interventions developed in the United States. Majority of the interventions (9) were one academic year long. It can be speculated that if the interventions are behavioural theory-based, then the intervention length can be shortened. All interventions that documented parental involvement successfully influenced obesity indices. Most interventions (16) focused on individual-level behaviour change approaches. Most published interventions (16) used experimental designs with at least 1-year follow-up. Recommendations from international settings for enhancing the effectiveness of school-based childhood obesity interventions are presented.

Free School Fruit – sustained effect three years later

Article

Full-text available

Feb 2007
INT J BEHAV NUTR PHY

Norwegian children consume less fruit and vegetables (FV) than recommended. In order to increase the intake, a School Fruit subscription programme is now offered to all Norwegian elementary and junior high schools. This programme has limited effect due to low participation by schools and pupils. However, recent evaluations of the programme offered for free have reported good effects in increasing FV intake. The purpose of the present study is to evaluate the long term effects of the Norwegian School Fruit programme, provided at no-cost to the pupils, three years after it was provided for free. A total of 1950 (85%) 6th and 7th grade pupils from 38 Norwegian elementary schools participated in the project. Nine schools were selected as intervention schools and participated for free in the Norwegian School Fruit programme for a school year (October 2001 until June 2002). A baseline questionnaire survey was conducted in September 2001, and follow-up surveys were conducted in May 2002 and May 2005. FV intake was assessed by a written 24-h recall (reporting FV intake at school and FV intake all day), and by four food frequency questions (reporting usual FV intake). Data were analysed by a linear mixed model for repeated measures. The pupils in the free fruit group increased their FV intake compared to pupils in the control group as a result of the intervention. Some of the effect was sustained three years later. The estimated long-term effects for FV all day were 0.38 and 0.44 portion/day for boys and girls, respectively. The results show long-term effects of a free school fruit programme.

Nelson M, Lowes K, Hwang V, Nutrition Group, School meals review panel. The contribution of school meals to food consumption and nutrient intakes of young people aged 4-18 years in England. Public Health Nutr 10, 652-662

Article

Full-text available

Aug 2007

To undertake secondary analyses of the 1997 National Diet and Nutrition Survey of Young People aged 4-18 years in order to describe the contribution of school meals to daily food and nutrient intakes; and to compare the findings from 1997 with data collected in English primary and secondary schools in 2004-2005. Cross-sectional analysis of 7-day weighed inventory food consumption data according to age, sex, household income, free school meals and breakfast consumption. Comparison of food consumption with the Balance of Good Health and of nutrient intake data with the Caroline Walker Trust (CWT) guidelines. United Kingdom. One thousand four hundred and fifty-six UK schoolchildren aged 4-18 years, 7058 English primary-school pupils and 5695 English secondary-school pupils. Pupils' school meal choices in 1997 did not accord with the Balance of Good Health. Food choices in school were less healthy than choices outside school. School meals failed to make good the shortfalls in daily intakes of non-starch polysaccharides and zinc in primary-school pupils, and of calcium, iron, zinc, vitamin A and non-starch polysaccharides in secondary-school pupils, nor excess daily intakes of saturated fatty acids, non-milk extrinsic sugars and sodium at all ages. School meals typically failed to meet CWT guidelines. They were more likely to meet CWT guidelines when choice of foods was restricted. School meals need substantial improvement to meet CWT guidelines for healthy eating. The introduction of food-based guidelines for school meals in England in 2001 did not improve the food choices in school meals.

The effects of a middle school healthy eating intervention on adolescents' fat and fruit intake and soft-drink consumption

Article

Full-text available

May 2007

To evaluate the effects of a middle-school healthy eating promotion intervention combining environmental changes and computer-tailored feedback, with and without an explicit parent involvement component. Clustered randomised controlled trial. Fifteen West-Flemish (Belgian) middle schools. A random sample of 15 schools with 2991 pupils in 7th and 8th grades was randomly assigned to an intervention group with parental support (n = 5), an intervention group without parental support (n = 5) and a control group (n = 5). In these 15 schools an intervention combining environmental changes with computer-tailored feedback was implemented. Fat and fruit intake, water and soft drinks consumption were measured with food-frequency questionnaires in the total sample of children. In girls, fat intake and percentage of energy from fat decreased significantly more in the intervention group with parental support, compared with the intervention alone group (all F>3.9, P < 0.05) and the control group (all F>16.7, P < 0.001). In boys, there were no significant decreases in fat intake (F = 1.4, not significant (NS)) or percentage of energy from fat (F = 0.7, NS) as a result of the intervention. No intervention effects were found in boys or in girls for fruit (F = 0.5, NS), soft drinks (F = 2.6, NS) and water consumption (F = 0.3, NS). Combining physical and social environmental changes with computer-tailored feedback in girls and their parents can induce lower fat intake in middle-school girls. However, to have an impact on the consumption of soft drinks and water, governmental laws that restrict the at-school availability of low-nutritive products may be necessary.

Does the School Fruit and Vegetable Scheme improve children’s diet? A non-randomised controlled trial

Article

Full-text available

Sep 2007

Evaluation of the impact on diet of the school fruit and vegetable scheme (SFVS). Non-randomised controlled trial. Infant and primary schools in the north of England. 3,703 children aged four to six years (reception, year 1, and year 2). One portion of fruit or vegetable provided per child on each school day between February and December 2004. Fruit and vegetables consumed and intake of nutrients. The SFVS was associated with an increase in fruit intake across reception and year 1 pupils of 0.4 portions (95% confidence interval, 0.2 to 0.5) and 0.6 portions (0.4 to 0.9), respectively, at three months, which fell to 0.2 (0.1 to 0.4) and 0.3 (0.1 to 0.6) at seven months. In year 2 it was associated with an increase of 0.5 portions (0.2 to 0.7) of fruit at three months, which fell to baseline values at seven months when these children were no longer eligible for the scheme. Overall, at seven months there were no changes in vegetable consumption, no associations between the SFVS and energy, fat, or salt intake, and small changes in carotene and vitamin C intake. The SFVS promoted an increase in fruit intake after three months. At seven months the effect remained significant but reduced, and it returned to baseline in year 2 when pupils were no longer part of the scheme. There was a small impact on the intake of some nutrients across the children surveyed.

Regulating and Litigating in the Public Interest: Regulating Food Marketing to Young People Worldwide: Trends and Policy Drivers

Article

Full-text available

Dec 2007
AM J PUBLIC HEALTH

Corinna Hawkes

The pressure to regulate the marketing of high-energy, nutrient-poor foods to young people has been mounting in light of concern about rising worldwide levels of overweight and obesity. In 2004, the World Health Organization called on governments, industry, and civil society to act to reduce unhealthy marketing messages. Since then, important changes have taken place in the global regulatory environment regarding the marketing of food to young people. Industry has developed self-regulatory approaches, civil society has campaigned for statutory restrictions, and governments have dealt with a range of regulatory proposals. Still, there have been few new regulations that restrict food marketing to young people. Despite calls for evidence-based policy, new regulatory developments appear to have been driven less by evidence than by ethics.

Effects of a comprehensive fruit- and vegetable-promoting school-based intervention in three European countries: The Pro Children Study

Article

Full-text available

May 2008

The objective of the present study was to evaluate the effects of the Pro Children intervention on schoolchildren's fruit and vegetable (FV) intake after 1 and 2 years of follow-up. The intervention combined a FV curriculum with efforts to improve FV availability at schools and at home. Effects were examined in a group-randomised trial among 1,472 10-11-year-old children from sixty-two schools in Norway, the Netherlands and Spain. FV intake was assessed by means of validated self-administered questionnaires completed before the intervention (September 2003), immediately after the first year of the intervention (May 2004) and 1 year later (May 2005). Data were analysed using multilevel linear regression analyses with age and sex as covariates. Significant intervention effects for FV intake were found at first follow-up in the total sample. The adjusted FV intake reported by the children from intervention schools was 20 % higher than FV intake reported by children from control schools. At 1 year later, a significant impact was only observed in Norway. Positive intervention effects on FV intake occurred both at school and outside school. We conclude that the Pro Children intervention is a promising means to promote European schoolchildren's FV intakes, but mainly fruit intake, in the short term. As shown in Norway, where the intervention was best implemented, the intervention might also result in longer-term effects. Further strategies need to be developed that can improve implementation, have an impact on vegetable intake and can secure sustained effects.

Interventions for preventing obesity in children

Article

WHO Global Database on Body Mass Index (BMI): An Interactive Surveillance Tool for Monitoring Nutrition Transition

Article

Jan 2006

WHO. Department of Nutrition for Health and Development

Gimme 5

Article

Mar 2002

Outcomes of a High School Program to Increase Fruit and Vegetable Consumption: Gimme 5 — A Fresh Nutrition Concept for Students

Article

Aug 1998
J SCHOOL HEALTH

This paper describes an intervention to increase high school students' fruit and vegetable consumption. Twelve schools were randomized to intervention or control conditions. The cohort (2,213 students; 56% females, 84% Caucasian) were followed from 9th to 12th grades. Interventions comprised a media campaign, classroom workshops, school meal modification, and parental support. Usual daily servings of fruit/vegetables increased 14% in the intervention compared to the control group (p>0.001) the first three years. At follow-up, consumption within the control group also increased, resulting in no significant difference between groups. Intervention group knowledge scores and awareness indicators were significantly higher than those of the control group (p<0.0001). Gimme 5 provided a first model to show that dietary habits of high school students can be influenced by positive media messages relative to that age group, increased exposure to a variety of tasty products, and minimal classroom activity

Using the School Environment to Promote Physical Activity and Healthy Eating

Article

Aug 2000

Background. The role of the community environment in shaping dietary and physical activity behaviors has received increasing attention in recent years. Al though schools are a key part of the community envi ronment, interventions that promote physical activity and healthy eating among students through changes in the school environment have received relatively lit tle attention.Method. After reviewing the role of environmental factors in shaping health behavior, this paper de scribes the various aspects of the school environment that influence physical activity and nutrition behav iors. Relevant research is described and new research directions are proposed for five key environmental in fluences: recess periods, intramural sports and physi cal activity programs, physical activity facilities, foods and beverages available at school outside of the school meals program, and psychosocial support for physical activity and healthy eating.Results. Recess, intramural programs, and access to school physical activity facilities outside of school hours can provide opportunities for health-enhancing physical activity. States, school districts, and schools can establish strong policies and implement creative interventions to promote healthy eating through the foods and beverages offered at school. Schools can offer psychosocial support for physical activity and healthy eating through school policies, administrative commit ment, role modeling by school staff, and the use of cues and incentives.Conclusions. Enough is known from theory, practice, and research to suggest that school-based environmen tal strategies to promote physical activity and healthy eating among young people merit implementation and ongoing refinement.

Measuring Implementation of School Programs and Policies to Promote Healthy Eating and Physical Activity among Youth

Article

Aug 2000

Background. The measurement of program implementation and policy adoption is an essential evaluation component of any health intervention program. Data on program implementation are used to monitor program progress; identify elements of a program to be strengthened or eliminated; provide accountability; and help explain program effects.Method. This paper reviews approaches to measuring the implementation of school-based programs and policy to promote physical activity and healthful eating among youth. Areas examined include classroom instruction, food service, physical activity classes, and school policies. Operational definitions of implementation and methods of collecting data are described and compared.Results. Most implementation measures are focused on two dimensions: quantity (dose or completeness) and quality (fidelity). Data collection methods include the use of teacher self-report recorded through checklists, questionnaires, and interviews. Classroom observations by a trained observer are also used. Studies of policy development have used archival records and semi-structured interviews.Conclusions. Considerable variability exists across studies in how program of implementation is defined and measured. This is in part due to the need to tie measures closely to the content and format of the intervention. More work is needed to assess and compare the reliability and validity of various approaches to measuring implementation.

Operational Design and Quality Control in the CATCH Multicenter Trial

Article

Jul 1996

Background.The Child and Adolescent Trial for Cardiovascular Health (CATCH) was the first multicenter school-based research study to employ the fundamentals of clinical trials including the standardized protocol and Manuals of Operation, a steering committee for study governance, a distributed data system, an extensive quality control system, and a Data and Safety Monitoring Board.Method.CATCH tested the effectiveness of changes in school lunches, physical education, smoking policy, curricula, and family activities. Ninety-six elementary schools in four states were randomized to intervention or control conditions. The baseline cohort comprised 5,106 ethnically diverse third graders followed through fifth grade.Results.The percentages of calories from fat and saturated fat were reduced significantly more in the intervention school lunches than among the controls. Significant increases in moderate to vigorous activity levels in existing physical education classes were made as well. Changes in self-reported dietary, physical activity, and psychosocial measures were significant. There were no significant differences in the physiological measures. Measurement error was generally low for all physiologic measures except skinfolds, indicating a high level of reliability. Across all sites, the coefficients of variation for lipids, height, and weight were less than 3%, whereas for skinfolds, they were considerably higher, ranging from 6 to 8%. Intraclass correlations for lipid studies were also uniformly high at 0.99. Interobserver agreement scores for SOFIT were greater than 90% for 9 of the 11 activities observed. Data entry error rates were low with less than five errors per 1,000 fields for all forms.Conclusions.The CATCH results provided more scientific evidence on the importance of schools in the population approach to health promotion. Many of the strategies used in this complex multicenter trial in the areas of design and analysis, measurement, training, data management, and quality control protocols might be appropriate for adoption in other studies.

Changes in the Nutrient Content of School Lunches: Results from the CATCH Eat Smart Food Service Intervention

Article

Jul 1996

Background: The Child and Adolescent Trial for Cardiovascular Health (CATCH) tested the effectiveness of a multilevel intervention aimed at promoting a healthful school environment and positive eating and physical activity behaviors in children. The CATCH Eat Smart Program targeted the school food service staff and aimed to lower the total fat, saturated fat, and sodium content of school meals. Methods: The Eat Smart intervention was conducted in 56 intervention schools over a 2(1/2)-year period.+Five consecutive days of school menu, recipe, and vendor product information were collected from intervention and control schools at three intervals, Fall 1991, Spring 1993, and Spring 1994, to assess the nutrient content of school menus as offered. Results: There was a significantly greater mean reduction in the percentage of calories from total fat (adjusted mean difference -4.1%; P < 0.0001) and saturated fat (adjusted mean difference -1.3%; P = 0.003) in intervention compared with control schools from baseline to follow-up. Although the sodium content of school lunches increased in both conditions, the mean increase was significantly lower in intervention schools (adjusted mean difference -89 mg; P = 0.034). There were no statistically significant differences for total amounts of cholesterol, carbohydrate, protein, dietary fiber, total sugars, calcium, iron, vitamin A value, and vitamin C. Average total calories decreased significantly; however, the mean total calories (683 kcal) for intervention schools remained above one-third of the Recommended Dietary Allowances for this age group. Conclusions: The CATCH Eat Smart intervention successfully lowered the total fat and saturated fat content of school lunches as offered, while maintaining recommended amounts of calories and essential nutrients.

Operational Design and Quality Control in the CATCH Multicenter Trial

Article

Jul 1996

The Child and Adolescent Trial for Cardiovascular Health (CATCH) was the first multicenter school-based research study to employ the fundamentals of clinical trials including the standardized protocol and Manuals of Operation, a steering committee for study governance, a distributed data system, an extensive quality control system, and a Data and Safety Monitoring Board. CATCH tested the effectiveness of changes in school lunches, physical education, smoking policy, curricula, and family activities. Ninety-six elementary schools in four states were randomized to intervention or control conditions. The baseline cohort comprised 5, 106 ethnically diverse third graders followed through fifth grade. The percentages of calories from fat and saturated fat were reduced significantly more in the intervention school lunches than among the controls. Significant increases in moderate to vigorous activity levels in existing physical education classes were made as well. Changes in self-reported dietary, physical activity, and psychosocial measures were significant. There were no significant differences in the physiological measures. Measurement error was generally low for all physiologic measures except skinfolds, indicating a high level of reliability. Across all sites, the coefficients of variation for lipids, height, and weight were less than 3%, whereas for skinfolds, they were considerably higher, ranging from 6 to 8%. Intraclass correlations for lipid studies were also uniformly high at 0.99. Interobserver agreement scores for SOFIT were greater than 90% for 9 of the 11 activities observed. Data entry error rates were low with less than five errors per 1,000 fields for all forms. The CATCH results provided more scientific evidence on the importance of schools in the population approach to health promotion. Many of the strategies used in this complex multicenter trial in the areas of design and analysis, measurement, training, data management, and quality control protocols might be appropriate for adoption in other studies.

Pricing Strategy to Promote Fruit and Vegetable Purchase in High School Cafeterias

Article

Oct 1997
J AM DIET ASSOC

Outcomes of a High School Program to Increase Fruit and Vegetable Consumption: Gimme 5 - A Fresh Nutrition Concept for Students

Article

Aug 1998

This paper describes an intervention to increase high school students' fruit and vegetable consumption. Twelve schools were randomized to intervention or control conditions. The cohort (2,213 students; 56% females, 84% Caucasian) were followed from 9th to 12th grades. Interventions comprised a media campaign, classroom workshops, school meal modification, and parental support. Usual daily servings of fruit/vegetables increased 14% in the intervention compared to the control group (p > 0.001) the first three years. At follow-up, consumption within the control group also increased, resulting in no significant difference between groups. Intervention group knowledge scores and awareness indicators were significantly higher than those of the control group (p < 0.0001). Gimme 5 provided a first model to show that dietary habits of high school students can be influenced by positive media messages relative to that age group, increased exposure to a variety of tasty products, and minimal classroom activity.

School-Based approaches for preventing and treating obesity

Article

Apr 1999

M Story

Schools have the potential to make valuable contributions to both the prevention and treatment of childhood obesity. This article reviews the research on school-based interventions to prevent and treat obesity. A literature search from 1965 to the present on school-based treatment of obesity, identified 11 controlled experimental studies. The results show positive, though modest short-term results. Relatively few primary prevention research studies, targeted specifically to preventing obesity, have been conducted. Therefore, efficacy has not been established. Both primary and secondary obesity interventions have a role in schools. A comprehensive, integrated model for school-based obesity prevention is presented. This model, building upon the comprehensive school health program model, consists of eight interacting components: health instruction; health services; school environment; food service; school-site health promotion for faculty and staff; social support services; physical education classes; and integrated and linked family and community health promotion efforts. While multi-faceted community-wide efforts are needed to address the growing problem of obesity, schools are in a unique position to play a pivotal role in promoting healthy lifestyles and helping to prevent obesity.

Small Taxes on Soft Drinks and Snack Foods to Promote Health

Article

Jul 2000

Health officials often wish to sponsor nutrition and other health promotion programs but are hampered by lack of funding. One source of funding is suggested by the fact that 18 states and 1 major city levy special taxes on soft drinks, candy, chewing gum, or snack foods. The tax rates may be too small to affect sales, but in some jurisdictions, the revenues generated are substantial. Nationally, about $1 billion is raised annually from these taxes. The authors propose that state and local governments levy taxes on foods of low nutritional value and use the revenues to fund health promotion programs.

Pricing and promotion effects on low-fat vending snack purchases: The CHIPS study

Article

Feb 2001

This study examined the effects of pricing and promotion strategies on purchases of low-fat snacks from vending machines. Low-fat snacks were added to 55 vending machines in a convenience sample of 12 secondary schools and 12 worksites. Four pricing levels (equal price, 10% reduction, 25% reduction, 50% reduction) and 3 promotional conditions (none, low-fat label, low-fat label plus promotional sign) were crossed in a Latin square design. Sales of low-fat vending snacks were measured continuously for the 12-month intervention. Price reductions of 10%, 25%, and 50% on low-fat snacks were associated with significant increases in low-fat snack sales; percentages of low-fat snack sales increased by 9%, 39%, and 93%, respectively. Promotional signage was independently but weakly associated with increases in low-fat snack sales. Average profits per machine were not affected by the vending interventions. Reducing relative prices on low-fat snacks was effective in promoting lower-fat snack purchases from vending machines in both adult and adolescent populations.

“Healthy-Start”: Outcome of an Intervention to Promote a Heart Healthy Diet in Preschool Children

Article

Mar 2002

We evaluated the effects of a preschool nutrition education and food service intervention "Healthy Start," on two-to-five-year-old children in nine Head Start Centers in upstate NY. The primary objective was to reduce the saturated fat (sat-fat) content of preschool meals to <10% daily energy (E) and to reduce consumption of sat-fat by preschoolers to <10% E. Six centers were assigned to the food service intervention and three to control condition. Food service intervention included training workshops for cooks and monthly site visits to review progress towards goals. Child dietary intake at preschool was assessed by direct observation and plate waste measurement. Dietary intake at home was assessed by parental food record and telephone interviews. Dietary data were collected each Fall/Spring over two years, including five days of menus and recipes from each center. Dietary data were analyzed with the Minnesota NDS software. Consumption of saturated fat from school meals decreased significantly from 1.0%E to 10.4%E after one year of intervention and to 8.0%E after the second year, compared with an increase of 10.2% to 13.0% to 11.4%E, respectively, for control schools (p < 0.001). Total caloric intake was adequately maintained for both groups. Analysis of preschool menus and recipes over the two-year period of intervention showed a significant decrease in sat-fat content in intervention preschools (from 12.5 at baseline to 8.0%E compared with a change of 12.1%E to >11.6%E in control preschools (p < 0.001)). Total fat content of menus also decreased significantly in intervention schools (31.0% to >25.0%E) compared with controls (29.9% to >28.4%E). The Healthy Start food service intervention was effective in reducing the fat and saturated fat content of preschool meals and reducing children's consumption of saturated fat at preschool without compromising energy intake or intake of essential nutrients. These goals are consistent with current U.S Dietary Guidelines for children older than two years of age.

Gimme 5: an innovative, school-based nutrition intervention for high school students

Article

Apr 2002
J AM DIET ASSOC

School-based health education programs can be maintained over time: Results from the CATCH Institutionalization study

Article

May 2004

Developing and evaluating interventions to influence students' opportunities for healthful choices has been a focus of school-based health promotion research; however, few studies have examined the sustainability of these programs and viability of continued organizational implementation. The purpose of this study was to determine the maintenance of Child and Adolescent Trial for Cardiovascular Health (CATCH) school-level changes in former intervention (n = 56) and former comparison (n = 20) schools 5 years post-intervention. Twelve schools unexposed to CATCH were measured as controls. Macronutrient content of 5 days of school lunch menus, amount and type of physical education (PE) classes, and health instruction practices in the classroom were assessed. An institutionalization score for schools was developed, using program maintenance variables: % kcal from fat and saturated fat in school lunches, % PE class spent in vigorous and moderate-to-vigorous physical activity, and class time devoted to CATCH topics. Menus from 50% of former intervention cafeterias met the Eat Smart guidelines for fat, compared to 10% of former control cafeterias and 17% of unexposed school cafeterias (P < 0.005). There were no significant differences in implementation of CATCH PE goals between conditions. Although the total time spent teaching CATCH was low in former CATCH schools, the former intervention schools spent significantly more time teaching CATCH and taught more lessons as compared to former comparison schools. Former intervention schools had a higher mean institutionalization score than former comparison schools (P < 0.001). Training had the greatest impact on maintenance of CATCH. Results from this study suggest that changes in the school environment to support healthful behaviors can be maintained over time. Staff training is an important factor in achieving institutionalization of these programs.

Getting children to eat more fruit and vegetables: A systematic review

Article

Mar 2006

There is growing recognition of the need to increase consumption of currently suboptimal levels of fruit and vegetables by children, given their known beneficial effects for health. There is, however, a need for a synthesis of the evidence on interventions that might achieve this policy goal. A systematic review of published and unpublished studies was carried out by searching 14 publication databases and contacting experts in the fields. All papers in eight languages were considered if they described individual- and population-based interventions and promotion programmes that encouraged the consumption of a diet relatively higher in fruit and/or vegetables in free-living, not acutely ill children of both genders, with follow-up periods of at least 3 months, measurement of change in intake and a control group. Fifteen studies focusing on children met the criteria for inclusion in the systematic review. None of the studies reviewed had a detrimental effect on fruit and vegetable consumption. Ten studies had a significant effect, ranging from +0.3 to +0.99 servings/day. More research is needed to examine in more depth, for longer follow-up periods, the effectiveness of interventions promoting fruit and vegetable consumption. The evidence is strongest in favor of multi-component interventions to increase fruit and vegetable consumption in children.

Influencing healthful food choices in school and home environments: Results from the TEENS study

Article

Aug 2006

The purpose of this research is to examine the effects of an intervention designed to increase the availability of fruits, vegetables and lower fat foods in homes and schools. This research is part of the TEENS study, a school-based intervention study. Sixteen schools in Minnesota were recruited to be in the study, and approximately 3600 middle school students in the eight intervention schools were exposed to a multi-component intervention. The TEENS intervention included classroom-based curricula, family newsletters, and changes in the school food environment including increasing more healthful options on a la carte and on the school lunch line. In addition to student-level outcomes, changes in availability of fruits, vegetables, and lower fat snacks in home and school environments were evaluated. The TEENS study was conducted from 1997 to 2000. Parents of students in intervention schools reported making healthier choices when grocery shopping as compared to parents of students in control schools (P = 0.01). No intervention effects were evident from a home food inventory. Compared to control schools, intervention schools offered (P = 0.04) and sold (P = 0.07) a higher proportion of healthier foods on a la carte, but no effects were seen for fruit and vegetables sales as part of the regular meal pattern lunch. Our results show mixed results for positively influencing adolescents' school and home environments.

Exploring changes in middle-school student lunch consumption after local school food service policy modifications

Article

Oct 2006

This study assessed the impact of changes in school food policy on student lunch consumption in middle schools. Two years of lunch food records were collected from students at three middle schools in the Houston, Texas area. During the first year, no changes occurred in the school food environment. After that school year was completed, chips and dessert foods were removed from the snack bars of all schools by the Food Service Director. Students recorded the amount and source of food and beverage items consumed. Point-of-service purchase machines provided a day-by-day electronic data file with food and beverage purchases from the snack bars during the 2-year period. Independent t-tests and time series analyses were used to document the impact of the policy change on consumption and sales data between the two years. In general, student consumption of sweetened beverages declined and milk, calcium, vitamin A, saturated fat and sodium increased after the policy change. Snack chips consumption from the snack bar declined in year 2; however, consumption of snack chips and candy from vending increased and the number of vending machines in study schools doubled during the study period. Ice cream sales increased significantly in year 2. Policy changes on foods sold in schools can result in changes in student consumption from the targeted environments. However, if all environments do not make similar changes, compensation may occur.

Students' Perceptions of the Impact of Nutrition Policies on Dietary Behaviors

Article

Jan 2007

Poor dietary habits, rising rates of overweight students, and lack of oversight of vending contracts prompted the Los Angeles Unified School District (LAUSD) to develop and implement 2 of the most comprehensive nutrition policies in the country. The Healthy Beverage Resolution and Obesity Prevention Motion limit the types of and access to beverages and snacks on school campuses. This study used qualitative and quantitative methods to document the development, implementation, and impact of the LAUSD nutrition policies. Questionnaires were administered to 399 12th-grade students in 2 LAUSD high schools to determine knowledge of the policies, perceptions of the impact of the policies on student dietary behaviors, and attitudes toward the policies and the school nutrition environment. Over one half of all students indicated that the policies impacted the foods and beverages they consumed at school, whereas only about one fifth indicated the policies impacted what they ate or drank at home/outside of school. However, for those students who indicated the policies had an impact, they reported they ate or drank fewer of the banned items both at school and at home/outside of school. These results point to the need for additional research to determine if school policies impact student behaviors outside of the school setting. Removing unhealthy food items from schools may not be enough to improve student's overall dietary behaviors. A coordinated multilevel approach including nutrition education, physical education, and parental involvement along with policies and modifications in food service is recommended.

Improving the School Food Environment: Results from a Pilot Study in Middle Schools

Article

Apr 2007
J AM DIET ASSOC

Our objective for this study was to examine the feasibility of instituting environmental changes during a 6-week pilot in school foodservice programs, with long-term goals of improving dietary quality and preventing obesity and type 2 diabetes in youth. Participants included students and staff from six middle schools in three states. Formative assessment with students and school staff was conducted in the spring of 2003 to inform the development of school foodservice policy changes. Thirteen potential policy goals were delineated. These formed the basis for the environmental change pilot intervention implemented during the winter/spring of 2004. Questionnaires were used to assess the extent to which the 13 foodservice goals were achieved. Success was defined as achieving 75% of goals not met at baseline. Daily data were collected on goal achievement using the schools' daily food production and sales records. Qualitative data were also collected after the pilot study to obtain feedback from students and staff. Formative research with staff and students identified potential environmental changes. Most schools made substantial changes in the National School Lunch Program meal and snack bar/a la carte offerings. Vending goals were least likely to be achieved. Only one school did not meet the 75% goal achievement objective. Based on the objective data as well as qualitative feedback from student focus groups and interviews with students and school staff, healthful school foodservice changes in the cafeteria and snack bar can be implemented and were acceptable to the staff and students. Implementing longer-term and more ambitious changes and assessing cost issues and the potential enduring impact of these changes on student dietary change and disease risk reduction merits investigation.

Addressing the Epidemic of Childhood Obesity Through School-Based Interventions: What Has Been Done and Where Do We Go From Here?

Article

Feb 2007

The obesity epidemic among children and adolescents in the United States continues to worsen. The most recent analysis of data from the National Health and Nutrition Examination Survey showed that the prevalence of overweight among children and adolescents – defined as a Body Mass Index (BMI) at or above the 95th percentile on gender-specific BMI-for-age growth charts developed by the Centers for Disease Control and Prevention (CDC) – increased significantly between 1999-2000 and 2003-2004. Over this period, the prevalence of overweight among children and adolescents aged 2-19 increased 23% – from 13.9% to 17.1%. In 2003-2004, 18.8% of children aged 6-11 and 17.4% of adolescents aged 12-19 were overweight. Roughly comparable proportions of each age group were considered to be at risk of becoming overweight (BMI equal to or higher than the 85th percentile and less than the 95th percentile).

Measuring Progress on School Wellness Policies: Are Nutrition Standards Making the Grade?

Article

Sep 2007
J AM DIET ASSOC

Jennifer A Weber

The Competitive Food Conundrum: Can Government Regulations Improve School Food?

Article

May 2007
DUKE LAW J

Increasing concerns over children's health have focused the nation's attention on what children are eating, especially in school. Lawmakers and advocates have cause to be optimistic that the intense focus on children's health and school nutrition will create of wave of competitive food reforms; previous determined efforts met with a modicum of success. Essentially, regulation of competitive foods was rolled back to its 1970 status, with the addition of a new narrow category of Foods of Minimal Nutritional Value (FMNV). The burgeoning junk food and soda sales that followed inexorably led to worsening student health. Soda-ban organizers, aware of the financial arguments that ultimately jettisoned previous competitive food restrictions, insisted this time that health issues be paramount and considered apart from financial ones and described the need to break the pernicious link between unhealthy products and supplemental funding for schools. Studies have increasingly connected competitive foods in general, and soft drink consumption in particular, to weight gain and nutritional deficits. There must be a national conversation about how best to ensure children's health, a conversation that embraces not only the radical improvement of school food, but includes all unhealthy societal influences that have proven detrimental to children's nutritional and developmental well-being.

Development of a School Nutrition–Environment State Policy Classification System (SNESPCS)

Article

Nov 2007
AM J PREV MED

As policy strategies are rapidly being developed to address childhood overweight, a system was developed to systematically and reliably classify state policies related to the school nutrition environment. This study describes the development process, the inter-rater reliability to code state policies enacted as of December 2003, and the variability in state policies related to the school nutrition environment. The development of the School Nutrition Environment State Policy Classification System (SNESPCS) included a comprehensive review of published literature, reports from government and nongovernmental sources, input from an expert panel, and select experts. Baseline statutes and regulations for each of the 50 states and the District of Columbia were retrieved from Westlaw (data retrieved in 2005-2006 and analyzed in 2006) and pilot testing of the system was conducted. SNESPCS included 11 policy areas that relate to a range of environmental and surveillance domains. At baseline, states had no (advertising/promotion and preferential pricing) or modest (school meal environment, reimbursable school meals, coordinating or advisory councils, body mass index screening) activities in many of the policy areas. As of 2003, 60% of the states had policies related to the sale of foods in school that compete with the school meal program. Evaluation of policies that affect the school-nutrition environment is in its earliest stage. SNESPCS provides a mechanism for assessing variation in state policies that can be incorporated in an evaluation framework aimed at elucidating the impact of state policies on the school environment, social norms, and children's dietary behaviors in schools.

Comparative Analysis of Nutrition Policies in the WHO European Region. World Health Organization-Regional Office for Europe

Dec 2006

U Trubswasser
F Branca
C Tirado

Trubswasser, U., Branca, F., Tirado, C., 2006. Comparative Analysis of Nutrition Policies in the WHO European Region. World Health Organization-Regional Office for Europe, Denmark. http://www.euro.who.int/Document/NUT/Instanbul_conf_%20ebd02. pdf (accessed Dec 2007).

Free school fruit — sustained effect three years later Portaria Interministerial n.1010. Diretrizes para a promoção da alimentação saudável nas escolas de educação infantil, fundamental e nível médio das redes públicas e privadas

Jan 2007

E Bere
M B Veierod
O Skare
K I Klepp

Bere, E., Veierod, M.B., Skare, O., Klepp, K.I., 2007. Free school fruit — sustained effect three years later. Int. J. Behav. Nutr. Phys. Act. 4, 5. Brasil. Ministério da Saúde. Ministério da Educação, 2006. Portaria Interministerial n.1010. Diretrizes para a promoção da alimentação saudável nas escolas de educação infantil, fundamental e nível médio das redes públicas e privadas, em âmbito nacional. http://dtr2004.saude.gov.br/nutricao/legislacao.php (accessed Dec 2007).

Hungry for success: a whole school approach to school meals in Scotland

Scotland

Scotland. HM Inspectorate of Education., 2007. Hungry for success: a whole school approach to school meals in Scotland. http://www.scotland.gov.uk/consultations/ education/hfsc-00.asp (accessed Dec 2007).

Do school based food and nutrition policies improve diet and reduce obesity?

Abstract

No full-text available

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