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Abstract Objective: To investigate the content of lunchboxes of primary school children and to examine children’s support and preferences for alternative healthy school lunch concepts. Design: A cross-sectional study among Dutch children from seven primary schools. The content of the lunchboxes was assessed by photographs. Support and preferences for alternative lunch concepts were examined via a self-reported questionnaire. Linear regression analyses were used to investigate the associations between children’s support and preferences and sex, educational group and migration background. Setting: The Netherlands. Participants: Primary school children. Results: A total of 660 children were included (average 9·9 years old). Most lunchboxes contained sandwiches and a drink. Few lunchboxes contained fruit or vegetables. The alternative school lunch concepts elicited mixed support among children. The lunch concepts ‘Sandwiches prepared by the children themselves’ and a ‘hot lunch buffet’ had the highest mean support, while the concept ‘a healthy lunch brought from home’ was the most preferred concept. Small significant differences were observed depending on sex, educational group and migration background. Conclusion: Lunchboxes of Dutch children contained sandwiches and a drink but rarely fruit and vegetables. Among different alternatives, children reported the highest support for the preparation of their own sandwiches in class or a hot lunch buffet. Future studies should investigate if these alternative lunch concepts improve the dietary intake of children.

Objective: To investigate the content of lunchboxes of primary school children and to examine children's support and preferences for alternative healthy school lunch concepts.Design: A cross-sectional study among Dutch children from seven primary schools. The content of the lunchboxes was assessed by photographs. Support and preferences for alternative lunch concepts were examined via a self-reported questionnaire. Linear regression analyses were used to investigate the associations between children's support and preferences and sex, educational group and migration background.Setting: The Netherlands.Participants: Primary school children.Results: A total of 660 children were included (average 9·9 years old). Most lunchboxes contained sandwiches and a drink. Few lunchboxes contained fruit or vegetables. The alternative school lunch concepts elicited mixed support among children. The lunch concepts 'Sandwiches prepared by the children themselves' and a 'hot lunch buffet' had the highest mean support, while the concept 'a healthy lunch brought from home' was the most preferred concept. Small significant differences were observed depending on sex, educational group and migration background.Conclusion: Lunchboxes of Dutch children contained sandwiches and a drink but rarely fruit and vegetables. Among different alternatives, children reported the highest support for the preparation of their own sandwiches in class or a hot lunch buffet. Future studies should investigate if these alternative lunch concepts improve the dietary intake of children. [ABSTRACT FROM AUTHOR]

ObjectiveSchool-based interventions and policies encourage youths to include and consume fruits and vegetables at lunchtime via school lunches, but limited research has examined how these behaviours compare when youths have home-packed lunches. The objective of the present study was to compare fruit and vegetable contents and consumption among students having school or home-packed lunches over the school week.DesignParticipants were observed over five consecutive days at school lunchtime. Trained analysts estimated students' lunchtime fruit and vegetable contents and consumption using digital imaging. Mixed models examined associations between fruit and vegetable dietary behaviours and lunch source (school v. home-packed), controlling for student gender, grade and school.SettingThree elementary schools in northern California, USA.ParticipantsFourth-, fifth- and sixth-grade students (nchildren 315; nobservations 1421).ResultsStudents were significantly less likely to have and to consume fruits and vegetables (all P

Objective: Schools can be an effective arena for food education. The Tasty School is a tailored teacher-driven food education model that provides tools for implementing food education in primary schools. This study aimed to investigate the effects of the Tasty School model on pupils' eating patterns and experiences. We also aimed to assess the implementation strength of the Tasty School.Design: A quasi-experimental study was conducted during one school year 2019-2020 in fifteen intervention and ten control schools. The intervention schools implemented the Tasty School food education model. The pupils completed web-based baseline and follow-up questionnaires in class during a school day. The principals were interviewed after the intervention. The data were analysed using a mixed-effects model for repeated measures, accounting for the implementation strength and selected standardisation effects.Setting: A total of twenty-five general Finnish primary schools.Participants: 1480 pupils from grades 3-6 (age 8-12 years) from five municipalities in Finland.Results: Percentages of pupils eating a balanced school meal increased in schools where food education was actively implemented (P = 0·027). In addition, pupils' experience of social participation in school dining strengthened in schools where the Tasty School model was implemented (5-point scale mean from 2·41 to 2·61; P = 0·017).Conclusions: Healthy eating patterns can be promoted by the active implementation of food education in primary schools. The Tasty School model offers a promising tool for developing healthy eating patterns and increasing social participation among pupils not only in Finland, but also potentially in other countries as well. [ABSTRACT FROM AUTHOR]

ObjectiveEnsuring ready access to free drinking-water in schools is an important strategy for prevention of obesity and dental caries, and for improving student learning. Yet to date, there are no validated instruments to examine water access in schools. The present study aimed to develop and validate a survey of school administrators to examine school access to beverages, including water and sports drinks, and school and district-level water-related policies and practices.DesignSurvey validity was measured by comparing results of telephone surveys of school administrators with on-site observations of beverage access and reviews of school policy documents for any references to beverages. The semi-structured telephone survey included items about free drinking-water access (sixty-four items), commonly available competitive beverages (twenty-nine items) and water-related policies and practices (twenty-eight items). Agreement between administrator surveys and observation/document review was calculated using kappa statistics for categorical variables, and Pearson correlation coefficients and t tests for continuous variables.SettingPublic schools in the San Francisco Bay Area, California, USA.SubjectsSchool administrators (n 24).ResultsEighty-one per cent of questions related to school beverage access yielded κ values indicating substantial or almost perfect agreement (κ>0·60). However, only one of twenty-eight questions related to drinking-water practices and policies yielded a κ value representing substantial or almost perfect agreement.ConclusionsThis school administrator survey appears reasonably valid for questions related to beverage access, but less valid for questions on water-related practices and policies. This tool provides policy makers, researchers and advocates with a low-cost, efficient method to gather national data on school-level beverage access.

Objective: To explore the factors influencing Taiwanese adolescents' consumption of sugar-sweetened beverages (SSB) and sugary snacks from a socio-ecological perspective.Design: This study adopted a qualitative design by using face-to-face, in-depth interviews guided by a semistructured questionnaire.Setting: Eight junior high schools in New Taipei City and Changhua County, Taiwan, September to November 2018.Participants: Fifty-nine participants aged 12-14 years participated in this study.Results: Reflexive thematic analysis was used to analyse the data. This study identified four themes to address the multifaceted factors that influence adolescents' consumption of SSB and sugary snacks. At the intrapersonal level, physiological factors, psychological factors, individual economic factors and taste preferences were mentioned in connection with people's consumption of SSB and sugary snacks. Positive or negative influences of parents, siblings, peers and teachers on SSB and sugary snack intake were identified at the interpersonal level. The availability of SSB and sugary snacks at home, their availability in vending machines or in school stores in the school environment and participants' access to convenience stores and hand-shaken drink shops in the broader community influenced SSB and sugary snack consumption. Additionally, food culture and food advertising were identified as influencing societal factors.Conclusions: Overall, this qualitative study determined not only that the consumption of SSB and sugary snacks is influenced by intrapersonal factors but also that interpersonal, environmental and societal factors affect adolescents' increased sugar intake. The findings are helpful to broaden the options for designing and developing interventions to decrease SSB and sugary snack consumption by adolescents. [ABSTRACT FROM AUTHOR]

Objective: To systematically review evidence from systematic reviews of interventions to improve dietary behaviours and reduce food wastage in secondary school pupils.Design: CINAHL, Cochrane Reviews, EMBASE, MEDLINE, PsychINFO and Web of Science were searched for systematic reviews of school-based dietary interventions from 2000 to 2020 published in a peer-reviewed journal in English. Articles were reviewed independently by two authors. AMSTAR-2 was used for quality assessment.Setting: Secondary school dietary interventions.Participants: Adolescents (aged 11-18).Results: In total, thirteen systematic reviews of dietary interventions in secondary schools met the inclusion criteria. A number of key characteristics of interventions that contributed to improvements in food choices in secondary school pupils were identified. These included the combination of education and environmental restructuring, incorporation of computer-based feedback, media or messaging, peer and/or parent involvement, an increase in the availability of healthy foods and the use of behavioural theory as a basis to the intervention. Intervention components that contributed specifically to a reduction in sugar-sweetened beverage intake or an increase in fruit and vegetable consumption, which are particularly relevant to adolescents, could not be determined. Similarly, evidence for interventions that improve nutritional knowledge and attitudes was limited.Conclusions: This systematic review of systematic reviews has identified a number of components of dietary interventions that can be explored to improve dietary behaviours in secondary school environments and, if demonstrated to be effective, be considered for inclusion in policies and strategies to improve the school food environment and promote dietary change. [ABSTRACT FROM AUTHOR]

Objective: This study evaluated the impact of the Addis Ababa School Feeding Program (SFP) on educational outcomes.Design: Single-group repeated measurement/longitudinal study design and multistage stratified sampling design were followed. Effect sizes estimates, repeated measures ANOVA, Chi-square, Generalised Additive Mixed Model and mixed effects negative binomial regression were used. Academic scores, attendance and dropout and height and weight of schoolchildren were collected.Setting: School Feeding Programs in Addis Ababa, Ethiopia.Participants: Schoolchildren in primary schools and school directors and teachers in fifteen randomly selected schools for Key Informant Interview (KII).Results: Anthropometric measurements of 4500 schoolchildren were taken from 50 schools. Academic scores of 3924 schoolchildren from 46 schools, class attendance records of 1584 schoolchildren from 18 schools and annual enrolment records of 50 schools were gathered. School meals achieved a minimum to large scale effects on educational outcomes with effect sizes (η2) of academic scores (boys = 0·023, girls = 0·04), enrolment (girls = 0·001, boys = 0·05) and attendance (Cramer's V = 0·2). The average scores of girls were significantly higher than that of boys (P < 0·0001). Height-for-age in all schoolchildren (P < 0·01) and BMI-for-age Z-scores in adolescent girls of 15-19 years (P < 0·0001) never had a significant positive relationship with average scores. Significant relation was observed between nutritional status and attendance (P = 0·021). KII showed that SFP created convenient teaching-learning environment and reduced hunger in schools, while boosting enrolment, attendance and academic performance among the schoolchildren.Conclusion: The Addis Ababa SFP has positively contributed to educational outcomes. Strengthening the program would enhance nutritional outcomes and diminish educational inequalities. [ABSTRACT FROM AUTHOR]

Objective: This study evaluated a simple environmental intervention called 'Water Schools' in Lower Austria providing free refillable water bottles and educational material.Design: Non-randomised controlled cluster trial with three measurements: at baseline (T0), after the intervention at 9 months (T1) and after 1-year follow-up (T2).Setting: Half-day elementary schools in Lower Austria (Austria).Participants: Third-grade pupils from twenty-two schools in the intervention group (IG) and thirty-two schools in the control group (CG) participated in the study. Data were analysed for 569 to 598 pupils in the IG and for 545 to 613 in the CG, depending on the time of measurement.Results: The consumption of tap water increased in the IG from baseline to T1 and then decreased again at T2, but this was similar in the CG (no statistically significant difference in the time trend between the IG and CG). Similar results were seen for tap water consumption in the mornings. The proportion of children who only drank tap water on school mornings increased significantly from baseline to T1 in the IG compared to the CG (P = 0·020). No difference in the changes over time occurred between the groups for the proportion of pupils drinking approximately one bottle of tap water during school mornings.Conclusions: Not only the children in the IG but also those in the CG drank more tap water after 1 school year than at the beginning. The measurement of drinking habits in the CG may have been intervention enough to bring about changes or to initiate projects. [ABSTRACT FROM AUTHOR]

Objective: To develop and evaluate a stand-alone Elementary School-aged Children's Index of Diet Quality (ES-CIDQ).Design: In this cross-sectional study, children filled in a food frequency questionnaire (FFQ) with twenty-nine multiple-item questions on the consumption of foods, portion sizes and eating frequency and a 5-d food diary. Nutrient intakes were calculated with nutrient analysis software. FFQ questions best reflecting a health-promoting diet with reference to dietary recommendations were identified by correlations, logistic regression modelling and receiver-operating characteristics curve analysis.Setting: Southwest and Eastern Finland.Participants: Healthy elementary school-aged volunteers [n 266, mean (sd) age 9·7 (1·7) years] were recruited between March 2017 and February 2018.Results: A set of questions was identified from the FFQ that best depicted the children's diet quality as defined in the dietary recommendations. These fifteen questions were scored and formulated into a stand-alone index as a continuous index score (range 0-16·5 points) and a two-category score: good and poor diet quality. The cut-off score of six points for a good diet quality had a sensitivity of 0·60 and a specificity of 0·78. Children with a good diet quality (49·8 % of the children) had higher intakes of protein, dietary fibre, and several vitamins and minerals, and lower intakes of sucrose, total fat, SFA and cholesterol compared to children with a poor diet quality.Conclusions: The developed short stand-alone index depicted diet quality as defined in the dietary recommendations. Thus, ES-CIDQ may be used for assessing diet quality in Finnish elementary school-aged children in school health care and nutrition research. [ABSTRACT FROM AUTHOR]

Objective: Fruits and vegetables (FV) distribution interventions have been implemented as a public health strategy to increase children's intake of FV at school settings. The purpose of this review was to examine whether snack-based FV distribution interventions can improve school-aged children's consumption of FV.Design: Systematic review and meta-analysis of articles published in English, in a peer-reviewed journals, were identified by searching six databases up to August 2020. Standardised mean differences (SMD) and 95 % CI were calculated using a random effects model. Heterogeneity was quantified using I2 statistics.Setting: Population-based studies of interventions where the main focus was the effectiveness of distributed FV as snacks to schoolchildren in North America, Europe and Pacific were included.Results: Forty-seven studies, reporting on fifteen different interventions, were identified; ten studies were included in the meta-analysis. All interventions were effective in increasing children's consumption of FV, with only one intervention demonstrating a null effect. Pooled results under all classifications showed effectiveness in improving children's consumption of FV, particularly for multi-component interventions at post-intervention (SMD 0·20, 95 % CI 0·13, 0·27) and free distribution interventions at follow-up (SMD 0·19, 95 % CI 0·12, 0·27).Conclusions: Findings suggest that FV distribution interventions provide a promising avenue by which children's consumption can be improved. Nonetheless, our results are based on a limited number of studies, and further studies should be performed to confirm these results. More consistent measurement protocols in terms of rigorous study methodologies, intervention duration and follow-up evaluation are needed to improve comparability across studies. [ABSTRACT FROM AUTHOR]

Objective: Increasing evidence links unhealthy food environments with diet quality and overweight/obesity. Recent evidence has demonstrated that relative food environment measures outperform absolute measures. Few studies have examined the interplay between these two measures. We examined the separate and combined effects of the absolute and relative densities of unhealthy food outlets within 1600 m buffers around elementary schools on children's diet- and weight-related outcomes.Design: This is a cross-sectional study of 812 children from thirty-nine schools. The Youth Healthy Eating Index (Y-HEI) and daily vegetables and fruit servings were derived from the Harvard Food Frequency Questionnaire for Children and Youth. Measured heights and weights determined BMI Z-scores. Food outlets were ranked as healthy, somewhat healthy and unhealthy according to provincial paediatric nutrition guidelines. Multilevel mixed-effects regression models were used to assess the effect of absolute (number) and relative (proportion) densities of unhealthy food outlets within 1600 m around schools on diet quality and weight status.Setting: Two urban centres in the province of Alberta, Canada.Participants: Grade 5 students (10-11 years).Results: For children attending schools with a higher absolute number (36+) of unhealthy food outlets within 1600 m, every 10 % increase in the proportion of unhealthy food outlets was associated with 4·1 lower Y-HEI score and 0·9 fewer daily vegetables and fruit.Conclusions: Children exposed to a higher relative density of unhealthy food outlets around a school had lower diet quality, specifically in areas where the absolute density of unhealthy food outlets was also high. [ABSTRACT FROM AUTHOR]

Objective: Reducing children's exposure to unhealthy food marketing is crucial to combat childhood obesity. We aimed to estimate the reduction of children's exposure to food marketing under different policy scenarios and assess exposure differences by socio-economic status., Design: Data on children's exposure to unhealthy food marketing were compiled from a previous cross-sectional study in which children ( n 168) wore wearable cameras and Global Positioning System (GPS) units for 4 consecutive days. For each exposure, we identified the setting, the marketing medium and food/beverage product category. We analysed the percentage reduction in food marketing exposure for ten policy scenarios and by socio-economic deprivation: (1) no product packaging, (2) no merchandise marketing, (3) no sugary drink marketing, (4) no confectionary marketing in schools, (5) no sugary drink marketing in schools, (6) no marketing in public spaces, (7) no marketing within 400 m of schools, (8) no marketing within 400 m of recreation venues, (9) no marketing within 400 m of bus stops and (10) no marketing within 400 m of major roads., Setting: Wellington region of New Zealand., Participants: 168 children aged 11-14 years., Results: Exposure to food marketing varied by setting, marketing medium and product category. Among the ten policy scenarios, the largest reductions were for plain packaging (60·3 %), no sugary drink marketing (28·8 %) and no marketing in public spaces (22·2 %). There were no differences by socio-economic deprivation., Conclusions: The results suggest that plain packaging would result in the greatest decrease in children's exposure to food marketing. However, given that children are regularly exposed to unhealthy food marketing in multiple settings through a range of marketing mediums, comprehensive bans are needed to protect children's health.

Objective: The objective of the current study was to identify factors across the socio-ecological model (SEM) associated with adolescents' sugar-sweetened beverage (SSB) intake.Design: This cross-sectional study surveyed adolescents using previously validated instruments. Analyses included descriptive statistics, ANOVA tests and stepwise nonlinear regression models (i.e., two-part models) adjusted to be cluster robust. Guided by SEM, a four-step model was used to identify factors associated with adolescent SSB intake - step 1: demographics (i.e., age, gender), step 2: intrapersonal (i.e., theory of planned behaviour (attitudes, subjective norms, perceived behavioural control, behavioural intentions), health literacy, media literacy, public health literacy), step 3: interpersonal (i.e., caregiver's SSB behaviours, caregiver's SSB rules) and step 4: environmental (i.e., home SSB availability) level variables.Setting: Eight middle schools across four rural southwest Virginia counties in Appalachia.Participants: Seven hundred ninety seventh grade students (55·4 % female, 44·6 % males, mean age 12 (sd 0·5) years).Results: Mean SSB intake was 36·3 (sd 42·5) fluid ounces or 433·4 (sd 493·6) calories per day. In the final step of the regression model, seven variables significantly explained adolescent's SSB consumption: behavioural intention (P < 0·05), affective attitude (P < 0·05), perceived behavioural control (P < 0·05), health literacy (P < 0·001), caregiver behaviours (P < 0·05), caregiver rules (P < 0·05) and home availability (P < 0·001).Conclusions: SSB intake among adolescents in rural Appalachia was nearly three times above national mean. Home environment was the strongest predictor of adolescent SSB intake, followed by caregiver rules, caregiver behaviours and health literacy. Future interventions targeting these factors may provide the greatest opportunity to improve adolescent SSB intake. [ABSTRACT FROM AUTHOR]

Objective: Ethiopia recently scaled up the implementation of a school feeding programme (SFP). Yet, evidence on the impact of such programmes on academic outcomes remains inconclusive. We evaluated the effect of the SFP on class absenteeism and academic performance of primary school students (grade 5-8) in Sidama zone, Southern Ethiopia.Design: This prospective cohort study enrolled SFP-beneficiary (n 240) and non-beneficiary (n 240) children 10-14 years of age from sixteen public schools and followed them for an academic year. School absenteeism was measured as the number of days children were absent from school in the year. Academic performance was defined based on the average academic score of the students for ten subjects they attended in the year. Data were analysed using multivariable mixed effects negative binomial and linear regression models.Setting: Food insecure districts in Sidama zone, Southern Ethiopia.Participants: SFP-beneficiary and non-beneficiary children 10-14 years of age.Results: The mean (sd) number of days children were absent from school was 4·0 (sd 1·5) and 9·3 (sd 6·0), among SFP beneficiaries and non-beneficiaries, respectively. Students not covered by the SFP were two times more likely to miss classes (adjusted rate ratio = 2·30; 95 % CI 2·03, 2·61). Pertaining to academic performance, a significant but small 2·40 (95 % CI 0·69, 4·12) percentage point mean difference was observed in favour of SFP beneficiaries. Likewise, the risk of school dropout was six times higher among non-beneficiaries (adjusted rate ratio = 6·04; 95 % CI 1·61, 22·68).Conclusions: SFP promotes multiple academic outcomes among socio-economically disadvantaged children. [ABSTRACT FROM AUTHOR]

Objective: Schools offer an ideal setting for childhood obesity interventions due to their access to children and adolescents. This review aimed to systematically review the impact of school-based intervention for the treatment of childhood obesity.Design: Eight databases were searched from inception till 30 May 2020. A revised Cochrane risk-of-bias tool and the Grading of Recommendations, Assessment, Development and Evaluations criteria were used to evaluate the risk of bias and overall evidence. Meta-analysis and meta-regression were performed on Stata software using the random effects model. Overall effect was evaluated using Hedges' g, and heterogeneity was assessed using Cochran's Q and I2.Setting: Cluster randomised controlled trials (cluster-RCT) delivered in school.Participants: Children and adolescents (6-18 years of age) with overweight and obesity.Results: Twelve cluster-RCT from seven countries with 1755 participants were included in the meta-analysis. School-based interventions for the treatment of childhood obesity reduced BMI and BMI z-scores with a medium effect (g = 0·52). Subgroup analyses showed greater effectiveness of brief school-based interventions and the interventions conducted in lower-middle to upper-middle economies. Meta-regression assessed the heterogeneity and the final model, with covariates of the type of economies and trial duration, accounted for 41·2 % of the variability. The overall quality of evidence was rated low because of the high risk of bias and inconsistency.Conclusions: School-based interventions are a possible approach to provide universal healthcare for the treatment of childhood obesity, and further well-designed cluster-RCT with longer follow-up are needed. This study is registered with PROSPERO (CRD42020160735). [ABSTRACT FROM AUTHOR]

Objective: To consider the principal effect of an interaction between year (pre- and post-Universal Infant Free School Meals (UIFSM)) and school on pupil's dietary intakes.Design: A repeated cross-sectional survey using dietary data from 2008 to 2009 (pre-) and 2017 to 2018 (post-UIFSM).Setting: Two primary schools, NE England.Participants: Pupils aged 4-7 years (2008-2009 n 121; 2017-2018 n 87).Results: At lunchtime, there was a statistically significant decrease in pupils non-milk extrinsic sugars intake (%E NMEs) pre- to post-UIFSM (mean change -4·6 %; 95 % CI -6·3, -2·9); this was reflected in total diet (-3·8 %; -5·2, -2·7 %). A year and school interaction was found for mean Ca intakes: post-UIFSM pupils in School 2 had a similar mean intake as pre; in School 1 intakes had increased (difference of difference: -120 mg; 95 % CI -179, -62); no reflection in total diet. Post-UIFSM mean portions of yogurt decreased in School 2 and remained similar in School 1 (-0·25; -0·46, -0·04); this was similar for 'cake/pudding' and fruit.Conclusions: Within the limitations, these findings highlight positives and limitations following UIFSM implementation and demonstrate the role of school-level food practices on pupil's choices. To facilitate maximum potential of UIFSM, national levers, such as discussions on updating school food standards, including sugars, could consider removing the daily 'pudding' option and advocate 'fruit only' options 1 d/week, as some schools do currently. Small school-level changes could maximise positive health impacts by decreasing NMEs intake. A more robust evaluation is imperative to consider dietary impacts, equitability and wider effects on schools and families. [ABSTRACT FROM AUTHOR]

Objective: The aim of the study was to assess the impact of different lunchbox messages on parents' intention to pack a healthy lunchbox.Design: This study employed an experimental design.Setting: A series of messages were developed to align with the six constructs of the Health Belief Model. Messages were also developed that were (and were not) personalised and varied based on the source of the information provided (university, school, dietitian and health promotion service). During a telephone survey, participants were read the content of each message and asked about their intention to pack a healthy lunchbox.Participants: Parents of primary school-aged children were randomised to receive different messages to encourage the packing of healthy lunchboxes.Results: The study was completed by 511 parents. Linear mixed regression analyses identified significant differences (P < 0·05) in intention scores between variant messages targeting the same behavioural constructs for 'susceptibility', 'severity', 'benefits' and 'barriers' but not 'cues to action' or 'self-efficacy'. The highest mean behavioural intention score was for 'benefits', whilst the lowest mean score was for 'barriers'. There were no significant differences in intention scores of parents receiving messages from a dietitian, university, health promotion team or school (P = 0·37). Intention scores did not differ in which messages were personalised based on child's name (P = 0·84) or grade level (P = 0·54).Conclusions: The findings suggest that messages that focus on the benefits of packing healthy lunchboxes may be particularly useful in improving intentions of parents to pack healthy foods for their children to consume at school. [ABSTRACT FROM AUTHOR]

Objective: To assess differences between traditional paper bag ordering and online ordering from primary school canteens in terms of menu, usage and lunch order characteristics.Design: A cross-sectional study.Setting: New South Wales (NSW) primary schools that offered both paper bag and online canteen ordering.Participants: Students (aged 5-12 years) with a lunch order on the day of the observation.Results: Across the six school canteens, 59-90 % of all available items were listed on both the online and paper menus, with no significant differences in the nutritional quality ('Everyday'/'Occasional') or nutritional content (kJ/saturated fat/sugar/sodium) of menu items. In total, 387 student lunch orders were placed, containing 776 menu items. Most orders (68 %) were placed online. There were no significant differences between order modality in the quantity of items ordered or the cost of orders, or the nutritional quality of orders based on the classification system of the NSW Healthy School Canteen Strategy ('Everyday'/'Occasional'). However, nutritional analysis revealed that paper bag orders contained 222 fewer kJ than online orders (P = 0·001), 0·65 g less saturated fat (P = 0·04) and 4·7 g less sugar (P < 0·001).Conclusions: Online canteens are commonly used to order canteen lunches for primary school children. This is the first study to investigate differences between traditional paper bag ordering and online ordering in this setting. Given the rapid increase in the use of online ordering systems in schools and other food settings and their potential to deliver public health nutrition interventions, additional research is warranted to further investigate differences in ordering modalities. [ABSTRACT FROM AUTHOR]

Objective: Short stature may reflect health in early life and be an enduring disability. How birth weight, gender, household, elementary schooling and diet play a role in associations between stature and overall school competence (OSC) have been assessed.Design: The 2001-2002 Nutrition and Health Survey in Taiwan (NAHSIT) for elementary schoolchildren (n 2274, 52·1 % boys) was linked to birth records. It provided sociodemographic, dietary quality, body compositional and school performance (as Scale for Assessing Emotional Disturbance, SAED; OSC as an SAED subscale) data. Lower birth weight was ≤15th percentile: 2850 g for boys and 2700 g for girls, and stature as z-scores for Taiwanese. Multivariable linear regression was used for relationships between OSC and stature. Trends in OSC by stature and school grade were assessed.Setting: The 2001-2002 NAHSIT for elementary schoolchildren.Participants: Totally, 2274 schoolchildren aged 6-13 years.Results: Compared to normal height (-2< height for age z-score (HAZ) <2), shorter girls (HAZ ≤ -2) had a lower OSC (8·87 v. 10·5, P < 0·05) and taller girls (HAZ ≥ 2) had a better OSC (12·3 v. 10·5, P < 0·001). Maternal education and household income each contributed more than 5 % of OSC variance. OSC and HAZ among girls were positively associated and emotional disturbance negatively associated. Shortness-associated lower OSC underwent remediation with advancing school grade. Stature and OSC were not evidently related in boys.Conclusions: Shorter stature can compromise OSC among school girls. The major determinants in shorter girls are less household income and limited parental education. [ABSTRACT FROM AUTHOR]

Objective: To test the effectiveness of a social network intervention (SNI) to improve children's healthy drinking behaviours.Design: A three-arm cluster randomised control trial design was used. In the SNI, a subset of children were selected and trained as 'influence agents' to promote water consumption-as an alternative to sugar-sweetened beverages (SSB)-among their peers. In the active control condition, all children were simultaneously exposed to the benefits of water consumption. The control condition received no intervention.Setting: Eleven schools in the Netherlands.Participants: Four hundred and fifty-one children (Mage = 10·74, SDage = 0·97; 50·8 % girls).Results: Structural path models showed that children exposed to the SNI consumed 0·20 less SSB per day compared to those in the control condition (β = 0·25, P = 0·035). There was a trend showing that children exposed to the SNI consumed 0·17 less SSB per day than those in the active control condition (β = 0·20, P = 0·061). No differences were found between conditions for water consumption. However, the moderation effects of descriptive norms (β = -0·12, P = 0·028) and injunctive norms (β = 0·11-0·14, both P = 0·050) indicated that norms are more strongly linked to water consumption in the SNI condition compared to the active control and control conditions.Conclusions: These findings suggest that a SNI promoting healthy drinking behaviours may prevent children from consuming more SSB. Moreover, for water consumption, the prevailing social norms in the context play an important role in mitigating the effectiveness of the SNI. [ABSTRACT FROM AUTHOR]

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

Objective: To determine the impact of an educational programme for primary schools that explored the biodiversity of tomato, by promoting science and sensory education with three distinct varieties of it, in the acceptance of vegetables.Design: A randomised controlled study in which children were exposed to the educational programme (intervention group) or remained in the class, as usual (control group). The educational programme consisted of three sessions where children explained the observed differences between the three varieties of tomato and individual perceptions of their flavours based on sensory-based food education and by planning and implementing experiments to explain those differences. We tested the effects on both children's willingness to try and their liking for tomato, and for lettuce and cabbage to study the carry-over effect, compared with the control group (Mann-Whitney U test; P < 0·05).Setting: The study took place in public primary schools in Porto, Portugal.Participants: Children in the third grade (8-13-year-old children) (n 136) were randomly assigned to intervention or control group.Results: Children in the intervention group reported significant increases in their willingness to try and liking for tomato compared to the control group (P < 0·05), but not for lettuce and cabbage (P > 0·05).Conclusions: These results highlight the potential for fostering children's acceptance of a vegetable by exploring biodiversity through science education. Further work may clarify the effects of exploring biodiversity on the consumption of vegetables and establish whether the results are stable over time and replicable across contexts and populations. [ABSTRACT FROM AUTHOR]

Objective: To conduct formative research using qualitative methods among stakeholders of secondary schools to explore their perceptions, barriers and facilitators related to healthy eating and physical activity (PA) among Malaysian adolescents.Design: A qualitative study involving eight focus groups and twelve in-depth interviews. Focus groups and interviews were recorded and transcribed verbatim. An inductive thematic analysis approach was used to analyse the data.Setting: Four secondary schools in Perak and Selangor states (two urban and two rural schools) in Malaysia.Participants: Focus groups were conducted with seventy-six adolescents aged 13-14 years, and in-depth interviews were conducted with four headmasters, four PA education teachers and four food canteen operators.Results: Stakeholders thought that adolescents' misperceptions, limited availability of healthy options, unhealthy food preferences and affordability were important challenges preventing healthy eating at school. Low-quality physical education (PE) classes, limited adolescent participation and teachers' commitment during lessons were perceived as barriers to adolescents being active at school. Affordability was the main challenge for adolescents from rural schools. Stakeholders perceived that a future school-based intervention should improve the availability and subsidies for healthy foods, provide health education/training for both adolescents and PE teachers, enhance active adolescent participation in PE and develop social support mechanisms to facilitate engagement with PA.Conclusions: These findings provide important insights into developing school-based lifestyle interventions to improve healthy eating and strengthening PA of Malaysian adolescents. [ABSTRACT FROM AUTHOR]

Objective: To investigate whether an after-school nutrition education (ASNE) programme can improve the nutrition knowledge and healthy eating behaviour of adolescents from economically disadvantaged families.Design: One-group pretest and posttest design. Nutrition knowledge and dietary intake were collected using a questionnaire, and anthropometric measurements were measured before and after the intervention. Nine components of healthy eating behaviour were assessed with reference to the Dietary Guideline of Taiwan. Pretest and posttest differences were analysed using generalised estimating equations.Setting: Three after-school programmes in central and southern Taiwan. The ASNE programme comprised three monthly 1-h sessions (20-30-min lecture and 30-40-min interaction).Participants: A total of 153 adolescents aged 10-15 years from economically disadvantaged families (seventy-eight elementary students and seventy-five junior high school students).Results: Elementary and junior high school students' nutrition knowledge scores (range 0-6) increased by 0·28 (+ 5·7 %, P = 0·02) and 0·30 points (+ 6·18 %, P = 0·02), respectively, but their fruit intake decreased by 0·36 serving/d (-22·9 %, P = 0·02) and 0·29 serving/d (-18·9 %, P = 0·03), respectively. Junior high school students' mean snacking frequency and fried food intake dropped to 0·75 d/week (-21·3 %, P = 0·008) and 0·10 serving/d (-28·8 %, P = 0·01), respectively.Conclusions: Short-term ASNE programmes can increase nutrition knowledge and reduce snacking frequency and fried food intake despite a decrease in fruit intake among adolescents from economically disadvantaged families. [ABSTRACT FROM AUTHOR]

Objectives: We examined the association of household food insecurity with educational outcomes and explored the moderating effect of gender and school lunch programme.Design: The study used a cross-sectional design. Data were collected in 2014 using interviewer-administered questionnaires and school administrative records. We measured household food insecurity using the Household Food Insecurity Access Scale. Educational outcomes referred to knowledge, attitudes and skills that students are expected to obtain while attending school. We obtained sixteen different measures of educational outcomes, ranging from academic grades to beliefs and attitudes towards school and education. Data were analysed using multilevel modelling with covariates at the student and school levels. We conducted moderation tests by adding a two-way interaction between food insecurity and gender, and between food insecurity and school lunch programme.Setting: The study was conducted in 100 schools located in fifty-four districts within Ghana's eight administrative regions in 2014.Participants: Participants included 2201 school-going adolescents aged 15-19 years.Results: More than 60 % of adolescents were from food-insecure households. Household food insecurity was negatively associated with Math grade and school attendance. Food insecurity was also inversely associated with socio-emotional outcomes, including academic self-efficacy, commitment to school and academic aspirations and expectations. We did not find a moderating effect of gender and school lunch programme.Conclusions: Food insecurity is negatively associated with wide-ranging educational outcomes related to both learning and socio-emotional abilities. Our study supports prior evidence suggesting the importance of food access on both cognitive and non-cognitive educational outcomes. [ABSTRACT FROM AUTHOR]

Objective: The research objectives were to evaluate factors that influence Canadian secondary school students' milk and milk alternatives (MMA) consumption and to explore associations through age and gender lenses., Design: A qualitative design was used, consisting of semi-structured interviews and photo-elicitation methods. Analysis was guided by the Theory of Planned Behaviour (TPB). Deductive and inductive thematic analyses were used to generate themes, charting data based on attributes such as gender and age., Setting: Interviews were held virtually or via telephone., Participants: Participants were twenty-eight high school students from Ontario, Canada, diverse in terms of gender and age., Results: Both desirable and undesirable beliefs about the health outcomes of consuming MMA were commonly discussed. These included health benefits such as strong bones, muscular strength, and growth, and health consequences like unwanted skin conditions, weight gain, and diseases. While boys and girls associated MMA consumption with muscular strength, boys predominantly considered this favourable, while girls discussed outcomes like unwanted skin conditions and weight gain more often. Adolescents' perspectives on taste/perceived enjoyment, environmentally friendly choices and animal welfare also influenced their MMA preferences. Parental influences were most cited among social factors, which appeared to be stronger during early adolescence. Factors involving cost, time and accessibility affected adolescents' beliefs about how difficult it was to consume MMA., Conclusions: Recommendations for shifting attitudes towards MMA are provided to address unfavourable beliefs towards these products. Interventions to increase MMA consumption among adolescents should include parents and address cost barriers.

Objective: This study aims at comparing two Italian case studies in relation to schoolchildren's plate waste and its implications, in terms of nutritional loss, economic cost and carbon footprint., Design: Plate waste was collected through an aggregate selective weighting method for 39 d., Setting: Children from the first to the fifth grade from four primary schools, two in each case study (Parma and Lucca), were involved., Results: With respect to the served food, in Parma, the plate waste percentage was lower than in Lucca ( P < 0·001). Fruit and side dishes were highly wasted, mostly in Lucca (>50 %). The energy loss of the lunch meals accounted for 26 % (Parma) and 36 % (Lucca). Among nutrients, dietary fibre, folate and vitamin C, Ca and K were lost at most (26-45 %). Overall, after adjusting for plate waste data, most of the lunch menus fell below the national recommendations for energy (50 %, Parma; 79 %, Lucca) and nutrients, particularly for fat (85 %, Parma; 89 %, Lucca). Plate waste was responsible for 19 % (Parma) and 28 % (Lucca) of the carbon footprint associated with the food supplied by the catering service, with starchy food being the most important contributor (52 %, Parma; 47 %, Lucca). Overall, the average cost of plate waste was 1·8 €/kg (Parma) and 2·7 €/kg (Lucca), accounting respectively for 4 % and 10 % of the meal full price., Conclusion: A re-planning of the school meals service organisation and priorities is needed to decrease the inefficiency of the current system and reduce food waste and its negative consequences.

Objective: To explore what Australian primary school parents want to learn about food and nutrition to improve their children's eating behaviours, as well as the associations between parents' personal and demographic characteristics and their views regarding their food and nutrition knowledge needs., Design: An online nationwide cross-sectional survey was conducted in 2021 using a mixed-methods approach. Logistic regression analysis was utilised to examine the relationship between parents' demographics, personal values and their views. Content analysis was performed using Leximancer., Setting: Australia., Participants: Seven hundred and eighty-seven parents., Results: Fifty-one per cent wanted to learn more about food and nutrition to improve their children's healthy eating habits, and 77% of those preferred schools to provide that information. Online/printed newsletters and YouTube were the most preferred methods for receiving food and nutrition related information. Higher universalism-concern value (concern for the welfare of those in the larger society and world) scores were positively associated parents' preference for schools to provide food and nutrition-related information. Parents with non-English-speaking backgrounds and younger parents were more likely to want to learn about food and nutrition. Parents wanted to learn more about encouraging healthy eating, ideas for the lunchbox, food labels and age-specific portion sizes and recommendations., Conclusions: Findings can inform public health educators and assist them in designing future food and nutrition education programmes and resources targeting primary school parents.

Objective: Within the UK, dietary fibre intakes are well below recommended intakes and associated with increased risk of obesity. This study aimed to explore the views of parents and children on barriers and facilitators to increasing fibre intakes and improving diets, alongside investigating the appropriateness of intervention components to overcome modifiable barriers., Design: Qualitative study including semi-structured interviews and focus groups informed by the Theoretical Domains Framework (TDF) and the Capability-Opportunity-Motivation-Behaviour (COM-B) model., Participants: Year 5 children (aged 9-10-years) and parents, recruited through London primary schools., Results: A total of twenty-four participants (eleven parents and thirteen children) took part. Five key themes were identified as barriers and facilitators, namely lack of (and improving) knowledge, social factors (including parent-child conflicts, limited time for food preparation, influence of peer and family members), current eating habits, influence of the school, community and home environment in shaping eating behaviours, and the importance of choice and variety in finding foods that are healthy and tasty. Parents strongly supported school-based dietary interventions to enable consistent messaging at home and school and help support dietary behaviour change. Practical sessions (such as workshops to strengthen knowledge, taste tests and food swap ideas) were supported by parents and children., Conclusions: By using a theory-driven approach to explore the barriers and facilitators to increasing fibre intake, this research identified important themes and modifiable barriers to behaviour change and identifies acceptable intervention components to overcome barriers and bring about sustained dietary behaviour change in primary school children.

Objective: To examine whether targeted determinants mediated the effects of the HEalth In Adolescents (HEIA) intervention on fruit and vegetable (FV) consumption and explore if these mediating effects were moderated by sex, parental education or weight status., Design: Cluster-randomised controlled trial., Setting: The HEIA study (2007-2009) was a Norwegian 20-month multi-component school-based intervention to promote healthy weight development. FV consumption and targeted determinants were self-reported at baseline, mid-way (8 months) and post-intervention (20 months)., Participants: Adolescents (11-13-year-old) in twenty-five control schools ( n 746) and twelve intervention schools ( n 375)., Results: At post-intervention, more adolescents in the intervention group compared with the control group had knowledge of the FV recommendations (OR: 1·4, 95 % CI 1·1, 1·9) and reported a decreased availability of vegetables at home ( β : -0·1, 95 % CI -0·2, 0·0). Availability/accessibility of FV at home, availability of vegetables at dinner, taste preferences for different types of FV and knowledge of the FV recommendations were positively associated with the consumption of FV. However, none of the post-intervention determinants significantly mediated the intervention effects on FV consumption. Although no moderating influences by sex, parental education or weights status were observed on the mediating effects, exploratory analyses revealed significant moderations in the b-paths., Conclusions: Since none of the targeted determinants could explain the increase in FV consumption, it remains unclear why the intervention was effective. Reporting on a wide range of mediators and moderators in school-based interventions is needed to reveal the pathways through which intervention effects are achieved.

Objective: Food environments are a major determinant of children's nutritional status. Scarce evidence on food environments exists in low- and middle-income countries (LMIC). This study aims to fill this gap by documenting the obesogenicity of food environments around schools in Greater Tunis, Tunisia - an LMIC of the Middle East and North Africa region with an ongoing nutrition transition and increasing rates of childhood obesity., Design: In this cross-sectional study, we assessed built food environments around fifty primary schools. Ground-truthing was performed to collect geographic coordinates and pictures of food retailers and food advertisement sets within an 800-m road network buffer of each school. Retailers and advertisement sets were categorised as healthy or unhealthy according to a NOVA-based classification. Associations between school characteristics and retailers or advertisement sets were explored using multinomial regression models., Setting: Greater Tunis, Tunisia., Participants: Random sample of fifty (thirty-five public and fifteen private) primary schools., Results: Overall, 3621 food retailers and 2098 advertisement sets were mapped. About two-thirds of retailers and advertisement sets were labelled as unhealthy. Most retailers were traditional corner stores (22 %) and only 6 % were fruit and vegetable markets. The prevailing food group promoted was carbonated and sugar-sweetened beverages (22 %). The proportion of unhealthy retailers was significantly higher in the richest v . poorest areas., Conclusions: School neighbourhood food environments included predominantly unhealthy retailers and advertisements. Mapping of LMIC food environments is crucial to document the impact of the nutrition transition on children's nutritional status. This will inform policies and interventions to curb the emergent childhood obesity epidemic.

Objective: Implementation of school meal guidelines is often inadequate, and evidence for effective implementation strategies for school-based nutrition interventions is limited. The aim of the present study was to examine the implementation and effectiveness of a multi-strategy implementation intervention to increase adherence to the Norwegian national school meal guideline., Design: The study was a school-based hybrid implementation effectiveness trial with a pre-post non-equivalent control group design, testing three implementation strategies: internal facilitation, training and an educational meeting., Setting: Primary schools and after-school services in two counties in south-east Norway., Participants: School principals, after-school leaders and class teachers from thirty-three schools in the intervention county and principals and after-school leaders from thirty-four schools in a comparison county., Results: There was a significant difference of 4 percentage points in change scores between the intervention and the comparison groups at follow-up, after adjusting for baseline adherence ( B = 0·04, se B = 0·01, t = 3·10, P = 0·003). The intervention effect was not associated with the school's socio-economic profile. School-level fidelity was the implementation dimension that was most strongly correlated ( r s = 0·48) with the change scores in the intervention group, indicating that principals' support is important for gaining the largest intervention effects., Conclusions: A school-based intervention with low intensity, based on trained teachers as internal facilitators, can increase adherence to the national school meal guideline among Norwegian primary schools, irrespective of local socio-economic conditions. Implementation fidelity, at an organisational level, may be a useful predictor for intervention outcomes in schools.

Objective: The aim of this study was to investigate the association of the number of hours of nutrition education and teachers' qualifications with nutrition knowledge and dietary behaviour in students.Design: In this representative cross-sectional study, socio-demographic data, anthropometric measurements, socio-economic status (SES), physical fitness, nutrition knowledge and eating habits were assessed. Differences between groups were tested by χ2 and t tests. Multiple linear and logistic regression modelling was used to examine the relationship between demographic characteristics, lifestyle and dietary behaviours, nutrition knowledge, nutrition-trained teachers and number of nutrition lessons.Setting: Sixteen secondary schools in urban (n 6) and rural regions (n 10) of Tyrol, Western Austria.Participants: Students (n 513) aged 14·2 (sd 0·7) years.Results: Higher nutrition knowledge was significantly associated with attending rural school (P = 0·001), having no migration background (P < 0·001), (very) good physical activity behaviour (P = 0·040), non-trained teacher (P = 0·006) but higher number of hours of nutrition education (P = 0·013). Regression models showed that higher nutrition knowledge was independently associated with lower intake of meat and iced tea and higher intake of vegetables and plant-based oils. A higher amount of nutrition education (h/week) was significantly associated with higher intake of dark (wholegrain) bread, lower intake of meat and of energy drinks sweetened with sweeteners.Conclusions: Our results suggest that more hours in nutrition education result in higher nutrition knowledge and greater nutrition literacy, which may lead to health-promoting dietary habits. School-based nutrition education can be seen as preventive measure to increase nutritional competences in adolescents independent of their SES. [ABSTRACT FROM AUTHOR]

Objective: In 2012, the US government overhauled school nutrition standards, but few studies have evaluated the effects of these standards at the national level. The current study examines the impact of the updated school nutrition standards on dietary and health outcomes of schoolchildren in a nationally representative data set.Design: Difference-in-differences. We compared weekday fruit and vegetable intake between students with daily school lunch participation and students without school lunch participation before and after implementation of updated school nutrition standards using a multivariable linear regression model. Secondary outcomes included weekday solid fat and added sugar (SoFAS) intake and overweight and obesity prevalence. We adjusted analyses for demographic and family socio-economic factors.Setting: USA.Participants: K-12 students, aged 6-20 years (n 9172), from the National Health and Nutrition Examination Survey, 2005-2016.Results: Implementation of updated school nutrition standards was not associated with a change in weekday fruit and vegetable intake (β = 0·02 cups, 95 % CI -0·23, 0·26) for students with daily school lunch participation. However, implementation of the policy was associated with a 1·5 percentage point (95 % CI -3·0, -0·1) decline in weekday SoFAS intake and a 6·1 percentage point (95 % CI -12·1, -0·1) decline in overweight and obesity prevalence.Conclusions: Changes to US school nutrition standards were associated with reductions in the consumption of SoFAS as well as a decrease in overweight and obesity in children who eat school lunch. However, we did not detect a change in weekday intake of fruits and vegetables associated with the policy change. [ABSTRACT FROM AUTHOR]

Objective: To investigate the relationships between children's food and drink choices at school lunch for children who consume high and low sugar intakes at home.Design: Children's food and drink consumption at home was assessed using diet diaries over three consecutive days. Children were classified as 'high' or 'low' sugar consumers at home using the WHO recommendation that free sugars should be less than 10 % of their daily total energy intake. A purposive sample of children was then selected and observed during school lunch, recording food selections, food left on plates and content of packed lunches.Setting: Six primary schools in Newham and Kent, England.Participants: Parents and children aged 6-7 years.Results: Seventy-one parents completed diet diaries. From the seventy-one, thirty-nine children were observed during school lunch. Twenty children were high sugar consumers, nineteen children were low sugar consumers; thirty-one children had a school meal. Eleven of the fifteen children (73 %) who had school meals and who were high sugar consumers selected a high-sugar dessert rather than fruit. Only five of the sixteen (31 %) children who had school meals and were low sugar consumers at home chose a high-sugar dessert. Most of the children who had packed lunches had sweet items, despite school policies.Conclusions: Children who consumed high sugar intake at home tended to select foods high in sugar for school meals or had packed lunches containing high-sugar foods. The implications for public health programmes include healthy eating workshops and implementing school food policies. [ABSTRACT FROM AUTHOR]

Objective: Schools have been recognised as a potential setting for improving young peoples' food and beverage choices; however, many schools fail to adhere to healthy food and beverage policy standards. The current study aimed to explore the enablers and barriers to effective implementation of and compliance with school-based food and beverage policies.Design: Systematic review and meta-synthesis. Eight electronic databases were searched for articles in June 2019. Studies were eligible for inclusion if they reported on implementation and/or compliance of school-based food and/or beverage policies with outcomes relating to enablers and/or barriers. This review had no restrictions on study design, year of publication or language. Seventy-two full-text articles were assessed for eligibility, of which twenty-eight were included in this review.Setting: Studies conducted globally that focused on schools.Participants: School-based healthy food and beverage policies.Results: Financial (cost of policy-compliant foods, decreased profit and revenue), physical (availability of policy-compliant foods, close geographical proximity to unhealthy food outlets) and social (poor knowledge, understanding, and negative stakeholders' attitudes towards policy) factors were the most frequently reported barriers for policy implementation. Sufficient funding, effective policy communication and management, and positive stakeholders' attitudes were the most frequently reported enablers for policy implementation.Conclusions: There is a need for better communication strategies, financial and social support prior to school-based food policy implementation. Findings of this review contribute to a thorough understanding of factors that underpin best practice recommendations for the implementation of school-based food policy, and inform those responsible for improving public health nutrition. [ABSTRACT FROM AUTHOR]

Objective: To identify correlates and underlying beliefs regarding the adolescents' intention to abstain from consuming sugar-sweetened beverages (SSB) and the consumption of ≤1 daily portion of SSB.Design: Correlational study.Setting: Region of Chaudière-Appalaches in the province of Quebec, Canada.Participants: 311 adolescents aged 13-18 years completed a self-administrated online questionnaire based on the Reasoned Action Approach. Frequency and quantity of different types of SSB within the past month were measured.Results: Total mean SSB intake was 882·6 ml/d (654·0 kJ/d ). Only 11·3 % abstained from SSB within the last month. Intention to abstain from SSB was explained by identification as SSB abstainers (β = 0·47), perceived norm (β = 0·32), attitude (β = 0·30), age 13-14 years (β = -0·27) and perception of the school environment (β = 0·14), which explained 66 % of the variance. Consumption of ≤1 daily portion of SSB was explained by the intention to abstain (OR = 1·55; 95 % CI 1·14, 2·11), perceived behavioural control to abstain (OR = 1·80; 95 % CI 1·29, 2·52), sex (girls v. boys: OR = 2·34; 95 % CI 1·37, 3·98) and socio-economic status (advantaged v. disadvantaged school: OR = 2·08; 95 % CI 1·21, 3·56). Underlying beliefs (i.e. more energy, decreased risk of addiction and friends' approval) associated with intention as well as perceived barriers (e.g. access to SSB, after an activity that makes you thirsty), and facilitating factors (e.g. access to water) linked to SSB consumption were identified.Conclusions: The results can inform public health interventions to decrease SSB consumption and their associated health problems among adolescents. [ABSTRACT FROM AUTHOR]

Objective: Children are surrounded by ubiquitous forms of unhealthy food marketing at home and in schools. The US Department of Agriculture now restricts food and beverage marketing that does not meet Smart Snacks in School standards. School superintendents, as districts' top administrators, play a critical role in ensuring marketing policies are implemented and adhered to; however, there is limited research involving this stakeholder group. The current study examined superintendents' perspectives on food marketing in schools and the marketing provision in wellness policies, as well as experiences with the implementation of such policies.Design: Qualitative focus groups and follow-up interviews (with focus group participants) were conducted by trained researchers.Setting: Focus groups occurred at The School Superintendents' annual meeting; follow-up interviews were over the telephone.Participants: Superintendents and assistant superintendents (n 39) from twenty-three states participated. Interviews were recorded and professionally transcribed; transcripts were team-coded in Atlas.ti using an iteratively revised coding guide to facilitate theme generation.Results: Despite common concerns that marketing to children was 'insidious', superintendents reported a wide range of food and beverage marketing policies. In addition, the main issue is fundraising - such as 'restaurant nights' - that results in marketing that occurs on- and off-campus and afterschool.Conclusions: Discrepancies between perspectives and practices point to the challenges that superintendents face with budgetary constraints, as well as relationships with parent-teacher organisations. These findings provide important insights about superintendents' perspectives and challenges, particularly for government and child health advocates supporting school districts, to implement these policies. [ABSTRACT FROM AUTHOR]

Objective: School lunches have potential to foster healthy diets in all children, but data on their importance are relatively scarce. The current study aimed to describe the dietary intake from school lunches by sex and school grade, and to assess how the daily intake, school lunch intake and the daily intake provided by lunch differ by sex and parental education.Design: Cross-sectional. All foods and drinks consumed for 1-3 weekdays were self-reported. Energy, absolute and energy-adjusted intakes of nutrients and food groups were calculated per weekday and per school lunch. Mixed-effects linear models assessed sociodemographic differences in dietary intakes. Nutrient and energy density at lunch and during the rest of the day were compared.Setting: Seventy-nine Swedish primary schools.Participants: Pupils in grades 5 and 8 (N 2002), nationally representative.Results: Lunch provided around half of daily vegetable intake and two-thirds of daily fish intake. Nutrient density was higher and energy density lower at lunch compared with the rest of the day (P < 0·001). Boys had greater energy-adjusted intakes of red/processed meat and lower intakes of vegetables and dietary fibre compared with girls (P < 0·001), overall and at lunch. Daily energy-adjusted intakes of most nutrients/food groups were lower for pupils of lower-educated parents compared with pupils of parents with higher education, but at lunch, only Fe and fibre intakes were significantly lower in this group.Conclusions: School lunches are making a positive contribution to the diets of Swedish children and may mitigate well-established sex differences and social inequalities in dietary intake. [ABSTRACT FROM AUTHOR]

Objective: We aimed to investigate the associations between school-level characteristics and obesity among Chinese primary school children with consideration of individual-level characteristics.Design: This cross-sectional study was conducted in 2015/2016. School-level characteristics were assessed using an interviewer-administered school questionnaire, and a 'school-based obesity prevention index' was further developed. Individual-level characteristics were collected by self-administered questionnaires. Objectively measured height and weight of students were collected, and obesity status was classified according to the International Obesity Task Force criteria for Asian children. Generalised linear mixed models were used to estimate the associations among the school- and individual-level characteristics and obesity of students.Setting: Thirty-seven primary schools from an urban and a rural district of Beijing, China.Participants: School staffs, 2201 students and their parents.Results: The school-based obesity prevention index involved the number of health professionals, availability of students' health records, monitoring students' nutrition status, frequency of health education activities, reporting achievements of obesity prevention activities to parents, duration of physical activity during school time and availability of playground equipment. The prevalence of obesity was lower in schools with the higher index value compared with that in schools with the lower index value (OR 0·56; 95 % CI 0·40, 0·79). Some individual-level characteristics were negatively associated with childhood obesity: liking sports, duration of screen time ≤2 h/d, perceived lower eating speed, parental non-overweight/obesity.Conclusions: Irrespective of individual-level characteristics, the specific school-level characteristics had a cumulative effect on obesity among Chinese primary school children. Further school-based obesity intervention should consider these characteristics simultaneously. [ABSTRACT FROM AUTHOR]

Objective: To identify key school-level contexts and mechanisms associated with implementing a provincial school food and beverage policy.Design: Realist evaluation. Data collection included semi-structured interviews (n 23), structured questionnaires (n 62), participant observation at public events (n 3) and scans of school, school district and health authority websites (n 67). The realist heuristic, context + mechanism → outcome configuration was used to conduct the analysis.Setting: Public schools in five British Columbia (BC), Canada school districts.Participants: Provincial and regional health and education staff, private food vendors and school-level stakeholders.Results: We identified four mechanisms influencing the implementation of BC's school food and beverage sales policy. First, the mandatory nature of the policy triggered some actors' implementation efforts, influenced by their normative acceptance of the educational governance system. Second, some expected implementers had an opposite response to the mandate where they ignored or 'skirted' the policy, influenced by values and beliefs about the role of government and school food. A third mechanism related to economics demonstrated ways vendors' responses to school demand for compliance with nutritional Guidelines were mediated by beliefs about food preferences of children, health and food. The last mechanism demonstrated how resource constraints and lack of capacity led otherwise motivated stakeholders to not implement the mandatory policy.Conclusion: Implementation of the food and beverage sales policy at the school level is shaped by interactions between administrators, staff, parent volunteers and vendors with contextual factors such as varied motivations, responsibilities and capacities. [ABSTRACT FROM AUTHOR]

Objective: The aim of the current study was to evaluate the effect on frequency, variety and amount of vegetables served and staff's food-related practices in the multicomponent BRA intervention.Design: Cluster randomised controlled trial, conducted between Spring 2015 and Spring 2016. For allocation of the kindergartens, a stratified block randomisation was used. Data were collected in three ways: (i) a questionnaire for pedagogical leaders assessing the variety and frequency of vegetables served, including staff's food-related practices assumed to be related to vegetable intake; (ii) a questionnaire for kindergarten assistants assessing staff's food-related practices; (iii) a 5-d weighted vegetable diary assessing amount of vegetables served in a department.Setting: The target group for this study was public and private kindergartens in the counties of Vestfold and Buskerud, Norway.Participants: A total of seventy-three kindergartens participated.Results: At follow-up I, the amount of vegetables served increased by approximately 20 g per person per day (P = 0·002), and the variety in served vegetables increased by one-and-a-half kind per month (P = 0·014) in the intervention group compared to the control group. No effects on the frequency of vegetables served or on staff's food-related practices were found.Conclusions: The BRA intervention was successful in increasing the amount and variety of vegetables served within intervention kindergartens. Further research is needed to understand the mechanisms that can affect the staff's food-related practices. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective: To identify the prevalence of unhealthy dietary behaviours and their social-ecological influences in adolescents.Design: The study used a sequential explanatory mixed-methods design, which begins with the collection of quantitative data, followed by the collection of qualitative data to explain and enrich the quantitative findings. Quantitative data were collected via a global school-based student health survey and were analysed using quantitative approaches. Qualitative data were obtained via focus group discussions and were analysed thematically.Setting: Middle and high secondary schools in Taza city, Morocco.Participants: Our quantitative analyses included 764 students (14-19 years). For the qualitative part, seventeen focus group discussions were conducted with 100 participants (fifty-six adolescents, twenty-six parents and eighteen teachers).Results: Of total student participants, 46·1 % skipped breakfast, 60·6 % had inadequate intake of fruits and vegetables (F&V), 39·4 % consumed soft drinks and 28·0 % consumed fast foods. All of these dietary behaviours could coexist in the same person except for inadequate intake of F&V. Gender, academic performance, age, perceived family income and education level of mother were associated with unhealthy dietary behaviours. Qualitative findings identified seven themes regarding social-ecological influences on adolescents' dietary behaviours: cognitive, affective/biological, lifestyle, outcome expectation, social network, accessibility/availability and macro-level influences.Conclusions: The prevalence of unhealthy dietary behaviours in our study group is a concern. Dietary behaviours are the result of inseparable interactions among social-ecological influences. Modifiable factors identified may be useful when designing a future intervention aimed at improving breakfast and F&V consumption and reducing fast/snack-food consumption among adolescents. [ABSTRACT FROM AUTHOR]

Objective: The present study describes the energy content of primary-school children's lunchboxes and the proportion of lunchbox foods considered discretionary. Subgroup analyses by sex, socio-economic status, age and weight status were undertaken.Design: A cross-sectional study was conducted. Mean kilojoule content, number of items and categorisation of foods and drinks in lunchboxes as 'everyday' (healthy) or discretionary (sometimes) foods were assessed via a valid and reliable lunchbox observational audit.Setting: Twelve Catholic primary schools (Kindergarten-Grade 6) located in the Hunter region of New South Wales, Australia.Participants: Kindergarten to Grade 6 primary-school students.Results: In total, 2143 children (57 %) had parental consent to have their lunchboxes observed. School lunchboxes contained a mean of 2748 kJ, of which 61·2 % of energy was from foods consistent with the Australian Dietary Guidelines and 38·8 % of energy was discretionary foods. The proportion of lunchboxes containing only healthy foods was 12 %. Children in Kindergarten-Grade 2 packed more servings of 'everyday' foods (3·32 v. 2·98, P < 0·01) compared with children in Grades 3-6. Children in Grades 3-6 had a higher percentage of energy from discretionary foods (39·1 v. 33·8 %, P < 0·01) compared with children in Kindergarten-Grade 2 and children from the most socio-economically disadvantaged areas had significantly higher total kilojoules in the school lunchbox compared with the least disadvantaged students (2842 v. 2544 kJ, P = 0·03).Conclusions: Foods packed within school lunchboxes may contribute to energy imbalance. The development of school policies and population-based strategies to support parents overcome barriers to packing healthy lunchboxes are warranted. [ABSTRACT FROM AUTHOR]

Objective: Survival rates for paediatric cancers have increased dramatically since the 1970s, but childhood cancer survivors (CCS) are at increased risk for several chronic diseases throughout life. Nutrition interventions promoting healthy family meals may support wellness for survivors, but little research has explored CCS family food preparation habits. The goal of the present study was to describe and compare food preparation practices of CCS and non-CCS families.Design: Observational.Setting: Typical evening meal preparation events were observed and recorded in participant homes. Recordings and notes were analysed using the Healthy Cooking Index (HCI), a measure of nutrition-optimizing food preparation practices relevant to survivor wellness. Demographics, BMI and nutrient composition of prepared meals were also collected.Participants: Forty parents with a CCS or non-CCS child aged 5-17 years were recruited.Results: There were no major differences between the CCS and non-CCS families with regard to summative HCI score or specific food preparation behaviours. Meals prepared by CCS and non-CCS families had similar nutrient compositions.Conclusions: The study revealed areas for practical nutrition intervention in CCS and non-CCS families. Future studies should consider adopting and tailoring nutrition intervention methods that have been successful in non-CCS communities. [ABSTRACT FROM AUTHOR]