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Universal school lunch programme closes a socioeconomic gap in fruit and vegetable intakes among school children in Japan


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Background: Universal school lunch programmes are expected to cover all children equally, compared with selective programmes that may stigmatize socially vulnerable children. However, the effectiveness of universal programmes in closing dietary disparity has not been empirically proven. We evaluated whether Japan's universal school lunch programmes contribute to a reduction in the socioeconomic status (SES)-related gradient in fruit and vegetable intakes. Methods: We analyzed data for 719 school children aged 6-12 years in a population-based survey conducted in the greater Tokyo metropolitan area. We measured dietary intakes using a validated self-administered brief diet history questionnaire for young children (BDHQ-10 y). We assessed parental education, annual household income and maternal employment status as SES indicators of children. We used multiple regression to estimate mean fruit and vegetable intakes by parental education and household income, and the contribution of school lunch to reducing the SES-related gradient in fruit and vegetable intakes. Results: Compared with children with high maternal education (>15 years), those with low maternal education (<13 years) had less vegetable intake by 22.3 g/1000 kcal (95% confidence interval = 12.5, 32.2) and less fruit intake by 7.5 g/1000 kcal (95% confidence interval = -2.4, 17.3). However, fruit and vegetable intakes from school lunch did not vary by SES, indicating that school lunch intake alleviated the SES-related gradient of total vegetable intake by 9.9% and that of fruit intake by 3.4%. Conclusions: Universal school lunch programmes can partially contribute to a reduction in the SES-related gradient in dietary intakes.
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The European Journal of Public Health, Vol. 28, No. 4, 636–641
The Author(s) 2018. Published by Oxford University Press on behalf of the European Public Health Association.
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doi:10.1093/eurpub/cky041 Advance Access published on 26 March 2018
Universal school lunch programme closes a
socioeconomic gap in fruit and vegetable intakes
among school children in Japan
Mai Yamaguchi, Naoki Kondo, Hideki Hashimoto
Department of Health and Social Behavior, School of Public Health, The University of Tokyo, Tokyo, Japan
Correspondence: Naoki Kondo, Department of Health and Social Behavior, School of Public Health, The University of
Tokyo, Hongo 7-3-1 Faculty of Medicine Building #3, S310, Bunnkyo-ku, Tokyo 113-0033, Japan, Tel: +81 (0) 3 5841 3513,
Fax: +81 (0)3 5684 6083, e-mail:
Background: Universal school lunch programmes are expected to cover all children equally, compared with
selective programmes that may stigmatize socially vulnerable children. However, the effectiveness of universal
programmes in closing dietary disparity has not been empirically proven. We evaluated whether Japan’s universal
school lunch programmes contribute to a reduction in the socioeconomic status (SES)-related gradient in fruit and
vegetable intakes. Methods: We analyzed data for 719 school children aged 6–12 years in a population-based
survey conducted in the greater Tokyo metropolitan area. We measured dietary intakes using a validated self-
administered brief diet history questionnaire for young children (BDHQ-10 y). We assessed parental education,
annual household income and maternal employment status as SES indicators of children. We used multiple
regression to estimate mean fruit and vegetable intakes by parental education and household income, and the
contribution of school lunch to reducing the SES-related gradient in fruit and vegetable intakes. Results:
Compared with children with high maternal education (>15 years), those with low maternal education
(<13 years) had less vegetable intake by 22.3 g/1000 kcal (95% confidence interval = 12.5, 32.2) and less fruit
intake by 7.5 g/1000 kcal (95% confidence interval = 2.4, 17.3). However, fruit and vegetable intakes from
school lunch did not vary by SES, indicating that school lunch intake alleviated the SES-related gradient of total
vegetable intake by 9.9% and that of fruit intake by 3.4%. Conclusions: Universal school lunch programmes can
partially contribute to a reduction in the SES-related gradient in dietary intakes.
Accumulated evidence shows that poor diet and unfavourable
weight statuses are more prevalent among socioeconomically
disadvantaged children.
More specifically, fruit and vegetable
intakes were found to be lower among impoverished children than
among their richer counterparts.
Because childhood diets affect
health throughout life, measures to improve childhood diets are
regarded as an important agenda in public health policies.
One strategy to improve the diet of children is to provide better
access to nutritious food at schools. Evidence supports the notion
that school lunch programmes improve diet quality and food
security among children,
especially those of low socioeconomic
status (SES).
School lunch programmes are often selectively
provided to children with socioeconomic difficulties. This selective
approach can efficiently reach populations in need but it may also
run the risk of stigmatizing children of low SES among their
Universal school lunch programmes may close the socioeconomic
disparity in nutrition among children in a more inclusive manner. In
Japan, universal school lunch programmes have been implemented
in the local municipalities in 1947
and expanded to cover 98.4% of
all elementary school children under a strict standardized
nationwide protocol for dietary contents.
In general, all children
in the same school are served with the same menu, except for
children with specific needs. All children have the lunch in a
classroom with their teachers and peers, as Basic Law on Shokuiku
has mentioned that the lunch is recognized as an opportunity for
education on diet, social manners and socialization in Japanese
primary education. The other features of school lunch in Japan
were described elsewhere.
Although previous studies have shown
that school lunch in Japan contributes to healthier nutrition intake
among Japanese school children,
evidence is scarce on the effects
of universal lunch programmes on reducing nutritional disparity
among school children.
The National Health Nutrition Surveys in 2010 and 2014 revealed
socioeconomic disparities in dietary intake, especially fruit and
vegetable intakes, among Japanese adults,
and similar disparities
are highly likely to exist among children. In this study, we aimed to
(i) examine the levels of socioeconomic disparity in fruit and
vegetable intakes among Japanese school children in metropolitan
setting and (ii) evaluate whether universal school lunch programmes
can close the gap if it exists.
Data sources
We used data from the Japanese Study on Stratification, Health,
Income and Neighbourhood (J-SHINE). Details of J-SHINE were
described elsewhere.
The participants were randomly selected from
community-dwelling residential records of people aged 25–50 years
in four municipalities in the greater Tokyo area. The original first-
wave survey was conducted in 2010, followed by supplemental
surveys for children aged under 18 years in 2011 and 2013. Among
the 2428 participating children, we used the data for 868 school
636 European Journal of Public Health
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children who went to public elementary schools (aged 6–12 years in
Japan). We asked the participating children to answer a dietary habit
questionnaire in 2013, the details of which are described briefly. We
excluded dietary report data that included energy intake estimates in
an outlier range (n= 39), following the criteria proposed in a
previous study.
We also excluded data for children who lacked
information on annual household income, parental education or
maternal employment (n= 110). Consequently, we analyzed the
data for 719 school children.
Fruit and vegetable intakes
The J-SHINE survey assessed vegetable and fruit intakes and total
energy intakes using the self-administered brief diet history ques-
tionnaire-10y (BDHQ-10y),
modified from a validated original
BDHQ for adults.
The children themselves filled in the question-
naire, with help from their primary caretakers if necessary. The
questionnaire initially examined the frequency of 54 food items
from sources other than school lunch, assuming average portion
sizes. The questionnaire then assessed food intakes from school
lunch for six items (rice/bread, meat, fish, vegetables, fruit and
milk) with a response set comprising ‘rarely eat’, ‘leave half of
dish’, ‘leave some of dish’, ‘eat all’, ‘sometimes have second
helpings’ and ‘often have second helpings’, by assuming a
nationwide standardized protocol for food components of school
The total intake was estimated by adding the intake
estimated from school lunch and that from other sources. The
validity of the total fruit and vegetable intakes was confirmed by
significant correlations with serum carotenoid concentrations in a
previous study but not by the duplicate method.
Finally, we
evaluated the contributions of school lunch to fruit and vegetable
intakes per total daily intakes.
Socioeconomic status
Following the guidelines of a recent study on social determinants of
we used annual household income, maternal and paternal
educational attainments and maternal employment status as
indicators of children’s SES. Although these indicators are likely to
correlate with each other, we specifically used income as an indicator
of household purchasing capacity while parental educational attain-
ments reflected knowledge and attitude towards healthier eating
habits. Maternal employment status may reflect availability for
meal preparation, which can have a high impact on children’s
diet. Annual household income was assessed by 15 categories. We
used the median value of each category and obtained an equivalent
household income based on a previous study.
It was examined
using six responses and re-categorized into three groups: low
(12 years), medium (13–15 years) and high (16 years). It was
examined by nine categories and re-categorized into four groups:
full-time worker (manager/executive and regular employee),
part-time worker (contract/temporary/fixed-term employee),
homemaker (unemployment) and other job (self-employed, family
Statistical analysis
After examining descriptive statistics, we performed multiple
regression analyses for the outcomes of total daily intakes and
share of school lunch-derived intakes per total intakes. We
regarded SES indicators (household income, maternal and paternal
educational attainments and maternal employment status) as main
explanatory variables, adjusting for children’s sex, age and munici-
pality of residence as covariates because school lunch provision is
under municipality management. We used robust standard errors to
consider intraclass correlations among children in the same
household. We conducted analyses with and without log-
transformed values of outcomes and found similar results.
Consequently, we report the results without log-transformation for
ease of interpretation. Finally, we estimated least-square means of
intakes by the levels of SES indicators. Throughout the analyses, we
combined the data for girls and boys because our preliminary
analyses showed similar values for the associations between SES
and fruit and vegetable intakes in both sexes. All analyses were
conducted using STATA statistical software, version 13.1 SE (Stata
Corporation, Collage Station, TX).
The mean age of the participants was 9.3 years, and 51.2% of the par-
ticipants were boys. The mean vegetable intake was 209.4 g/day and the
mean fruit intake was 123.4 g/day. Overall, 26% of mothers and 55% of
fathers graduated from college or higher education (table 1).
Maternal education was significantly related to vegetable intake. By
reference to children with high maternal education (>15 years), those
with low maternal education (<13years) were estimated to have 22.3 g
[95% confidence interval (CI) = 12.5, 32.2] less vegetable intake per
1000 kcal intake. The corresponding value for fruit intake was 7.5 g
(95% CI = 2.4, 17.3). Meanwhile, paternal education was not
associated with both fruit and vegetable intakes (data not shown).
Every 1 million yen unit increase in annual household income was
associated with 2.4 g/1000 kcal (95% CI = 0.2, 4.6) more fruit intake
(table 2). Among children with low maternal education, the share of
school lunch in vegetable intake was 7.4% (95% CI= 4.2, 10.6) higher
than that for children with high maternal education. The share of
school lunch in fruit intake for children with higher household
Table 1 Participant characteristics
Variables n(%) or
mean (SD)
Boys 368 (51.2)
Age 9.3 (1.7)
1st grade 126 (17.5)
2nd grade 106 (14.7)
3rd grade 122 (17.0)
4th grade 127 (17.5)
5th grade 111 (15.4)
6th grade 124 (17.2)
Dietary intake Vegetable intake (g) 209.4 (88.3)
Fruit intake (g) 123.4 (91.0)
Vegetable intake (g/1000 kcal) 115.4 (47.0)
Fruit intake (g/1000 kcal) 66.6 (45.4)
Total energy intake (kcal) 1852 (431.3)
Share of vegetable intake from
school lunch (%)
39.1 (14.9)
Share of fruit intake from school
lunch (%)
20.6 (17.1)
Maternal education Low (<13 years) 210 (29.6)
Medium (13–15 years) 319 (44.4)
High (>15 years) 190 (26.4)
Paternal education Low (<13 years) 184 (25.6)
Medium (13–15 years) 140 (19.5)
High (>15 years) 395 (54.9)
Household income
(million yen)
3.48 (1.6)
Full-time 78 (10.8)
Part-time 228 (31.7)
Homemaker 370 (51.5)
Other job 43 (6.0)
Notes. SD, standard deviation. Share of vegetable intake from
school lunch (%) = (vegetable intake from school lunch/total
vegetable intake) 100. Share of fruit intake from school lunch
(%) = (fruit intake from school lunch/total fruit intake) 100.
Maternal employment status: ‘homemaker’ includes unemploy-
ment and ‘other job’ refers to self-employment or family worker.
Universal school lunch program closes a socioeconomic gap 637
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income was 0.8% (95% CI = 1.6, 0.0) lower than that for children
with lower household income (table 2).
The fruit and vegetable intakes from school lunch did not vary
large by SES, despite the existence of SES-based differences in the
total amounts of fruit and vegetable intakes (figure 1). Thus, school
lunch contributed to a reduction in the inequality of vegetable intake
by 9.9% and fruit intake by 3.4% (table 3).
The key findings of this study are as follows. First, maternal
education was associated with overall fruit and vegetable intakes
independently of other individual and household sociodemographic
characteristics, while paternal education was not. Household income
was only associated with fruit intake. These results are consistent
with those of previous studies conducted in Western countries,
showing that maternal education is positively associated with fruit
and vegetable intakes among school children.
Second, we
demonstrated that children whose mothers were less educated had
greater reliance on school lunch for their vegetable intake, and
children with lower household income had more contribution
from school lunch to their fruit intake. However, because the
serving of fruit in school lunches as well as overall fruit intake is
low in Japan compared with Western countries,
the attributable
effects of school lunch in reducing the socioeconomic disparity in
regard to fruit intake may be limited.
Our study adds new evidence that universal school lunch
programmes are effective in at least partially reducing the gap in
diet across parental SES. Lower socioeconomic children had less
access to high quality and balanced meals at home, and universal
school lunch programmes may provide greater contributions to
children in lower socioeconomic conditions.
In our study, maternal education had stronger associations with
fruit and vegetable intakes than paternal education. This may reflect
the notion that the person who usually cooks at home affects the
nutritional intake of their children. In the majority of Japanese
households, mothers are more likely to prepare most meals for their
children. According to a government nationwide survey comprising a
general survey of social life, women spend 2.5h/day on housekeeping
including meal preparation, while men spend only 0.3 h/day.
Household income was also associated with fruit intake. Fruits
might be considered ‘luxury items’. This was reflected by the
Figure 1 Average vegetable and fruit intake by household SESs, adjusting for all other socioeconomic indicators, children’s sex and age and
municipality of residence
Table 2 Associations of vegetable or fruit intake and share of vegetable or fruit intake from school lunch with SES by multiple regression
analysis among school children in Japan (n= 719)
Vegetable intake
(g/1000 kcal)
Share of vegetable intake
from school lunch (%)
Fruit intake
(g/1000 kcal)
Share of fruit intake
from school lunch (%)
Coeff. 95% CI Coeff. 95% CI Coeff. 95% CI Coeff. 95% CI
Maternal education
High (>15 years) 0.0 Ref. 0.0 Ref. 0.0 Ref. 0.0 Ref.
Medium (13–15 years) 17.5 26.1, 8.9 2.7 0.0, 5.3 5.1 13.7, 3.5 0.6 3.6, 2.5
Low (<13 years) 22.3 32.2, 12.5 7.4 4.2, 10.6 7.5 17.3, 2.4 4.2 0.5, 8.8
Household income (per 1 million yen) 1.1 3.5, 1.3 0.0 0.7, 0.8 2.4 0.2, 4.6 0.8 1.6, 0.0
Maternal employment status
Full-time 0.0 Ref. 0.0 Ref. 0.0 Ref. 0.0 Ref.
Part-time 5.5 7.3, 18.2 2.2 6.5, 2.2 1.4 11.9, 9.1 0.5 3.3, 4.4
Homemaker 3.1 8.2, 14.4 1.6 5.8, 2.5 4.8 6.1, 15.6 1.0 2.7, 4.8
Other job 10.0 2.4, 1.5 0.3 5.9, 6.5 2.0 18.7, 22.7 5.7 2.0, 13.4
Notes. CI, confidence interval; Coeff., coefficient. Share of vegetable intake from school lunch (%) = (vegetable intake from school lunch/
total vegetable intake) 100. Share of fruit intake from school lunch (%) = (fruit intake from school lunch/total fruit intake) 100.
Adjustment for: age, sex and municipality of residence.
638 European Journal of Public Health
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governmental survey of price elasticity that categorized fruit and
snacks as amenity foods.
Additionally, maternal skills and
knowledge on diet may have less effect on their children’s fruit
intake than on their vegetable intake. The correlation between
vegetable intake and income was not statistically significant. This
was not consistent with the National Health and Nutrition
A potential explanation of the inconsistency may be
the difference in age distribution between the groups. This study
focuses on children, who are more influenced by parental food
choices and household characteristics. Alternatively, the measure-
ment of income is significantly different between the studies. The
National Surveys used only three categories (2 million yen, 2–6
million yen, 6 million yen) when determining household income,
potentially more vulnerable to error. Further studies are needed to
conclude the correlation between vegetable intake and household
income in Japanese children.
Given that maternal education may reflect their skills and
knowledge on diet to serve healthy meals, it is plausible that
mothers with lower educational attainment may have difficulties in
regularly providing balanced meals at home. Maternal food prefer-
ences may also affect children’s diet. Evidence suggests strong correl-
ations between mothers and children in their vegetable and fruit
Thus, the socioeconomic gap in dietary intakes
among children is likely to be mainly derived from their home intakes.
However, we found that SES did not impact fruit and vegetable
intake from school lunch. These findings are particularly noteworthy
because they strongly suggest that universal school lunch
programmes could equally provide the opportunities for fruit and
vegetable intake to all children regardless of their SES. Nonetheless,
SES-based disparity remained at 22.3 g/1000 kcal for vegetable intake
and 7.5 g/1000 kcal for fruit intake between low and high maternal
educational attainments. To further reduce these gaps, additional
measures to secure more availability and accessibility of fruit and
vegetables through school meal programmes
and other sources
including home intakes are warranted. For example, providing
opportunities for children, in community settings, to eat balanced
meals for breakfast and dinner that are free or available at affordable
prices may help to further reduce the health disparity in diets.
Nutrition and cooking education during early childhood may also
contribute to children acquiring cooking skills and nutritional
knowledge regardless of their SES.
We used adjusted values for total and school lunch-derived fruit
and vegetable intake per 1000 kcal to account for age-related
variation in caloric intake. In studies in the USA, children of
lower SES have been found to have higher energy intake due to
excess portions and snacking. In this case, it may be more
important to reduce caloric intake rather than enhance vegetable
intake. However, studies in Japan
have not shown a clear correl-
ation between children’s SES and energy intake. In our sample,
energy intake was slightly higher among children of higher
household income.
There are limitations to this study. First, the generalizability of the
study may be limited because all participants were selected from four
municipalities in the greater Tokyo metropolitan area.
studies should evaluate the effectiveness of universal school lunch
programmes in other settings in terms of place, culture and quality
of lunch. Second, the validity of fruit and vegetable intakes specifically
from school lunch estimated by the BDHQ-10y has not yet been
examined. Compared with a school nutrition report in 2015,
total vegetable intake from school lunch was 17.5g less in this study,
while the total fruit intake from school lunch did not differ much.
These data partly support the validity of the BDHQ-10y as a tool for
nutritional analysis of Japanese school lunch. Third, some younger
children were helped to answer dietary habit questionnaire, which
may be susceptible to reporting bias by their mothers, especially
with higher education and consciousness about healthy diet.
However, sub-analysis limited to those that children answered by
themselves did not make change in the results. Household income
and parental education were self-reported; therefore, the possibility of
misclassification exists. Furthermore, we did not have information
about the curricula of the schools, which may have an effect on
student eating habits. School lunch programmes were highly
standardized by each municipality’s education authority under the
School Lunch Program Act. Hence, we included municipality
dummy codes in our regression analysis to incorporate any fixed
effects related to differences between municipalities.
Achievement of standardized universal school lunch programmes
is a challenge. Sustainability in food logistics systems and financing
for nationwide universal school lunch programmes are other topics
to be investigated. Other challenges in universal school lunch
programmes are the costs required to meet various needs for food
preferences based on religious and cultural diversity in schools.
Studies investigating the cost-effectiveness of universal lunch
programmes are warranted. Although there are some challenges,
notwithstanding this successful case in Japan—where the school
lunch program was started in 1947 under the support of United
Nations Children’s Fund (UNICEF) and the School Lunch Law
was established in 1954—we believe that the promotion of
universal school lunch programmes can be an effective vehicle for
closing the nutrition-associated gap in schoolchildren overcoming
socioeconomic challenges.
In this study, we demonstrated the effectiveness of standardized
universal school lunch programmes in partially reducing the
maternal–education-related gradient in vegetable intake and
household income-related fruit intakes in the Japanese elementary
school setting. Additional community interventions may be needed
to further close the gap in children’s dietary intake.
The authors thank Satoshi Sasaki and Satomi Kobayashi for advice
on the statistical analyses.
Table 3 Average total vegetable intake, vegetable intake from home by maternal education and average total fruit intake, fruit intake
from home by household income, adjusting for all SES indicators, children’s sex and age and municipality of residence
Maternal education Household income Ratio of
Change of
ratio (%)
(>15 years)
(<13 years)
million yen)
million yen)
Total vegetable intake (g/1000 kcal) 129.7 107.5 1.21 9.89
Vegetable intake from home (g/1000 kcal) 88.1 65.8 1.34
Total fruit intake (g/1000 kcal) 69.7 60.5 1.15 3.36
Fruit intake from home (g/1000 kcal) 61.3 51.5 1.19
Universal school lunch program closes a socioeconomic gap 639
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The Japanese Study on Stratification, Health, Income and
Neighbourhood (J-SHINE) was supported by a Grant-in-Aid for
Scientific Research on Innovative Areas (No. 21119002) from the
Ministry of Education, Culture, Sports, Science and Technology,
Japan and the Ministry of Health, Labour and Welfare, Japan
(H27–junkankitou-ippan-002, H28-junkankitou-ippan-008).
Conflicts of interest: None declared.
Key points
Parental SES was associated with overall fruit and vegetable
Children whose mothers were less educated had greater
reliance on school lunch for their vegetable intake.
Children with lower household income had more contribu-
tion from school lunch to their fruit intake.
Universal school lunch programmes can in part contribute
to a reduction in the SES-related gradient in diets.
1 Wang Y, Beydoun MA. The obesity epidemic in the United States–gender, age,
socioeconomic, racial/ethnic, and geographic characteristics: a systematic review
and meta-regression analysis. Epidemiol Rev 2007; 29:6–28.
2 Ueda P, Kondo N, Fujiwara T. The global economic crisis, household income and
pre-adolescent overweight and underweight: a nationwide birth cohort study in
Japan. Int J Obes 2015; 39:1414–20.
3 Zarnowiecki D, Ball K, Parletta N. Describing socioeconomic gradients in children’s
diets – does the socioeconomic indicator used matter? Int J Behav Nutr Phys Act
2014; 11:44.
4 Zarnowiecki DM, Dollman J, Parletta N. Associations between predictors of
children’s dietary intake and socioeconomic position: a systematic review of the
literature. Obes Rev 2014; 15:375–91.
5 Bere E, van Lenthe F, Klepp K-I, Brug J. Why do parents’ education level and
income affect the amount of fruits and vegetables adolescents eat? Eur J Public
Health 2008; 18:611–5.
6 Rasmussen M, Krølner R, Klepp K-I, et al. Determinants of fruit and vegetable
consumption among children and adolescents: a review of the literature. Part I:
quantitative studies. Int J Behav Nutr Phys Act 2006; 3:22.
7 Huang J, Barnidge E. Low-income children’s participation in the National School
Lunch Program and household food insufficiency. Soc Sci Med 2016; 150:8–14.
8 Huang J, Barnidge E, Kim Y. Children receiving free or reduced-price school lunch
have higher food insufficiency rates in summer. J Nutr 2015; 145:2161–8.
9 Longacre MR, Drake KM, Titus LJ, et al. School food reduces household income
disparities in adolescents’ frequency of fruit and vegetable intake. Prev Med 2014;
10 Robinson-O’Brien R, Burgess-Champoux T, Haines J, et al. Associations between
school meals offered through the National School Lunch Program and the School
Breakfast Program and fruit and vegetable intake among ethnically diverse, low-
income children. J Sch Health 2010; 80:487–92.
11 Bhatia R, Jones P, Reicker Z. Competitive foods, discrimination, and participation
in the National School Lunch Program. Am J Public Health 2011; 101:1380–6.
12 Egner R, Oza-Frank R, Cunningham SA. The School Breakfast Program: a view of
the present and preparing for the future – a commentary. J Sch Health 2014;
13 Marmot M, Allen J, Goldblatt P, et al. Fair Society, Healthy Lives (The Marmot
Review), Strategic Review of Health Inequalities in England post-2010.
14 Ministry of Education, Culture, Sports, Science, and Technology. Study for the
school lunch program, 2014. Available at:
chousa05/kyuushoku/1267027.htm (1 August 2016, date last accessed).
15 Asakura K, Sasaki S. School lunches in Japan: their contribution to healthier
nutrient intake among elementary-school and junior high-school children. Public
Health Nutr 2017; 20:1523–33.
16 Toshiyuki K, Naoko K, Tatsuki I, Satoshi S. Effects of the National School Lunch
Program on bone growth in Japanese Elementary School Children. J Nutr Sci
Vitaminol 2016; 62:303–9.
17 Nishi N, Horikawa C, Murayama N. Short communication characteristics of food
group intake by household income in the National Health and Nutrition Survey,
Japan. Asia Pac J Clin Nutr 2017; 26:156–9.
18 Ministry of Health Labour and Welfare. National health and nutrition survey, 2014.
Available at: (25
October 2017, date last accessed).
19 Takada M, Kondo N, Hashimoto H. J-SHINE Data Management Committee.
Japanese study on stratification, health, income, and neighborhood: study protocol
and profiles of participants. J Epidemiol 2014; 24:334–44.
20 Shinozaki K, Okuda M, Sasaki S, et al. Dietary fiber consumption decreases the risks
of overweight and hypercholesterolemia in Japanese children. Ann Nutr Metab 2015;
21 Okuda M, Sasaki S, Bando N, et al. Carotenoid, tocopherol, and fatty acid
biomarkers and dietary intake estimated by using a brief self-administered diet
history questionnaire for older Japanese children and adolescents. J Nutr Sci
Vitaminol 2009; 55:231–41.
22 Kobayashi S, Honda S, Murakami K, et al. Both comprehensive and brief self-ad-
ministered diet history questionnaires satisfactorily rank nutrient intakes in Japanese
adults. J Epidemiol 2012; 22:151–9.
23 Kobayashi S, Murakami K, Sasaki S, et al. Comparison of relative validity of food
group intakes estimated by comprehensive and brief-type self-administered diet
history questionnaires against 16 d dietary records in Japanese adults. Public Health
Nutr 2011; 14:1200–11.
24 Ministry of Education, Culture, Sports, Science, and Technology. Nutritional
standards for school lunch, 2013. Available at:
hakusho/nc/1332086.htm (4 February 2017, date last accessed).
25 Ministry of Education, Culture, Sports, Science, and Technology. The food construction
table for school lunch, 2011. Available at:
contents/0000007/7121/25.3siryou6-2.pdf (4 February 2017, date last accessed).
26 Galobardes B, Shaw M, Lawlor DA, et al. Indicators of socioeconomic position
(part 1). J Epidemiol Community Health 2006; 60:7–12.
27 Higashi K, Itoh M, Toyokawa S, Kobayashi Y. Subsidy and parental attitudes toward
pediatric health care in the Tokyo metropolitan area. Pediatr Int 2016; 58:132–8.
28 van Ansem WJ, Schrijvers CT, Rodenburg G, van de Mheen D. Maternal educa-
tional level and children’s healthy eating behaviour: role of the home food envir-
onment (cross-sectional results from the INPACT study). Int J Behav Nutr Phys Act
2014; 11:113.
29 European Food Safety Authority. The EFSA comprehensive European food con-
sumption database, 2008. Available at:
sumption/comprehensive-database (29 October 2017, date last accessed).
30 Ministry of Internal Affairs and Communications. General survey of social life, 2011.
Available at: (23 September
2017, date last accessed).
31 Saito M, Matsuo Y. Estimation of price elasticity. Econ Anal 1979; 74:94.
32 Campbell KJ, Abbott G, Spence AC, et al. Home food availability mediates associ-
ations between mothers’ nutrition knowledge and child diet. Appetite 2013; 71:1–6.
33 Ball K, Crawford D. Socio-economic factors in obesity: a case of slim chance in a fat
world? Asia Pac J Clin Nutr 2006; 15 Suppl:15–20.
34 Parmenter K, Waller J, Wardle J. Demographic variation in nutrition knowledge in
England. Health Educ Res 2000; 15:163–74.
35 Hanks AS, Just DR, Brumberg A. Marketing vegetables in elementary school
cafeterias to increase uptake. Pediatrics 2016; 138:e20151720.
36 The Asahi Shimbun. ‘Children’s cafeterias’ combat poverty, neglect in Japan, 2016.
Available at: (6 October
2016, date last accessed).
37 Baba Y, Kondo K. Case studies: hints to health Japan 21 (the second term), Adachi
vegetable life – let’s eat vegetables. Jpn J Public Heal Nurse 2016; 72:586–94.
38 Murayama N, Ishida H, Yamamoto T, et al. Household income is associated with
food and nutrient intake in Japanese schoolchildren, especially on days without
school lunch. Public Health Nutr 2017; 20:2946–58.
640 European Journal of Public Health
Downloaded from by guest on 27 March 2020
39 Kepper M, Tseng T-S, Volaufova J, et al. Pre-school obesity is inversely
associated with vegetable intake, grocery stores and outdoor play. Pediatr Obes 2016;
40 Ministry of Education, Culture, Sports, Science, and Technology. School nutrition
report, 2015. Available at:
gaiyou/1376285.htm (19 September 2016, date last accessed).
The European Journal of Public Health, Vol. 28, No. 4, 641–646
The Author(s) 2018. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
doi:10.1093/eurpub/cky062 Advance Access published on 17 April 2018
Infant abuse diagnosis associated with abusive
head trauma criteria: incidence increase due to
Ulf Ho
, Erik Lampa
¨ran Ho
, Peter Aspelin
, Fredrik Serenius
, Ingemar Thiblin
1 Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
2 UCR-Uppsala Clinical Research Centre, Uppsala University, Uppsala, Sweden
3 Child and Adolescent Psychiatric Unit, Department of Women’s and Children’s Health, Karolinska Institute, Stockholm,
4 Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden
5 Forensic Medicine, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
Correspondence: Ulf Ho
¨gberg, Uppsala University, Department of Women’s and Children’s Health, Akademiska
Sjukhuset, SE-751 85 Uppsala, Sweden, Tel: +46 186115246, Fax: +46 186115583, e-mail:
Background: The hypothesis of this study is that the diagnosis of infant abuse is associated with criteria for shaken
baby syndrome (SBS)/abusive head trauma (AHT), and that that changes in incidence of abuse diagnosis in infants
may be due to increased awareness of SBS/AHT criteria. Methods: This was a population-based register study.
Setting: Register study using the Swedish Patient Register, Medical Birth Register, and Cause of Death Register.
The diagnosis of infant abuse was based on the International Classification of Diseases, 9th and 10th revision.
Participants: All children born in Sweden during 1987–2014 with a follow-up until 1 year of age (N= 2 868 933).
SBS/AHT criteria: subdural haemorrhage, cerebral contusion, skull fracture, convulsions, retinal haemorrhage,
fractures rib and long bones. Outcomes: Incidence, rate ratios, aetiologic fractions and Probit regression
analysis. Results: Diagnosis of infant abuse was strongly associated with SBS/AHT criteria, but not risk exposure
as region, foreign-born mother, being born preterm, multiple birth and small for gestational age. The incidence of
infant abuse has increased tenfold in Sweden since the 1990s and has doubled since 2008, from 12.0 per 100 000
infants during 1997–2007 to 26.5/100 000 during 2008–2014, with pronounced regional disparities. Conclusions:
Diagnosis of infant abuse is related to SBS/AHT criteria. The increase in incidence coincides with increased medical
preparedness to make a diagnosis of SBS/AHT. Hidden statistics and a real increase in abuse are less plausible.
Whether the increase is due to overdiagnosis cannot be answered with certainty, but the possibility raises ethical
and medico-legal concerns.
In 1962 battered child syndrome was first described in a clinical
In 1972 it was proposed that subdural haematomas could
be caused by whiplash shaking
and in 1974 the term ‘shaken baby
syndrome (SBS)’ was coined to describe a condition inflicted by
violent shaking and identified by the triad retinal haemorrhage,
subdural haemorrhage and encephalopathy.
The diagnosis of
abusive head trauma (AHT), departing from the three diagnostic
criteria for SBS, now has a broader categorization that may also
include apnoea, seizures, fractures of the skull, metaphyses and
shaft of long bones and ribs, and inability of parents/carers to
provide an explanation for accidental trauma, the former findings
and symptoms being considered highly specific for non-accidental
Shaken baby syndrome/AHT is not a diagnosis classified in the
International Classification of Diseases (ICD-9/ICD-10); however,
physical abuse and battered baby or child syndrome is defined as
maltreatment syndrome. In an intercountry epidemiological study,
Gilbert et al. described the maltreatment syndrome/assault and
included in their classification the diagnoses of intracranial injury
and long bone fractures.
The incidence of maltreatment syndrome has shown a variation
by country,
from 11.5 per 100 000 infants in Sweden (1987–2009),
to 34.6 in England (1997–2008), to 118.9 in Western Australia
(1980–2005), with only England showing a declining trend.
incidence of non-fatal AHT among infants, based on the case
definition of the US Center of Disease Control and Prevention
(CDC), was 32.3 per 100 000,
while a Canadian study on infant
AHT found an incidence of 13.0–15.5 for 2002–2007.
In Scotland
in 1998–1999, the incidence of shaken impact syndrome among
infants was 24.6 per 100 000.
Shaken baby syndrome has, since 1997,
been questioned as a
diagnostic entity, and emerging imaging technology demands further
differential diagnostic considerations.
Furthermore, the precision
of the SBS/AHT diagnosisis lost when excluding the diagnostic criterion
of incompatibility between the carer’s report of history and the
investigating doctor’s interpretation of the findings.
In 2016, a
systematic literature review by the Swedish Agency for Health
Technology Assessment and Assessment of Social Service (SBU)
concluded that there is limited scientific evidence that the triad can be
explained by isolated shaking, and that there is insufficient evidence to
assess the diagnostic accuracy of the triad to identify SBS/AHT.
Infant abuse diagnosis based on criteria for abusive head trauma 641
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... Third, in contrast to an already rich body of literature on the impact of social interventions on bodyweight and mental health in Western countries, our study focuses on an East-Asian country, South Korea, and therefore adds to a scant literature that mostly focuses on Japan (Asakura & Sasaki, 2017;Ishida, 2015;Kohri et al., 2016;Murayama et al., 2017;Yamaguchi et al., 2018). Moreover, the case of South Korea is interesting in its own right because of the country's very rapid development. ...
... Evidence from Japan, which is probably most comparable to South Korea, supports this view. School lunch programs are shown to close the high-quality nutritional intake gap between students from different socio-economic backgrounds (Asakura & Sasaki, 2017;Yamaguchi et al., 2018). Assessing which of these two explanations (or yet another) is most relevant, however, is beyond the scope of our paper. ...
Full-text available
In spring 2015, the South Korean province of South Gyeongsang stopped providing free school lunches to primary and secondary school students while large portions of schools in other provinces continued to provide free lunches at school. After the provincial government faced strong opposition, South Gyeongsang reintroduced the free-school-lunch program the very next year. Using a difference-in-differences design, we exploit these policy changes to evaluate their impact on students' body mass index (BMI) and on a measure related to students’ mental health status (MH). Our results show that the abolishment of free school lunches harmed (female) underweight students by causing additional weight losses of about 4.5 percent whereas the reintroduction of free school lunches led to an average weight loss of 2.1 percent among overweight students (both male and female). Moreover, the school lunch policy changes had significant impacts on our MH measure: crying without any reason increased when the free-school-lunch policy was abolished and it decreased when the policy was reintroduced. The results are of great interest to decision makers: introducing free school lunches helps to achieve healthier weights and decreases crying without any reason and as a result, benefits student welfare. Free-school-lunch policies, therefore, may provide simple and inexpensive means to improve the health and welfare of students.
... According to the Standards, school lunches should provide more than onethirds of the daily requirement of children with medium level physical activity, shown in the Dietary Reference Intakes for Japanese. A cross-sectional study in metropolitan areas in Japan showed maternal educational status was associated with overall fruit and vegetable intakes, and household income was associated with fruit intake [18]. Therefore, universal school lunch programs may partially contribute to a reduction in the socioeconomic status related diet disparities. ...
... 99.1% of elementary schools and 89.9% of junior high school serve school lunches [16]. To date, Yamaguchi and colleagues reported that school lunch programs contribute to the reduction of socioeconomic disparities in diet intake in Japan [18]. Additionally, another cross-sectional study in Japan supported the benefits of school lunch programs [25]. ...
Full-text available
Background/objectives Although higher diet quality is related to higher socioeconomic status among adults, it is unclear whether this result could be generalized to children. Elementary and junior high school lunch programs may contribute to the reduction of socioeconomic disparities in diet quality. We examined the association between diet quality and household income level in school children in Japan according to age subgroups. Methods This cross-sectional study was conducted in 866 household members (435 men and 431 women) aged 6–18 years old from the 2014 National Health and Nutrition Survey, Japan. Dietary intake was assessed by 1 day semi-weighted household dietary record, and the Japanese Food Guide Spinning Top scores (range 0–70) were calculated. The household income was assessed by low, middle, and high. Associations between diet quality and household income levels were examined by age subgroups (6–14 years and 15–18 years), i.e., those with and without school lunch programs Results Higher dietary scores were observed in those with higher household income in the 15–18 year-olds; the multivariate adjusted mean (95% CI) of diet score was 44.3 (39.0–49.7), 48.8 (47.1–50.6), 51.6 (49.7–53.4) in children with the lowest household income level through the highest, respectively (P for trend = 0.003). However, there were no significant associations among those who were 6–14 years old. Conclusions Our findings suggest that school lunch program in elementary and junior high schools might help to reduce socioeconomic disparities in diet quality. The development of healthy food environment in high schools without school lunch programs, should also be considered.
... However, an application must be submitted for every child, a procedure that might be daunting, especially for low-educated parents. School-based lunch programs have the potential to address this problem and to facilitate access to lunch participation [2,6,22,[45][46][47]. ...
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Despite growing school lunch availability in Germany, its utilization is still low, and students resort to unhealthy alternatives. We investigated predictors of school lunch participation and reasons for nonparticipation in 1215 schoolchildren. Children reported meal habits, parents provided family-related information (like socioeconomic status), and anthropometry was conducted on-site in schools. Associations between school lunch participation and family-related predictors were estimated using logistic regression controlling for age and gender if necessary. School was added as a random effect. School lunch participation was primarily associated with family factors. While having breakfast on schooldays was positively associated with school lunch participation (ORadj = 2.20, p = 0.002), lower secondary schools (ORadj = 0.52, p < 0.001) and low SES (ORadj = 0.25, p < 0.001) were negatively associated. The main reasons for nonparticipation were school- and lunch-related factors (taste, time constraints, pricing). Parents reported pricing as crucial a reason as an unpleasant taste for nonparticipation. Nonparticipants bought sandwiches and energy drinks significantly more often on school days, whereas participants were less often affected by overweight (OR = 0.66, p = 0.043). Our data stress school- and lunch-related factors as an important opportunity to foster school lunch utilization.
... One study in Japan examining the mandatory school lunches served in elementary and junior high schools found that consuming school lunches was positively associated with total diet quality [34]. Additionally, a study conducted in the greater Tokyo area among children ages 6-12 found that providing universal (mandatory) school lunches was associated with a reduction in SES-related dietary disparities, particularly regarding fruit and vegetable consumption [80]. A smaller study conducted in one kindergarten class in New Zealand found that offering free lunches to all students in the class was associated with significant reductions in snack food consumption while at school (although this study was assessed to have a very high risk of bias) [81]. ...
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The school environment plays an important role in children’s diets and overall health, and policies for universal free school meals have the potential to contribute to positive child health outcomes. This systematic review evaluates studies examining the association between universal free school meals and students’ school meal participation rates, diets, attendance, academic performance, and Body Mass Index (BMI), as well as school finances. The search was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA). A search for studies published in economically developed countries published through December 2020 was performed in PubMed, Education Resources Information Center (ERIC), Thomson Reuters’ Web of Science, and Academic Search Ultimate, followed by examining the references in the resultant literature. A total of 47 studies were identified and the Newcastle-Ottawa Scale (NOS) was applied to assess bias. Nearly all studies examining universal free school meals found positive associations with school meal participation. Most studies examining universal free school meals that included free lunch found positive associations with diet quality, food security, and academic performance; however, the findings of studies examining only universal free breakfast were mixed. Research findings were similarly mixed when examining attendance as an outcome. Concerns about adverse outcomes on student BMI were not supported by the literature; in fact, several studies detected a potentially protective effect of universal free school meals on BMI. Research examining the impact of universal free meals on school finances was limited, but suggest that lower-income school districts in the U.S. may have positive financial outcomes from participation in universal free school meal provisions. Additionally, providing free meals to students may be associated with improved household incomes, particularly among lower-income families with children. Further research is needed to examine the financial implications of universal free meals for both school districts and families. Overall, universal free school meals may have multiple benefits for students and countries should consider universal free school meal provisions with strong nutrition guidelines. (PROSPERO registration: CRD42020221782).
... Moreover, the mean number of school lunches provided in 2018 was 191 in elementary schools and 186 in junior high schools, and the mean school lunch fee per month per capita was 4,343 yen (about USD 40) in elementary schools and 4,941 yen (about USD 45) in junior high schools. School lunch programs in elementary schools might help to reduce socioeconomic disparities in diet intake27) . It may be important to improve children's growth and a healthy food environment, for example by increasing the school lunch coverage in junior high schools.Among adolescents, a high percentage of underweight (19.8%) was observed in 2015, reflecting a gradual increase over the past 30 years. ...
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Objective: This study aimed to describe prevalence and trends in Japan in nutritional indicators/nutritional status, according to the Global Nutrition Monitoring Framework on Maternal, Infant and Young Child Nutrition (WHO, 2014). Methods: We used vital statistics data on birth weight since 1951. Height and weight data for children, adolescents, and women of reproductive age, and hemoglobin concentration data for women were obtained from the National Nutrition Survey of Japan (NNS-J) and National Health and Nutrition Survey of Japan (NHNS-J). Underweight and overweight/obesity was defined using the percentage of overweight (POW) and body mass index (BMI). Anemia was defined as hemoglobin < 12 g/dl in non-pregnant women. Status on primary outcome indicators for the six global nutrition targets were observed regardless of data availability of annual trends. Results: A high prevalence and increasing trends were observed in low birth weight (< 2,500 g) infants since 1975. Trends in the nutritional status among children under 5 years were unclear. Obesity (POW ≥ 20%) among school-aged children has declined. There were high percentages of underweight (BMI < 18.5 kg/m²) among adolescents and young women, with increasing trends since 1980. The percentage of overweight/obesity was consistently high among women aged ≥ 20 years. A high prevalence of anemia was consistently found among women of reproductive age since 1997. Conclusions: Progress on reducing Japanese maternal and child malnutrition remains challenging. Continuous assessment of key indicators of maternal and child nutritional status will help to shape future strategies to encourage health and well-being through the life course.
... This may be because socioeconomic disadvantages per se, including low household income, is a risk factor for childhood obesity [29,30]. Adolescents in low-middle income households may have poorer quality food intake than those in high-income households, due to less healthy food availability in the home and inadequate knowledge regarding healthy lifestyles [31]. In addition, although most Japanese adolescents rarely prepare their own meals [32], mothers in low-middle income households (irrespective of work schedules) may be less able to address their children's diet quality and physical activity due to time pressure and inadequate access to healthy food, especially compared with mothers in high-income households [33]. ...
Full-text available
Background Many wage earners in developed countries have irregular shift patterns and work evenings, nights, and weekends. Some studies have demonstrated that the nonstandard work schedules of parents have adverse effects on their children’s weight, specifically leading to or worsening obesity. However, no such study has been conducted in adolescents of high school age. This study examined the association between mothers’ nonstandard work schedules and adolescent obesity. Methods A cross-sectional study of adolescents aged 16–17 years ( n = 1743) used paired matches of self-administered questionnaires for adolescents and their mothers from Tokyo, Japan. Obesity was defined by International Obesity Task Force cut-offs. Nonstandard work schedules were defined as working early mornings, nights, overnights, or weekends. Chi-square tests were conducted to examine the association between the mothers’ work schedules and their adolescent children’s poor lifestyles, overall and stratified by income levels. Then, logistic regression analyses were conducted to examine the association between mothers’ work schedules and obesity of their adolescent children, overall and stratified by income levels. Results Overall, 6.5% of adolescents had obesity. The prevalence of obesity was higher among adolescents from low-middle income groups (8.2%) than that among those from high-income groups (5.9%). No clear patterns were found between mothers’ work schedules and adolescents’ poor lifestyles when stratified by income levels. Mothers’ nonstandard work schedules were significantly associated with adolescent obesity (odds ratio [OR]: 1.56, 95% confidence interval [CI]: 1.02–2.40). However, this association was not significant after adjustment for confounders. After stratification by income levels, mothers’ nonstandard work schedules significantly associated with their children’s obesity (OR: 2.93, 95% CI: 1.45–5.92) only in high-income groups. This association remained after adjustment of the adolescents’ lifestyles and their mothers’ working hours. Conclusions Our results suggest that mothers’ nonstandard work schedules have adverse effects on adolescent obesity only in high-income families. Low-middle income families experienced higher levels of adolescent obesity, regardless of the mothers’ work schedules. Policy makers should consider mothers’ work schedules as a factor in preventing adolescent obesity.
... [15][16][17]19,20 Previous literature evaluating the impact of federally funded school meals programs have reported improved quality of children's diet 21,22 and a reduction in disparities in children's fruit and vegetable intake across socioeconomic lines. 23 Leading national and international agencies including the Pan-Canadian Joint Consortium for School Health 24 and the World Health Organization 25,26 have long acknowledged the importance of promoting health and improving dietary outcomes through schools. ...
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Background Recent federal proposals in Canada have called for changes in the delivery and funding of school lunches. Yet little evidence has documented the nutritional quality of meals eaten by school children, which is needed to inform school lunch reforms. Objectives To assess the dietary contributions of lunch foods to daily food and nutrient intakes on school days and compare dietary intakes across eating locations (school, home, and off campus). Design Cross-sectional analyses of school day data from the 2015 Canadian Community Health Survey—Nutrition. Participants/setting Children aged 6 to 17 years who completed a 24-hour dietary recall falling on a school day in 2015 (n=2,540). Main outcome measures Mean percent of daily intakes of energy, food groups, and nutrients contributed by foods reported at lunch and energy-adjusted intakes of nutrients and food groups consumed during the lunch meal. Statistical analyses Descriptive statistics were used to assess the percent of daily energy, nutrients, and food groups contributed by lunch foods. Multivariable linear regression models examined differences in dietary outcomes across eating locations for the full sample and stratified by age group, with separate models for children aged 6 to 13 and 14 to 17 years. Results On average, foods reported at lunch provided ∼26% of daily calories on school days. Relative to energy, lunch foods provided lower contributions of dark green and orange vegetables, whole fruit, fruit juice, whole grains, milk and alternatives, fluid milk; minimally nutritious foods including sugar-sweetened beverages; and several related nutrients including total sugars; vitamins A, D, B-6, and B-12; riboflavin; and calcium. Yet, lunch foods provided proportionally higher contributions of grain products, non–whole grains, meat and alternatives, and sodium. Children aged 14 to 17 years who ate lunch at school reported higher intakes of total vegetables and fruit, whole fruit, whole grains, fiber, vitamin C, and magnesium but reported fewer calories from sugar-sweetened beverages compared with their peers who ate lunch off campus. Conclusions Relative to its contribution to energy, lunch on school days contributed to proportionally lower intakes of many healthful foods such as dark green and orange vegetables, whole fruit, whole grains, and fluid milk but also proportionally lower intakes of other high-fat and high-sugar foods including sugar-sweetened beverages. This study adds to the growing body of evidence on dietary concerns during school time for Canadian children and highlights particular nutritional challenges for adolescents consuming lunch off campus.
... In addition to its environmental and financial costs, school lunch waste is a significant issue because students who throw away their food do not benefit from the nutrition it could provide. The impact of school lunch waste may be greatest for lowincome children who depend on school meals as an important source of nutrition (8)(9)(10) . Studies of waste in the NSLP have focused on increasing consumption of fruits and vegetables through strategies such as extending the lunch period (11) , scheduling recess before lunch (12) or creating share tables where students can leave whole food or beverage items they do not want to eat, making the items available to students who want additional servings. ...
Objective To explore factors that minimize lunch waste in Tokyo elementary schools and to consider how such factors can be modified and applied in US schools. Design Focused ethnographic study using interviews, observation, participant observation and document review. Data were analysed using thematic analysis. Setting Tokyo, Japan. Participants Five school dietitians participated in the study. Data collection methods included in-depth interviews, observation of nutrition education lessons, participant observation of school lunchtime and review of relevant school documents (e.g. lunch menus, food waste records). Results Five themes emerged from the analysis: (i) reinforcement of social norms to eat without waste; (ii) menu planning to increase exposure to unfamiliar and/or disliked foods; (iii) integration of food and nutrition education into the school curriculum; (iv) teacher lunchtime practices related to portion sizes, distributing leftover food and time management; and (v) engagement of students in reducing school lunch waste. Practical and tangible applications to US schools include measuring and reporting lunch waste to influence social norms, teaching students about the importance of reducing food waste, offering flexible school lunch portion sizes and providing students with meaningful opportunities to contribute to solving the problem of school lunch waste. Conclusions Japan offers a model for minimizing school lunch waste through a holistic approach that includes factors that operate at and interact across multiple levels of society. Modifying and applying such an approach in US schools is worth considering given the urgent need to address food waste in order to support healthy diets and sustainable food systems.
Objective: The present cluster randomized controlled trial with sixth grade school children aimed to prevent cardiovascular diseases among these participants by increasing their fruit intake. Methods: Overall, 104 children (52 boys and 52 girls) were assigned to the intervention (48 children from 2 primary schools) and control (56 children from 3 primary schools) groups. The intervention group was educated regarding the importance of fruit intake via one 45-min session. Self-administered questionnaires regrading fruit intake were filled by the participants before and after the education. The first-morning spot urinary sodium-to-potassium ratio was measured in both groups, 2 months after the educational session. Results: Before the educational session regarding fruit intake, there were no significant differences between the two groups. After the session, 31.6% of the boys and 26.9% of the girls in the intervention group, and 11.8% of the boys and 0.0% of the girls in the control group consumed fruits > 4 days per week, with the percentage of boys and girls being significantly higher in the intervention group than in the control group (p < 0.001 and p = 0.018, respectively). However, there was no significant difference in the urinary sodium-to-potassium ratio between the intervention and control groups. Conclusion: These results suggest that the school-based intervention was effective in promoting fruit intake. Such interventions are necessary to further enhance the nutrition education provided to children.
Background The prevalence of grandparent coresidence is increasing. However, the impact of grandparent coresidence on weight change among school‐age children remains unclear. Objectives The objective of the study is to examine the association between grandparent coresidence and obesity‐related behaviours and change in body mass index (BMI) z scores among school‐age children. Methods In total, 3422 caregivers of first‐grade children in Adachi City, Tokyo, participated in surveys and health checkups in 2016 and 2017 with no change in their grandparent coresidence status (response rate: 80.1% and 81.4%, respectively). Association between grandparent coresidence and obesogenic dietary, physical activity, and screen‐based sedentary behaviours was measured using Poisson regression with robust error variance analysis, while change in BMI z scores was determined by linear regression and adjusting for potential covariates. Results Grandparent coresidence was associated with increased prevalence rate (PR) of irregular snack foods intake (PR: 1.38, 95% confidential interval (CI): 1.19, 1.61); however, children who live with grandparents showed a lower BMI z scores in the second grade (coefficient: −0.048, 95% CI: −0.094 to −0.0013) after adjustment for BMI z scores in the first grade, family sociodemographics, and obesogenic behaviours. Conclusion Grandparent coresidence is associated with lower BMI z scores among early primary school‐age Japanese children living in urban areas.
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Objectives: Children do not eat enough servings of vegetables, underscoring the need for effective interventions encouraging this behavior. The purpose of this research was to measure the impact that daily exposure to branded vegetable characters has on vegetable selection among boys and girls in elementary schools. Methods: In a large urban school district, 10 elementary schools agreed to participate in the study. They were randomly assigned to a control condition or 1 of 3 treatment conditions: (1) a vinyl banner displaying vegetable characters that was fastened around the base of the salad bar; (2) short television segments with health education delivered by vegetable characters; or (3) a combination of the vinyl banner and television segments. We collected 22 206 student-day observations over a 6-week period by tallying the number of boys and girls taking vegetables from the school's salad bar. Results: Results show that 90.5% (from 12.6% to 24.0%; P = .04) more students took vegetables from the salad bar when exposed to the vinyl banner only, and 239.2% (from 10.2% to 34.6%; P < .001) more students visited the salad bar when exposed to both the television segments and vinyl banners. Both boys and girls responded positively to the vinyl banners (P < .05 in both cases). Conclusions: Evidence from this study highlights the positive impact of branded media on children's vegetable selection in the school cafeteria. Results from this study suggest potential opportunities for using branded media to encourage healthier choices for children.
Objective The present study aimed to examine the association between household income and the intake of foods and nutrients by Japanese schoolchildren, and any differences between days with and without school lunch. Design This was a cross-sectional study. Children, with the support of their parents, kept dietary records with photographs for 4 d (2 d with school lunch and 2 d without). The socio-economic status of each family was obtained from a questionnaire completed by the parents. Setting Japan. Subjects All students in 5th grade (10–11 years old) at nineteen schools in four prefectures and their parents (1447 pairs of students and parents) were invited to take part in the study; 836 pairs of complete data sets were analysed. Results The average results of four days of dietary records showed that lower income level was associated with a lower intake of fish/shellfish, green vegetables and sugar at the food group level, a lower intake of protein and several micronutrients, and a higher energy intake from carbohydrates at the nutrient level among the children. These associations between income and food/nutrient intake were not significant on days with school lunches, but were significant on days without school lunch. Conclusions Our study confirmed an association between household income and the amount of foods and nutrients consumed by Japanese schoolchildren, and suggested that school lunches play a role in reducing disparities in the diets of children from households with various incomes.
Objective: The role of school lunches in diet quality has not been well studied. Here, we aimed to determine the contribution of school lunches to overall nutrient intake in Japanese schoolchildren. Design: The study was conducted nationwide under a cross-sectional design. A non-consecutive, three-day diet record was performed on two school days and a non-school day separately. The prevalence of inadequate nutrient intake was estimated for intakes on one of the school days and the non-school day, and for daily habitual intake estimated by the best-power method. The relationship between food intake and nutrient intake adequacy was examined. Setting: Fourteen elementary and thirteen junior high schools in Japan. Subjects: Elementary-school children (n 629) and junior high-school children (n 281). Results: Intakes between the school and non-school days were significantly different for ≥60 % of nutrients. Almost all inadequacies were more prevalent on the non-school day. Regarding habitual intake, a high prevalence of inadequacy was observed for fat (29·9-47·7 %), dietary fibre (18·1-76·1 %) and salt (97·0-100 %). Inadequate habitual intake of vitamins and minerals (except Na) was infrequent in elementary-school children, but was observed in junior high-school children, particularly boys. Conclusions: School lunches appear to improve total diet quality, particularly intake of most vitamins and minerals in Japanese children. However, excess intakes of fat and salt and insufficient intake of dietary fibre were major problems in this population. The contribution of school lunches to improving the intakes of these three nutrients was considered insufficient.
This study examines the relationship between of food group intake and household income in a representative Japanese population. A total of 11,015 subjects (5,127 men and 5,888 women) aged 20 to 79 years, in 5,475 households who were part of the National Health and Nutrition Survey, Japan, in 2010 and 2011 were analyzed. Dietary intake was recorded for one day in November for those aged one year and older, from 300 randomly selected survey districts. Household income per year was recorded in the questionnaire in three categories: low (< 2 million yen), middle (2-6 million yen) and high (≥6 million yen). Multilevel regression modelling was applied to take into account the hierarchical data structure of subjects nested within households, and households nested within survey districts. Dichotomous variables divided at the median intake of each food group were used. In a model where sex, age, household size and population size of municipalities to which survey districts belonged were adjusted, the total energy intake was found to be highest in individuals from middle income households, and lowest for those from low income households. In models where a total energy intake was additionally adjusted, household members with low and middle incomes had a significantly higher intake of cereals, and a lower intake of potatoes and starches, pulses, vegetables, fruits, mushrooms, fish and shellfish, milk and seasonings and spices compared with those with high incomes. In conclusion, household members with lower incomes in Japan consumed more staple foods, but less vegetable, fruit and fish.
The Japanese school lunch program with milk was designed to supply 33-50% of the necessary nutrients per day and 50% of the recommended dietary allowance for calcium, which is difficult to obtain from Japanese meals. Although this program contributes to the mental and physical development of children, the effect of these meals on the bone growth in children remains unknown. Therefore, we compared the effect of school lunch with milk on bone growth between elementary school children attending schools that did not enforce the school lunch with milk program (box-lunch group) and those attending schools that did enforce the program (school-lunch group). The study subjects included fourth-grade children during the 2009-2013 school years, of whom 329 children were in the school-lunch group and 484 children in the box-lunch group. The bone area ratio of the right calcaneus was evaluated using quantitative ultrasound (Benus III). Dietary intakes were assessed using brief self-administered diet history questionnaires. The subjects were asked to record their activities for 3 d so that the mean physical activity intensity and the time spent sleeping could be estimated. The bone area ratios (%) were significantly higher in the school-lunch group than in the box-lunch group (males 31.0±0.3 vs. 30.3±0.2; females 30.6±0.2 vs. 29.7±0.2). This tendency did not change even after adjustment for confounding factors associated with bone growth. The results suggest that nutrients supplied by the Japanese school lunch program contributed to increased bone growth in elementary school children.
This paper describes a nutrition knowledge survey carried out on a cross-section of the adult population of England (n = 1040), looking at knowledge relating to current dietary recommendations, sources of nutrients, healthy food choices and diet-disease links. Serious gaps in knowledge about even the basic recommendations were discovered, and there was much confusion over the relationship between diet and disease. Significant differences in knowledge between socio-demographic groups were found, with men having poorer knowledge than women, and knowledge declining with lower educational level and socio-economic status. Possible reasons for these differences and implications for public education campaigns and socio-economic inequalities in health are discussed.
Assessing the impact of the National School Lunch Program (NSLP) on household food insufficiency is critical to improve the implementation of public food assistance and to improve the nutrition intake of low-income children and their families. To examine the association of receiving free/reduced-price lunch from the NSLP with household food insufficiency among low-income children and their families in the United States, the study used data from four longitudinal panels of the Survey of Income and Program Participation (SIPP; 1996, 2001, 2004, and 2008), which collected information on household food insufficiency covering both summer and non-summer months. The sample included 15, 241 households with at least one child (aged 5-18) receiving free/reduced-price lunch from the NSLP. A dichotomous measure describes whether households have sufficient food to eat in the observed months. Fixed-effects regression analysis suggests that the food insufficiency rate is .7 (95%CI: .1, 1.2) percentage points higher in summer months among NSLP recipients. Since low-income families cannot participate in the NSLP in summer when the school is not in session, the result indicates the NSLP participation is associated with a reduction of food insufficiency risk by nearly 14%. The NSLP plays a significant role to protect low-income children and their families from food insufficiency. It is important to increase access to school meal programs among children at risk of food insufficiency in order to ensure adequate nutrition and to mitigate the health problems associated with malnourishment among children.
The study determined the association between body mass index (BMI) z score and fruit and vegetable intake, frequency and ratio of fast food outlets and grocery stores in concentric areas around the child's residence, outdoor play and total crime index. Data from 78 Louisiana pre-school children were analyzed using Pearson's correlation and multiple regression analysis. Parental-reported fruit intake was linearly associated with increased number of grocery store counts in concentric areas around the child's residence (P = 0.0406, P = 0.0281). Vegetable intake was inversely (P = 0.04) and the ratio of fast food outlets to grocery stores in a 2-mile concentric area around the child's residence was positively (P = 0.05) associated to BMI z score after applying Best Model regression analysis (F = 3.06, P = 0.0346). Children residing in neighbourhoods with greater access to fast foods and lower access to fruits and vegetables may be at higher risk for developing obesity during pre-school years. © 2015 World Obesity.
It remains inconclusive whether high dietary fiber intake decreases the risk of obesity, hypercholesterolemia or high blood pressure during childhood. Therefore, this study investigated the relationships of dietary fiber intake with weight status and related clinical parameters among Japanese children. We analyzed the data of 5,600 subjects aged 10-11 years, between 2006 and 2010. Fiber intake was assessed using the Brief-type Diet History Questionnaire. Body height and weight and blood pressure were measured. Serum levels of total cholesterol, low- and high-density lipoprotein cholesterol and triglycerides were analyzed. Fiber intake was categorized into quintiles, and multivariate models were used to adjust for lifestyle factors. Total fiber intake decreased the risks of overweight and high total cholesterol (OR Quintile 5 vs. Quintile 1 overweight: 0.71 for boys, 0.40 for girls; total cholesterol: 0.60 for boys, 0.66 for girls). Water-soluble fiber intake was associated with a lower risk of high blood pressure, although the ORs were not significant. Increasing the dietary fiber intake in Japanese children may have favorable effects on overweight and hypercholesterolemia. © 2015 S. Karger AG, Basel.
In Japan, the number of municipalities that offer free medical care for children has increased. This policy, however, might unintentionally aggravate the overcrowded situation of pediatric ambulatory services in Japan. We investigated the relationships of parents' health care seeking attitudes by children's symptom severity with the amount of copayment as well as parents' socioeconomic and demographic factors. We used data of 4385 people from the Japanese Study of Stratification, Health, Income and Neighborhood (J-SHINE); stratified random sampling of those aged from 25 to 50 years who lived in Tokyo and neighboring areas. Outcome variables were the respondents' health care seeking attitudes toward their children's mild and severe symptoms of cold. Logistic regression models were developed for each dependent variable. A total of 1606 respondents with one or more children under the age of 15 years were included in the analysis. For mild symptoms of cold, no subsidy (OR: 0.51, 95% CI: 0.38-0.69) and partial subsidy (OR: 0.71, 95% CI: 0.54-0.95) were associated with the less "visits on that day" answer, when compared with a full subsidy. Income and respondents' educational level were not associated with the outcome. For severe symptoms of cold, the odds ratio of no subsidy (0.61 (95% CI: 0.30-1.23)) and partial subsidy (0.91 (95%CI: 0.40-2.07)), were not statistically significant. Our results show that imposing a small amount of copayment might prevent visits to medical facilities for mild symptoms of cold, but will not prevent visits for severe symptoms of cold. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.