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School feeding programs can support children's nutrition, health, and education in emergencies. This study assessed the feasibility, trade-offs, cost efficiency, and perceived benefits of school feeding modalities operating in urban Yemen. It draws on primary data from a qualitative evaluation with 21 school feeding implementers and 88 beneficiaries conducted in Feb-Mar 2023, and secondary data from a desk review of published and program literature on school feeding operations. Results showed that school feeding provided students with on average 18%, 40%, and 66% of daily energy, protein, and micronutrient requirements, respectively. Models including fortified snacks were 3-11 times more cost-efficient in terms of nutrient delivery. The most prominent strength of the models examined were the perceived benefits on child, family, and financial outcomes. Among the main weaknesses was the poor nutritional quality of the meal, which in turn emerged as a primary opportunity to improve school feeding through hybrid models providing a combination of fortified snacks and healthy meals. Other weaknesses such as poor water, sanitation, and hygiene infrastructure, and desired improvements such as the school kitchen and canteen, require considerable investments. Hybrid models are cost-efficient, acceptable, and feasible in Yemen and can serve the diet and nutrition needs of school-aged children., (© 2024 The Author(s). Annals of the New York Academy of Sciences published by Wiley Periodicals LLC on behalf of The New York Academy of Sciences.)

Introduction: The U.S. Child and Adult Care Food Program (CACFP) provides tiered reimbursements for healthy foods for children at participating family childcare homes (FCCH). Higher tier 1 reimbursements are for providers who operate in low-income communities or who are themselves living on a low income. All FCCHs received a higher rate to address food insecurity during the COVID-19 pandemic. Methods: A survey was administered in the spring of 2023 to a randomly selected sample of licensed California FCCHs to assess the perceived impacts of the increased reimbursement on CACFP participation and anticipated challenges with reinstated tiered rates. A total of 518 surveys (261 tier 1, 257 tier 2) were analyzed using linear or logistic regression, adjusting for confounders. Results: Among tier 1 and tier 2 providers combined, over half reported lowering out-of-pocket spending for food (59%) and serving greater variety (55%) and quality (54%) of foods. Tier 2 providers reported experiencing more benefits ( p < 0.05) and tended to be more likely to implement optional CACFP best practices (although not significantly different between tiers). Most FCCH providers found reimbursement rates were inadequate before (83%) the pandemic; this amount decreased to 54% post-pandemic for tier 1 and tier 2 providers combined. Conclusions: The temporary CACFP reimbursement positively impacted the perceived quality and variety of foods served to children, especially among tier 2 providers. Increased reimbursements for all FCCHs may ensure children have access to the healthy meals and snacks provided by the CACFP.

Introduction: Unhealthy diets pose a significant public health risk among European children, contributing to the increasing prevalence of overweight and non-communicable diseases. Children spend a substantial amount of time at school daily, including lunchtime, so the school setting becomes crucial for promoting healthy diets and lifestyle habits. While there is a large body of literature on the impact of school food policies on health and non-health outcomes, it is essential to identify which policies are effective and can be recommended for implementation to ensure the efficient use of resources. This article presents a protocol for a scoping review that aims to map the current published literature on the effects of school food policies on health outcomes, acceptance and affordability in secondary school children in Europe. Moreover, the scoping review will map the measurements used to assess health outcomes, acceptance and affordability., Methods and Analysis: The scoping review protocol and review follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Review. To identify eligible studies, we will search MEDLINE, PsycINFO, CINAHL and Web of Science. The reference lists of the included articles will be checked for additional studies. In addition, country-specific ministry reports from Member States of the European Union, the UK, Norway, Iceland and Switzerland will be identified. The WHO and European Commission websites will also be searched for relevant reports. The scoping review will include literature published until 20 September 2023. No restrictions to study design and language will be applied. Screening and data extraction will be carried out independently by three reviewers. Disagreements will be resolved by discussion. A pretested data charting table will be used to extract key information. Findings will be presented in tabular and visualised summaries and a narrative summary., Ethics and Dissemination: This scoping review does not require ethical approval. Our dissemination strategy comprises peer-reviewed publications, conference presentations and recommendations to policy-makers., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

States in the U.S. are newly implementing universal school meal (USM) policies, yet little is known about the facilitators of their success and the challenges they confront. This study evaluated the challenges and facilitators faced by school food authorities (SFAs) implementing California's universal school meal (USM) policy during its inaugural year (2022-2023) using an online survey. In March 2023, 430 SFAs reported many benefits, including increased meal participation (64.2% of SFAs) and revenues (65.7%), reduced meal debt (41.8%) and stigma (30.9%), and improved meal quality (44.3%) and staff salaries (36.9%). Reported challenges include product/ingredient availability (80.9%), staffing shortages (77.0%), vendor/distributor logistics issues (75.9%), and administrative burden (74.9%). Top facilitators included state funding (78.2%) and increased federal reimbursement (77.2%). SFAs with fewer students eligible for free or reduced-price meals (as opposed to SFAs with more) reported greater increases in meal participation and reductions in stigma but also more administrative burdens. Larger SFAs reported greater increases in revenues, staff salaries, and improvements in meal quality than smaller SFAs but also more challenges. Overall, California's USM policy has enhanced student access to healthy meals while mitigating social and financial barriers. Understanding California's experience can inform other jurisdictions considering or implementing similar policies.

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.

Background: Overconsumption of energy from food is a major contributor to the high rates of overweight and obesity in many populations. There is growing evidence that interventions that target the food environment may be effective at reducing energy intake. The current study aimed to estimate the effect of decreasing the proportion of higher energy (kcal) foods, with and without reducing portion size, on energy purchased in worksite cafeterias., Methods and Findings: This stepped-wedge randomised controlled trial (RCT) evaluated 2 interventions: (i) availability: replacing higher energy products with lower energy products; and (ii) size: reducing the portion size of higher energy products. A total of 19 cafeterias were randomised to the order in which they introduced the 2 interventions. Availability was implemented first and maintained. Size was added to the availability intervention. Intervention categories included main meals, sides, cold drinks, snacks, and desserts. The study setting was worksite cafeterias located in distribution centres for a major United Kingdom supermarket and lasted for 25 weeks (May to November 2019). These cafeterias were used by 20,327 employees, mainly (96%) in manual occupations. The primary outcome was total energy (kcal) purchased from intervention categories per day. The secondary outcomes were energy (kcal) purchased from nonintervention categories per day, total energy purchased per day, and revenue. Regression models showed an overall reduction in energy purchased from intervention categories of -4.8% (95% CI -7.0% to -2.7%), p < 0.001 during the availability intervention period and a reduction of -11.5% (95% CI -13.7% to -9.3%), p < 0.001 during the availability plus size intervention period, relative to the baseline. There was a reduction in energy purchased of -6.6% (95% CI -7.9% to -5.4%), p < 0.001 during the availability plus size period, relative to availability alone. Study limitations include using energy purchased as the primary outcome (and not energy consumed) and the availability only of transaction-level sales data per site (and not individual-level data)., Conclusions: Decreasing the proportion of higher energy foods in cafeterias reduced the energy purchased. Decreasing portion sizes reduced this further. These interventions, particularly in combination, may be effective as part of broader strategies to reduce overconsumption of energy from food in out-of-home settings., Trial Registration: ISRCTN registry ISRCTN87225572., Competing Interests: The authors have declared that no competing interests exist.

The United States Department of Agriculture (USDA) National School Lunch and Breakfast Programs are critical for the health and food security of U.S. schoolchildren, but access to these programs was disrupted by COVID-19 pandemic-related school closures in spring 2020. While temporary policy changes to the programs enabled school food authorities (SFAs) to pivot towards distributing meals throughout their communities instead of within school buildings, SFAs faced complex challenges during COVID-19 with minimal external support. This mixed methods study investigates the implementation and financial challenges experienced by twelve of the largest urban SFAs in the U.S. during COVID-19. We conducted semi-structured interviews with SFA leaders and analyzed alongside quantitative financial data. We found that SFAs reconfigured their usual operations with nearly no preparation time while simultaneously trying to keep staff from contracting COVID-19, accommodate stakeholders with sometimes competing priorities, and remain financially solvent. Because student participation was much lower than during regular times, and revenue is tied to the number of meals served, SFAs saw drastic decreases in revenue even as they carried regular operating costs. For future crises, disaster preparedness plans that help SFAs better navigate the switch to financially viable community distribution methods are needed.

Few online food ordering systems provide tailored dietary feedback to consumers, despite suggested benefits. The study aim was to determine the effect of providing tailored feedback on the healthiness of students' lunch orders from a school canteen online ordering system. A cluster randomized controlled trial with ten government primary schools in New South Wales, Australia was conducted. Consenting schools that used an online canteen provider ('Flexischools') were randomized to either: a graph and prompt showing the proportion of 'everyday' foods selected or a standard online ordering system. Students with an online lunch order during baseline data collection were included ( n = 2200 students; n = 7604 orders). Primary outcomes were the proportion of foods classified as 'everyday' or 'caution'. Secondary outcomes included: mean energy, saturated fat, sugar, and sodium content. There was no difference over time between groups on the proportion of 'everyday' (OR 0.99; p = 0.88) or 'caution' items purchased (OR 1.17; p = 0.45). There was a significant difference between groups for average energy content (mean difference 51 kJ; p -0.02), with both groups decreasing. There was no difference in the saturated fat, sugar, or sodium content. Tailored feedback did not impact the proportion of 'everyday' or 'caution' foods or the nutritional quality of online canteen orders. Future research should explore whether additional strategies and specific feedback formats can promote healthy purchasing decisions.

Digital food environments are now commonplace across many food service and retail settings, influencing how the population orders and accesses foods. As such, digital food environments represent a novel platform to deliver strategies to improve public health nutrition. The purpose of this review was to explore the impact of dietary interventions embedded within online food ordering systems, on user selection and purchase of healthier foods and beverages. A systematic search of eight electronic databases and grey literature sources was conducted up to October 2020. Eligible studies were randomized controlled trials and controlled trials, designed to encourage the selection and purchase of healthier products and/or discourage the selection and purchase of less-healthy products using strategies delivered via real-world online food ordering systems. A total of 9441 articles underwent title and abstract screening, 140 full-text articles were assessed for eligibility, and 11 articles were included in the review. Meta-analysis of seven studies indicated that interventions delivered via online food ordering systems are effective in reducing the energy content of online food purchases (standardized mean difference (SMD): -0.34, p = 0.01). Meta-analyses including three studies each suggest that these interventions may also be effective in reducing the fat (SMD: -0.83, p = 0.04), saturated fat (SMD: -0.7, p = 0.008) and sodium content (SMD: -0.43, p = 0.01) of online food purchases. Given the ongoing growth in the use of online food ordering systems, future research to determine how we can best utilize these systems to support public health nutrition is warranted.

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).

The Community Eligibility Provision (CEP) of the Healthy, Hunger-Free Kids Act of 2010 allows the provision of universal free meals (UFMs) in high-poverty school areas. Participation in UFM programs, including through CEP, could reduce meal costs due to economies of scale and a lower administrative burden. We analyzed the School Nutrition and Meal Cost Study (SNMCS) data from 508 UFM-eligible schools (103 UFMs) to evaluate whether meal costs varied by UFM status. We used school-level data to address the non-random selection to UFMs with inverse probability of treatment weighting (IPTW). We estimated a generalized linear model with a log link and gamma distribution to predict meal costs by UFM status and school size. Full costs among medium and large schools were marginally lower in UFM schools for lunch (-$0.673; 95% CI: -1.395, 0.0499; p = 0.068) and significantly lower for breakfast (-$0.575; 95% CI: -1.077, -0.074; p = 0.025). UFM was not associated with meal costs among smaller schools. Healthy Eating Index scores did not vary significantly by UFMs, suggesting that lower costs could be achieved without an adverse effect on nutritional quality. This analysis is limited by the lack of identified student percentage (ISP) data needed to definitively identify CEP eligibility, although results were robust to sensitivity analyses addressing the lack of ISP data. The potential policy impact of these findings emphasizes the need for future studies that assess ISP and cost with more recent data and longitudinal designs.

Our food systems depend on complex interactions between farmers and food producers, local and federal governments, and consumers. Underlying these interactions are economic, environmental, and societal factors that can impact the types of food available, access to food, affordability, and food safety. The recent SARS-CoV-2 global pandemic has affected multiple aspects of our food systems, from federal governments' decisions to limit food exports, to the ability of government agencies to inspect food and facilities to the ability of consumers to dine at restaurants. It has also provided opportunities for societies to take a close look at the vulnerabilities in our food systems and reinvent them to be more robust and resilient. For the most part, how these changes ultimately affect the safety and accessibility of food around the world remains to be seen., (© 2020 New York Academy of Sciences.)

The emergence of COVID-19 in the United States led most states to close or severely limit the capacity of their early child-care and education (ECE) programs. This loss affected millions of young children, including many of the 4.6 million low-income children who are provided free meals and snacks by their ECE programs through support from the federal Child and Adult Care Food Program (CACFP).Although Congress swiftly authorized waivers that would allow CACFP-participating ECE programs to continue distributing food to children, early evidence suggests that most ECE programs did not have the capacity to do so, leaving a fragmented system of federal, state, and local food programs to fill the gaps created by this loss.Critical steps are needed to repair our nation's fragile ECE system, including greater investment in CACFP, to ensure the nutrition, health, and development of young children during the COVID-19 pandemic and beyond.

Childhood obesity remains a pressing public health concern. Children consume a substantial amount of their caloric intake while in school, making the passage of the Healthy Hunger-Free Kids Act (HHFKA) in 2010 and the subsequent improvements to the school meal standards a key policy change. Using data from the School Nutrition and Meal Cost Study, this paper seeks to re-examine the association between students' ( N = 1963) weight status and participation in the National School Lunch Program (NSLP) and School Breakfast Program (SBP) since the implementation of these policy changes to determine whether, and how, this relationship has changed. After controlling for a wide array of student characteristics and school-level fixed effects, findings from the multivariate regression analyses indicate that usual participation in the school meal programs has no clear association with students' weight status, which contradicts findings from earlier studies conducted prior to the passage of the HHFKA. These findings are discussed in relation to changes in the demographic composition of usual NSLP participants over time.

Objectives: The objectives of the study were to investigate access to free school meals (FSMs) among eligible children, to describe factors associated with uptake and to investigate whether receiving FSMs was associated with measures of food insecurity in the UK using the Coronavirus (COVID-19) wave of the UK Household Longitudinal Study., Study Design: The study design was cross-sectional analyses of questionnaire data collected in April 2020., Methods: Six hundred and thirty-five children who were FSM eligible with complete data were included in the analytic sample. Accessing a FSM was defined as receiving a FSM voucher or a cooked meal at school. Multivariable logistic regression was used to investigate (i) associations between characteristics and access to FSMs and (ii) associations between access to FSMs and household food insecurity measures. All analyses accounted for survey design and sample weights to ensure representativeness., Results: Fifty-one percent of eligible children accessed a FSM. Children in junior schools or above (aged 8+ years) (adjusted odds ratio [AOR]: 11.81; 95% confidence interval [CI]: 5.54, 25.19), who belonged to low-income families (AOR: 4.81; 95% CI: 2.10, 11.03) or still attending schools (AOR: 5.87; 95% CI: 1.70, 20.25) were more likely to receive FSMs. Children in Wales were less likely to access FSMs than those in England (AOR: 0.11; 95% CI: 0.03, 0.43). Receiving a FSM was associated with increased odds of recently using a food bank but not reporting feeling hungry., Conclusions: In the month after the COVID-19 lockdown, 49% of eligible children did not receive any form of FSMs. The present analyses highlight that the voucher scheme did not adequately serve children who could not attend school during the lockdown. Moreover, more needs to be done to support families relying on income-related benefits, who still report needing to access a food bank. As the scheme may be continued in summer or in a potential second wave, large improvements will be needed to improve its reach., (Copyright © 2020 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

The Healthy, Hunger-Free Kids Act strengthened competitive food standards (i.e., Smart Snacks), but an exemption allows reimbursable meal entrées that do not meet Smart Snack standards to be sold as "competitive entrées" on the same day they are served in the reimbursable meal, and the following day. Proposed rollbacks would enable these competitive entrées to continue to be sold on a third day, increasing the availability of competitive foods exempt from Smart Snacks standards. This study compared the Healthy Eating Index (HEI) scores of potential competitive entrées alone versus full reimbursable school lunches, and examined the nutritional characteristics of potential competitive entrées. Data were from a national sample of 1108 schools from the School Nutrition and Meal Cost Study. Linear regression models, accounting for school-level and state and district policy characteristics, found that HEI scores of competitive entrées were an average of 30 points lower than HEI scores of reimbursable lunches, with greater differences in small and rural schools. Less than 1% of common potential competitive entrees met Smart Snack standards, primarily due to higher sodium and saturated fat levels. The proposed rollbacks are estimated to potentially add approximately 662 mg of sodium and 3 g of saturated fat over three days (1103 mg sodium and 5 g saturated fat over a week) on average relative to Smart Snacks limits. Instead of increasing opportunities to sell competitive entrées, their sales should be further limited.

The U.S. Department of Agriculture's (USDA) Child and Adult Care Food Program (CACFP) updated meal pattern standards took effect in October 2017. The aim of this quasi-experimental, pre-post study is to identify changes in food and beverage practices of CACFP-participating centers due to implementation of updated CACFP meal patterns over a 21-month period. Eight hundred and fifty-eight centers located in 47 states and the District of Columbia completed a survey (primarily electronic) at both time points (67.6% follow-up response rate). Multivariable logistic regressions with robust standard errors assessed changes over time, accounting for repeated observations within each site. From baseline to follow-up, centers reported the increased familiarity and implementation, albeit with time, money, and staffing-related challenges. Significant improvements were seen in not serving sugary cereals or flavored milk, in serving 100% whole grains, and serving processed meats less than once a week. While CACFP-participating centers reported making significant progress in meeting the updated meal pattern standards and suggested best practices within 15-19 months of their effective date, reported compliance and adherence to the standards and best practices was not universal. USDA, state agencies, and technical assistance providers should work to provide centers with additional guidance to help them with implementation.

This study aimed to determine the impact of 2017 revisions to the Child and Adult Care Food Program (CACFP) nutrition standards on foods and beverages served and meal costs in family child care homes (FCCHs). Our pre-post study utilized four weeks of menus and food receipts from 13 FCCH providers in Boston, MA prior to CACFP nutrition standards changes in 2017 and again one year later, resulting in n = 476 menu observation days. We compared daily servings of food and beverage items to the updated standards. Generalized estimating equation models tested for changes in adherence to the standards and meal costs. FCCHs offered more whole grains and less juice and refined grains from baseline to follow-up. FCCHs were more likely to meet the revised whole grain standard at follow-up (OR = 2.7, 95% CI: 1.4, 5.2, p = 0.002), but rarely met all selected standards together. Inflation-adjusted meal costs increased for lunch (+$0.27, p = 0.001) and afternoon snack (+$0.25, p = 0.048). FCCH providers may need assistance with meeting CACFP standards while ensuring that meal costs do not exceed reimbursement rates.

The Healthy, Hunger-Free Kids Act (HHFKA), a public law in the United States passed in 2010, sought to improve the healthfulness of the school food environment by requiring updated nutrition standards for school meals and competitive foods. Studies conducted since the passage of the HHFKA indicate improvements in the food environment overall, but few studies have examined whether these improvements varied by the socioeconomic and racial/ethnic composition of students in schools. To better understand the extent of disparities in the school food environment after HHFKA, this paper examined differences in the healthfulness of school food environments and the nutritional quality of school lunches by the school poverty level and racial/ethnic composition of students using data from the School Nutrition and Meal Cost Study. Results from chi-square analyses showed lower proportions of high poverty, majority black, and majority Hispanic schools had access to competitive foods, while higher proportions of these schools had a school wellness policy in addition to a district wellness policy. The overall nutritional quality of school lunches, as measured by total Healthy Eating Index (HEI)-2010 scores, did not vary significantly across school types, although some HEI component scores did. From these findings, we concluded that there were disparities in the school food environment based on the socioeconomic and racial/ethnic composition of students in schools, but no significant disparities in the overall nutritional quality of school lunches were found.

Many adolescents have poor eating habits. As a major part of their caloric intake takes place at school, the present study aims to examine the effect of increasing the availability of healthier foods in school canteens on sales, student attitude and self-reported behaviour. A quasi-experimental study was carried out at two vocational schools in the Netherlands over a 10-month period, where the visible share of healthier products was gradually or abruptly increased from 60% to 80%. Outcome measures were sales data for healthier and less healthy foods and drinks in the canteens, as well as surveys. The proportion of healthier products sold increased from 31.1% during the baseline period to 35.9% in the final period. A gradual increase led to higher relative sales of healthier products (40%) than an abrupt change (34.5%). Survey data showed that students' moderate satisfaction remained insensitive to the changes over time. Overall, results suggest that increasing the availability of healthier products in school canteens leads to small positive changes in sales of products, particularly in the product groups beverages and sandwiches. A gradual introduction may ensure that students slowly get used to assortment changes.

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.

Early childhood education and care services are a significant feature of Australian family life, where nearly 1.4 million children attended a service in 2019. This paper reports on the cost of food provided to children in long day-care (LDC) services and extrapolates expenditure recommendations to support food provision compliance. A cross-sectional audit of LDC services in metropolitan Perth was conducted to determine food group provision by weighing raw ingredients of meal preparation-morning tea, lunch, and afternoon tea (MT, L, AT). Ingredients were costed at 2017 online metropolitan pricing from a large supermarket chain. Across participating services, 2 days of food expenditure per child/day ranged between $1.17 and $4.03 across MT, L, AT, and averaged $2.00 per child/day. Multivariable analysis suggests that an increase of $0.50 per child/day increases the odds of a LDC service meeting >50% of Australian Dietary Guideline (ADG) recommendations across ≥4 core food groups by fourfold ( p = 0.03). Given the fact that the literature regarding food expenditure at LDC services is limited, this study provides information about food expenditure variation that impacts planning and provision of nutritionally balanced menus recommended for children. An average increase of food expenditure of $0.50 per child/day would increase food provision compliance., Competing Interests: R.S., A.D., R.W., L.C., and J.L have no conflicts of interest.

OBJECTIVE To analyze how the profile of food purchases from family farming under the National School Feeding Program (PNAE) is related to socioeconomic and demographic indicators in Brazilian capitals. METHODS This cross-sectional and descriptive study was based on secondary data from 2016 and 2017 from the Brazilian government. We used demographic and socioeconomic data, as well as the amount of federal funding; the percentage used purchases of food from family farming and the public call notices. RESULTS The capitals in the largest quartile of HDI and funding by the federal government used less than 30% of the resource for the purchase of crops from family farming in 2016. All capitals of the Northern region used more than 30%, while the Southern and Southeastern regions did not comply with the legislation. We highlight that most analyzed food items were in natura. CONCLUSIONS The implementation of this public policy occurs unequally in Brazilian capitals, with greater difficulty in those supposedly with better institutional structure and higher volume of resources destined to the National School Feeding Program. The program, however, maintains its potential for the promotion of adequate and healthy food in schools, due to the quality of food included in public calls.

The study aimed to verify the adequacy of funds for food purchases from family farming in the scope of the National School Food Program (PNAE) in Brazil's state capitals and the Federal District. This was a descriptive study based on secondary data obtained from the webpage of the National Fund for the Development of Education (FNDE) in the link dedicated to information on family farming. We analyzed the amounts transferred to the FNDE and the percentage used in purchasing foods from family farmers for school meals in the state capitals and Federal District from 2011 to 2017. Data were collected in May 2019. One-third of the 27 cities (33.3%) reported purchases above the minimum recommended level (30%). The North of Brazil complied with the recommended level (39.4%), while the Southeast reported the lowest level (6.4%). There was an increase from 2011 to 2017 in the total amounts invested and in the number of cities that purchased foods from family farming. Boa Vista (Roraima) was the capital that spent the largest share of its school meal funds on foods produced by family farmers (56.6%). In 2017, the local governments in Boa Vista and Aracaju (Sergipe) offered matching funds for the funds transferred from the FNDE for these food purchases. In conclusion, from 2011 to 2017, only one-third of the capital cities adequately used the percentage of funds for purchasing foods from family farming, although there was a gradual increase in the purchase of these foods, especially in the state capitals from North and Northeast Brazil.

Background: Locally grown foods, through farm-to-school (FTS) activities, may be a key component to balancing foodservice budgets and alleviating financial constraints in school districts. Therefore, the purpose of this study is to examine the impact of local food expenditures on school foodservice revenues and earnings. We anticipated a positive impact of local food expenditures on foodservice revenues and earnings., Methods: Ordinary Least Squares (OLS) regression analysis was conducted using data from the 2013 US Department of Agriculture Farm to School Census. The questionnaire primarily asked all US public school districts about their FTS operations during 2011-2012 school year., Results: Although our results initially showed a negative impact of local milk and nonmilk expenditures on foodservice revenues from food sales, when combined with revenues from the federal government, the impact is positive. The positive effect seems to hold when adding foodservice revenues from both food sales and federal funds. Our study found a similar pattern for foodservice earnings., Conclusions: This may indicate that competitive foods are still widely preferred in school districts. Revenue from the federal government is critical to maintain FTS activities viable to students and community members although federal funds and food sales may not cover total foodservice expenditures., (© 2019, American School Health Association.)

Background: Children spend a considerable amount of time at school and consume at least one meal/day. This study aimed to investigate if a free, healthy school meal every day for one school year was associated with children's intake of healthy foods at school, weight status and moderating effects of socio-economic status., Methods: A non-randomized study design with an intervention and a control group was used to measure change in children's dietary habits at lunchtime. In total, 164 children participated; 55 in the intervention group and 109 in the control group (baseline). Intervention-children were served a free, healthy school meal every school day for one year. Participating children completed a food frequency questionnaire at baseline, at five months follow-up and after one year. Children's anthropometrics were measured at all three timepoints. Intervention effects on children's Healthy food score, BMI z-scores, and waist circumference were examined by conducting a Repeated Measures Multivariate ANOVA. Moderating effects of children's gender and parental socio-economic status were investigated for each outcome., Results: A significant intervention effect on children's outcomes (multivariate) between baseline and after one year (F = 2.409, p < 0.001), and between follow-up 1 at five months and after one year (F = 8.209, p < 0.001) compared to the control group was found. The Univariate analyses showed a greater increase in the Healthy food score of the intervention group between baseline and follow-up 1 (F = 4.184, p = 0.043) and follow-up 2 (F = 10.941, p = 0.001) compared to the control group. The intervention-children had a significant increase in BMI z-scores between baseline and follow-up 2 (F = 10.007, p = 0,002) and between follow-up 1 and 2 (F = 22.245, p < 0.001) compared to a decrease in the control-children. The intervention-children with lower socio-economic status had a significantly higher increase in Healthy food score between baseline and follow-up 2 than the control-children with lower socio-economic status (difference of 2.8 versus 0.94), but not among children with higher socio-economic status., Conclusions: Serving a free school meal for one year increased children's intake of healthy foods, especially among children with lower socio-economic status. This study may contribute to promoting healthy eating and suggests a way forward to reduce health inequalities among school children., Trial Registration: ISRCTN61703361 . Date of registration: December 3rd, 2018. Retrospectively registered.

Background: Many students experience challenges participating in the School Breakfast Program (SBP) when breakfast is served before school in the cafeteria. Serving breakfast free to all students or offering innovative breakfast serving models, such as breakfast in the classroom (BIC), grab n' go, or second chance breakfast, may encourage higher SBP participation rates., Objective: To examine the association between offering breakfast free to all students as well as breakfast serving model with student participation in the SBP in October 2017 among public schools in North Carolina., Design: Cross-sectional study using data from the North Carolina Department of Public Instruction., Participants/setting: This study included data from 2,285 North Carolina public schools who served breakfast in October 2017 with 1,445,287 students., Main Outcome Measures: The main outcome measures are the odds of a student participating in the SBP among students overall, students eligible for free or reduced-price (FRP) meals, and students not eligible for FRP meals., Statistical Analyses Performed: Multiple logistic regression assessed the association between offering breakfast free to all students and breakfast serving model with the probability of participating in the SBP (number of students participating out of number of students enrolled) for students overall, eligible for FRP meals, and not eligible for FRP meals. Statistical models were stratified by school type (elementary, middle, and high schools)., Results: Breakfast serving models positively associated with SBP participation were BIC and BIC plus grab n' go for elementary and high school students and grab n' go and second chance for middle and high school students (P<0.05). Serving breakfast free to all students was positively associated with SBP participation alone and in combination with BIC, second chance, and BIC plus grab n' go (P<0.05)., Conclusions: Serving breakfast free to all students and breakfast serving model were associated with SBP participation, and different relationships existed for different school levels., (Copyright © 2019 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Proper food safety training is essential to decrease incidences and overall rates of foodborne illnesses and outbreaks. Though many commercial restaurants should provide proper food safety training to food handler employees, this training is not always offered or effective. Here, we summarize the results of a primary literature study concerning the effectiveness of food safety training in commercial settings. The literature chosen for review contained only studies with experimental food safety training, with before and after training data. Through evaluation of these studies, the best practice for ensuring effective training and follow-through were the use of food safety training programs, which incorporated both knowledge and behavior-based training. PRACTICAL APPLICATION: Food safety managers in food service establishments may consider reevaluating their current food safety training program to incorporate behavioral-based food safety training in addition to knowledge-based training., (© 2019 Institute of Food Technologists®.)

Background: School breakfast is an important nutritional component of a student's day. Many schools operate a school breakfast program, but high schools have low rates of participation. This study aimed to investigate the economic impact on school food service, of expanding the school breakfast program to increase participation in high schools., Methods: Ten rural high schools participated in the economic analysis of expanding their school breakfast program. Schools provided data on costs of daily operation and start-up costs. Analyses calculated the daily breakeven point, revenue, cost, and days needed to recoup costs., Results: Schools sold enough breakfast meals to break even on daily costs of operating an expanded program. Schools saw daily profits ranging from $196-$432 and recouped costs associated with expanding the breakfast program within 15-46 days., Conclusions: Expanding the school breakfast program can be economical for schools, while increasing student exposure to the health and academic benefits of school breakfast., (© 2019, American School Health Association.)

Numerous governments in developing countries institute school lunch programs or school feeding programs as a strategy to address high malnutrition and low education rates among children. In 2005, the Ghanaian government launched the Ghana School Feeding Programme (GSFP). The GSFP policy does not document (1) the actual meal and associated nutrient profile received by the student, (2) the cost of the meal ingredients to the caterer who prepares the food, nor (3) the recipe derivations that may supply an enhanced nutritional profile. We address these 3 information gaps by employing a detailed case study of 4 caterers supplying a traditional tomato stew recipe in northern Ghana within GSFP-supported school lunch programs. Specifically, we explore the following propositions: (1) GSFP caterers can deliver a school lunch for under 100 pesewas (1 GH¢ or $0.21 USD) per student; (2) the meal meets the recommended daily allowance for protein; (3) soy can serve as a cost-effective ingredient to fortify the meal in terms of protein level and protein quality; and (4) significant differences exist in the macro- and micronutrient profile due to caterer discretion. We answer the above 4 propositions, and by doing so show the importance of accurately measuring the nutritional content, costs, and quantities of the actual school lunch under study. Second, among our results, we show the economy of locally produced soy flour as an ingredient that can lower costs and raise nutrition when substituting for other locally produced proteins such as ground beef and mackerel.

Intervention: British Columbia's (BC) provincial school food and beverage sales policy., Research Question: What are the processes associated with district-level implementation of BC's school food and beverage sales policy?, Methods: We adopted a realist approach and a qualitative, multiple case study design that included three urban and two rural BC school districts. Data collection involved semi-structured interviews and questionnaires with health, education, and industry stakeholders, observations, document analysis and website scans. Analysis identified: (i) mechanisms influencing if and how stakeholders engage in implementation activities at the district level and (ii) specific dimensions of context influencing these mechanisms., Results: We identified three mechanisms driving implementation processes at the school district level associated with BC's school food and beverage sales policy. These mechanisms are influenced by various dimensions of context that lead to a range of implementation outcomes. The 'mandatory mechanism' refers to the mandatory nature of the policy effectively triggering implementation efforts, influenced by a normative acceptance of the education system hierarchy. The 'money mechanism' refers to how this district demand leads vendors to create a compliant supply; it is influenced by beliefs about children's food preferences, health and food, and the existence of competition. Finally, the 'monitoring mechanism' refers to how systems of informal monitoring are used to promote compliance in the context of a competitive sales environment., Conclusion: The outcomes of these three policy mechanisms are influenced by complex dimensions of context. Identifying context-mechanism interactions can help inform public health policymakers interested in interventions for improving school food environments.

The integration of family farming with school meals has the potential to improve the variety of school menus thereby bringing the production and consumption of food into closer alignment. This study researched the Brazilian municipalities with respect to the purchase of food from family farms for the National School Food Program. It involved a cross-sectional study conducted via an electronic questionnaire sent to 5,565 municipalities in the country. The research included 93.2% of the municipalities (n = 5,184), 78.5% of which acquired food from family farms, with the highest frequency (95.5%) of the municipalities making the purchase in the southern region, and the lowest (67.9%) in the Central West region. The large-scale municipalities, with mixed, decentralized or outsourced school food management, and without a nutritionist as technical manager, purchased food less frequently from family farms. The conclusion reached is that, despite the widespread acquisition of food from family farms in the program throughout the country, 50% of municipalities did not invest the minimum required by law, requiring actions aimed at compliance with legislation and greater investment, especially in states and regions which revealed the greatest difficulties.

This study aimed to analyze the financial investment used for the procurement of food for the Brazilian National School Food Program (PNAE) in a city in the South of Brazil. The bidding process, the public calls and accountability reports of the PNAE were analyzed in the following variables: I) municipal financial complementation values; II) percentage of resources used to purchase foods from Family Farmer (FF), and Recommended, Restricted, Prohibited and others foods. The comparison of proportions was employed as a test to identify differences between investments. The municipal financial complementation was 65% of the total. The total amount used to purchase foods was distributed as follows: 65.5% for the Recommended, 27.9% for the Restricted, 6.5% for the Other and 0% for the Prohibited. The expenditure on Recommended foods was higher (p < 0.001) compared to the remaining groups. FF provided only Recommended foods, representing 12.1% of total (municipality and federal) expenditure and 29.5% of total federal funds. The direct purchase from FF contributed to the purchase of recommended foods. The municipal financial complementation was not geared to FA, which can compromise the potential of the school food program to promote healthy and sustainable food systems.

Objective: To (i) describe the proportion of foods and beverages available on school canteen menus classified as having high ('green'), moderate ('amber') or low ('red') nutritional value; (ii) describe the proportion of these items purchased by students; and (iii) examine the association between food and beverage availability on school canteen menus and food and beverage purchasing by students., Design: A cross-sectional study was conducted as part of a larger randomised controlled trial (RCT)., Setting: A nested sample of fifty randomly selected government schools from the Hunter New England region of New South Wales, Australia, who had participated in an RCT of an intervention to improve the availability of healthy foods sold from school canteens, was approached to participate., Subjects: School principals, canteen managers and students., Results: The average proportion of green, amber and red items available on menus was 47·9, 47·4 and 4·7 %, respectively. The average proportion of green, amber and red items purchased by students was 30·1, 61·8 and 8·1 %, respectively. There was a significant positive relationship between the availability and purchasing of green (R 2=0·66), amber (R 2=0·57) and red menu items (R 2=0·61). In each case, a 1 % increase in the availability of items in these categories was associated with a 1·21, 1·35 and 1·67 % increase in purchasing of items of high, moderate and low nutritional value, respectively., Conclusions: The findings provide support for school-based policies to improve the relative availability of healthy foods for sale in these settings.

Purpose: University students may be at risk for food insecurity (FI) due to low income coupled with rising tuition, housing, and food costs. This study aimed to determine the prevalence of FI and potential correlates among students at a small, rural Canadian university., Methods: Health Canada's 10-item household food security survey module (HFSSM) was adapted to assess food security status within the postsecondary student population. An additional 11 items measured food access and demographics. The validated, web-based survey was distributed by email and completed by 218 students (15.6% response rate). Participants were classified as food secure, moderately food insecure, or severely food insecure using the HFSSM Adult scale., Results: An overall FI rate of 37.2% was observed. This included 25.7% moderately food insecure and 11.5% severely food insecure. Students in higher years of study and who lived off campus had higher rates of FI., Conclusions: FI appears to be a significant concern for university students and has potential health and academic implications. Further research is needed to clarify the determinants and extent of FI for postsecondary students and to develop strategies to mitigate the prevalence and effects of food insecurity in these young adults.

Purpose: To compare sales of Food Resources and Education for Student Health (FRESH) Approved versus non-FRESH Approved menu cycle items pre- and postimplementation of the FRESH program., Methods: Sales data from 2011-2015 of FRESH Approved versus non-FRESH Approved menu items were analyzed. Fruit and milk items sold, net sales, and the cost of free fruit and milk redeemed through the FRESH Reward Card (FRC) program, were also analyzed., Results: FRESH Approved items sold more often than non-FRESH Approved items in the latter 2 years (P = 0.01). Prices of FRESH Approved menu items were significantly lower than non-FRESH Approved items for all years (e.g., $1.52 ± $0.94 vs $2.21 ± $1.02 per serving in 2014-2015; P < 0.001). Across all FRESH implementation years, FRESH Approved menu items were found more often on the 6-week menu (P < 0.05). The number of fruit items sold increased from a baseline of 143 052 to 170 954, and net sales increased from $135 450 to $154 248 after 3 years of the FRC implementation., Conclusions: FRESH Approved items were less expensive, available more often, and had higher sales. The FRC increased net fruit sales despite the cost of free fruit. Highlighting and reducing the cost of healthy foods are promising practices to improve campus food environments.

Background: More than 3.6 million children are served daily by the Child and Adult Care Food Program (CACFP)-participating child day care centers. This study provides a nationwide assessment of center-level responsibilities for menu, meal/snack preparation, meal preparer training, and food and beverage (F&B) purchasing., Methods: A nationally representative survey of 5483 CACFP child day care centers was conducted between August 22, 2017, and September 30, 2017. One thousand three hundred forty-three centers (25% response) in 47 states and the District of Columbia responded. Descriptive statistics describe center-level menu, meal, and purchasing practices and center characteristics. Multivariate logistic regressions examined characteristics associated with F&B purchasing sources., Results: Menus were primarily prepared by directors/assistant directors and on-site food manager/cooks, while site staff primarily prepared meals/snacks. Fifty-two percent of meal preparers held a food sanitation license, but only 5% had formal nutrition training (e.g., Registered Dietician). Most centers purchased F&B from food service providers (63%), local grocery stores (59%), warehouse stores (40%), or from 2+ sources (50%). Independent centers were more likely to purchase F&B from local grocery stores or 2+, while free or state-subsidized sites were more likely to purchase from a food service provider and less likely to purchase from other sources than were centers charging between $101 and $201.99 per week. Centers where an on-site cook/food manager prepared the menus were significantly more likely to purchase their F&B from local grocery and/or warehouse stores and/or from 2+ sources., Conclusions: Opportunities exist to target CACFP training to specific roles within and specific types of CACFP-participating child day care centers to facilitate compliance with the updated CACFP standards.

Background: Early care and education (ECE) policies can improve childhood obesity risk factors. We evaluated barriers and facilitators to implementing mandatory nutrition standards for foods provided in South Carolina ECE centers serving low-income children, comparing centers participating in the Child and Adult Care Food Program (CACFP) with non-CACFP centers., Methods: We mailed 261 surveys (demographics, policies and practices, barriers and facilitators) to center directors after new state nutrition standards were implemented in South Carolina. We conducted univariate and bivariate analyses to explore relationships between barriers, facilitators, and center-level characteristics, by CACFP status., Results: We received 163 surveys (62% response rate). Centers had a median [interquartile range (IQR)] of 5 (4-7) classrooms and 59 (37.5-89) total children enrolled. More than half (60.1%) of directors reported they were moderately or fully informed about the standards. The most common barriers were food costs (17.8%) and children's food preferences (17.8%). More non-CACFP directors reported food costs as a barrier (28.6% vs. 6.5%, p < 0.001), having to spend additional money on healthier foods (48.8% vs. 28.6%, p = 0.01), and having to provide additional nutrition education to parents (28.6% vs. 11.7%, p = 0.01), compared with CACFP directors., Conclusions: Center directors were generally well informed about the nutrition standards. The most common barriers to implementing the standards were food costs and children's food preferences. Centers participating in CACFP may be in a better position to adhere to new state nutrition standards, as they receive some federal reimbursement for serving healthy foods and may be more accustomed to regulation.

Community Servings, a not-for-profit organization in the Boston area, delivers medically tailored meals that take into account the nutritional needs of people with chronic illnesses. The idea is to ensure that a patient's food addresses his or her specific health conditions.

It is the position of the Academy of Nutrition and Dietetics that children and adolescents should have access to safe and healthy foods that promote physical, cognitive, and social growth and development. Federally funded nutrition assistance programs, such as food assistance, meal service, and nutrition education, play a vital role in ensuring that children and adolescents have access to the foods they need and in improving the overall nutrition and health environments of communities. Federally funded nutrition assistance programs help to ensure that children and adolescents receive safe, healthy foods that provide adequate energy and nutrients to meet their growth and development needs. These programs provide access to adequate food supplies to combat hunger and food insecurity; provide healthy foods to children and adolescents who have nutritional or medical risk factors, such as iron deficiency anemia; and provide nutrition education. In addition, federally funded nutrition assistance programs serve as a means to prevent or reduce obesity and other chronic diseases. It is important that permanent and full federal funding be provided for these programs, which have been consistently shown to have a positive impact on child and adolescent nutrition and health outcomes. Registered dietitian nutritionists and nutrition and dietetic technicians, registered-trained in food science, nutrition, and food systems to implement programs to monitor, evaluate, and improve the nutritional status of children and adolescents-are preeminently qualified to implement and evaluate nutrition assistance programs for children and adolescents., (Copyright © 2018 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

This study aimed to examine: (1) how the Internet has changed consumers food-buying behavior and identify its associated factors; (2) consumers' concern about food safety information of online food products. A cross-sectional study was performed from October to December 2015 in Hanoi-a Vietnamese epicenter of food service. One thousand seven hundred and thirty six (1736) customers were randomly chosen from food establishments of 176 communes. Data were collected through face-to-face interviews using structured questionnaires. The majority of participants reported using the Internet to search for food products (81.3%). The most crucial factors influencing food purchases through the Internet were convenience (69.1%) and price (59.3%). Only one-third of participants selected products based on accurate evidence about food safety certification or food origin. The majority of participants were concerned about the expiration date (51.6%), while brand (9.8%) and food licensing information (11.3%) were often neglected. People who were:(1) female, (2) highly influenced by online relationships, and (3) having difficulty in doing usual activities were more likely to look for online food products. These findings produce practical advice to consumers when purchasing their desired food products on the Internet, to online food retailers and to the Government of Vietnam to implement appropriate legislation regarding trading online food products.

Introduction: In sub-Saharan Africa foodborne disease and foodborne disease outbreaks are frequently ascribed to poor personal hygiene of street food vendors and food handlers in food establishments. Evidence on the level of food hygiene practices and food safety measures among food handlers is required for proper planning and implementation of targeted interventions. In this study, we aimed to determine the level of food hygiene and safety measures among street food vendors and food handlers in food establishments of Dessie Town, Ethiopia., Method: A community-based cross-sectional study was performed in Dessie town, Ethiopia from December 2013 to June 2014. Data were collected using a pre-tested structured questionnaire and an observational checklist by a trained data collector among 116 food handlers from 116 food establishments and 19 food handlers from 19 street food vendors. Multivariable logistic regression analysis with 95% confidence interval (CI) was used to identify the factors significantly associated with good level of food hygiene and safety practices., Result: Almost three-quarter (72%; 84/116) of food handlers in food establishments had a good level of food hygiene and safety practices compared to nearly half (53%; 10/19) of street food vendors. However, this difference was not statistically significant. Average monthly income of >$21 US (adjusted odds ratio [AOR] = 3.2; 95%CI: 1.3-7.7), availability of service training (AOR = 6.7; 95%CI: 1.8-25), wearing a gown during food handling (AOR = 19; 95%CI: 6.8-51) and medical checkup (AOR = 5.2; 95%CI: 2.1-13) were significantly associated with good levels of food hygiene and safety measures., Conclusion: Comprehensive health education and promotion programs through continuous training on food hygiene and safety, with promotion of wearing gown during food handling, regular medical checkups of food handlers and programs that enhance the monthly income of food handlers are promising strategies for promoting proper food handling practices in Dessie town, Ethiopia.

Background: observational studies have shown that nutritional strategies to manage malnutrition may be cost-effective in aged care; but more robust economic data is needed to support and encourage translation to practice. Therefore, the aim of this systematic review is to compare the cost-effectiveness of implementing nutrition interventions targeting malnutrition in aged care homes versus usual care., Setting: residential aged care homes., Methods: systematic literature review of studies published between January 2000 and August 2017 across 10 electronic databases. Cochrane Risk of Bias tool and GRADE were used to evaluate the quality of the studies., Results: eight included studies (3,098 studies initially screened) reported on 11 intervention groups, evaluating the effect of modifications to dining environment (n = 1), supplements (n = 5) and food-based interventions (n = 5). Interventions had a low cost of implementation (<£2.30/resident/day) and provided clinical improvement for a range of outcomes including weight, nutritional status and dietary intake. Supplements and food-based interventions further demonstrated a low cost per quality adjusted life year or unit of physical function improvement. GRADE assessment revealed the quality of the body of evidence that introducing malnutrition interventions, whether they be environmental, supplements or food-based, are cost-effective in aged care homes was low., Conclusion: this review suggests supplements and food-based nutrition interventions in the aged care setting are clinically effective, have a low cost of implementation and may be cost-effective at improving clinical outcomes associated with malnutrition. More studies using well-defined frameworks for economic analysis, stronger study designs with improved quality, along with validated malnutrition measures are needed to confirm and increase confidence with these findings.

Objective: To assess (i) the extent to which stakeholders have accepted and implemented a Healthy Food and Drink Policy for schools a decade after its introduction and (ii) any resulting implications for canteen profitability., Design: Online survey distributed via electronic newsletter to school principals., Setting: Western Australian public schools., Subjects: Principals, teachers, canteen managers, and parents and citizens committee presidents (n 307)., Results: Large majorities of respondents reported that the policy has made the foods and drinks provided in schools healthier (85 %) and that the policy constitutes a good opportunity to teach children about healthy eating (90 %). Only small proportions of respondents felt it had been difficult to implement the policy in their schools (13 %) or that the policy fails to accommodate parents' rights to choose the foods consumed by their children (16 %). Most of the policy outcomes assessed in both the initial post-implementation evaluation (2008) and the 10-year follow-up evaluation (2016) demonstrated significant improvement over time., Conclusions: The study results indicate that comprehensive school food policies can favourably influence the foods and drinks provided on school premises and can be highly acceptable to key stakeholders, without adversely affecting profitability. The results are encouraging for policy makers in other jurisdictions considering the implementation of similar policies.

A mixed-methods needs assessment was conducted in an urban senior center serving lower-income seniors in Toronto, Ontario, to determine whether they should offer a congregate meal program. Methods included three focus groups with participants (n = 31), a focus group with staff (n = 8), a center-wide survey (n = 36), and a community scan of programs in the area. Interviews with five coordinators at other seniors' centers who offered meal programs were also used to gauge interest and assist with program development. The results of these activities supported offering a twice weekly lunch program with user fees. Over a 6-month pilot period, process evaluation was conducted, comprising observations, record review, and focus groups with participants (n = 9) and staff/volunteers (n = 7) to examine delivery, usage, and costs. Results indicated that the program was well-received and affordable, and that demands on staff were reasonable when a facilitator with culinary training was available. The lessons learned can be used to guide other senior centers in developing and evaluating congregate meal programs.

Background: School food environment policies may be a critical tool to promote healthy diets in children, yet their effectiveness remains unclear., Objective: To systematically review and quantify the impact of school food environment policies on dietary habits, adiposity, and metabolic risk in children., Methods: We systematically searched online databases for randomized or quasi-experimental interventions assessing effects of school food environment policies on children's dietary habits, adiposity, or metabolic risk factors. Data were extracted independently and in duplicate, and pooled using inverse-variance random-effects meta-analysis. Habitual (within+outside school) dietary intakes were the primary outcome. Heterogeneity was explored using meta-regression and subgroup analysis. Funnel plots, Begg's and Egger's test evaluated potential publication bias., Results: From 6,636 abstracts, 91 interventions (55 in US/Canada, 36 in Europe/New Zealand) were included, on direct provision of healthful foods/beverages (N = 39 studies), competitive food/beverage standards (N = 29), and school meal standards (N = 39) (some interventions assessed multiple policies). Direct provision policies, which largely targeted fruits and vegetables, increased consumption of fruits by 0.27 servings/d (n = 15 estimates (95%CI: 0.17, 0.36)) and combined fruits and vegetables by 0.28 servings/d (n = 16 (0.17, 0.40)); with a slight impact on vegetables (n = 11; 0.04 (0.01, 0.08)), and no effects on total calories (n = 6; -56 kcal/d (-174, 62)). In interventions targeting water, habitual intake was unchanged (n = 3; 0.33 glasses/d (-0.27, 0.93)). Competitive food/beverage standards reduced sugar-sweetened beverage intake by 0.18 servings/d (n = 3 (-0.31, -0.05)); and unhealthy snacks by 0.17 servings/d (n = 2 (-0.22, -0.13)), without effects on total calories (n = 5; -79 kcal/d (-179, 21)). School meal standards (mainly lunch) increased fruit intake (n = 2; 0.76 servings/d (0.37, 1.16)) and reduced total fat (-1.49%energy; n = 6 (-2.42, -0.57)), saturated fat (n = 4; -0.93%energy (-1.15, -0.70)) and sodium (n = 4; -170 mg/d (-242, -98)); but not total calories (n = 8; -38 kcal/d (-137, 62)). In 17 studies evaluating adiposity, significant decreases were generally not identified; few studies assessed metabolic factors (blood lipids/glucose/pressure), with mixed findings. Significant sources of heterogeneity or publication bias were not identified., Conclusions: Specific school food environment policies can improve targeted dietary behaviors; effects on adiposity and metabolic risk require further investigation. These findings inform ongoing policy discussions and debates on best practices to improve childhood dietary habits and health.