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Gangrade N, St Fleur K, Leak TM. Factors That Influence Snacking Behaviors of Adolescents From Urban Communities: A Qualitative Study. JOURNAL OF NUTRITION EDUCATION AND BEHAVIOR 2022; 54:521-531. [PMID: 35351357 DOI: 10.1016/j.jneb.2021.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 12/21/2021] [Accepted: 12/24/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To qualitatively explore factors that influence snacking behaviors of adolescents from urban communities. DESIGN One-time, semistructured phone interviews based on Social Cognitive Theory. SETTING Boys and Girls Club in New York City. PARTICIPANTS A total of 30 adolescents (aged 12-18 years; mean age 15.2 years, mostly female [57%], and Black or African American [83%]) were purposively recruited. This sample is representative of adolescent members at this Boys and Girls Club in New York City. PHENOMENON OF INTEREST Adolescents were asked about personal, environmental, and behavioral factors influencing snacking. ANALYSIS Interviews were audio-recorded, transcribed, and transcripts were analyzed using the thematic analysis approach in NVivo (version 12). RESULTS In terms of personal factors, adolescents' snacking was influenced by preference (eg, taste and brand), health benefits, and health concerns. Regarding the social environment, adolescents remarked that snacking with peers promoted unhealthy snacking, while snacking, with family promoted healthier snacking. The family culture was also a salient factor. In addition, adolescents discussed how proximity to corner stores in their physical environment fostered unhealthy snacking. Finally, behavioral factors that influenced frequent snacking were high self-efficacy and food autonomy. CONCLUSIONS AND IMPLICATIONS Snacking among adolescents from urban communities is influenced by preference, health, family/peer influence, neighborhood availability/access, and high autonomy. These factors can be targeted in interventions to improve snacking among this demographic.
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Affiliation(s)
- Navika Gangrade
- Division of Nutritional Sciences, Cornell University, Ithaca, NY.
| | | | - Tashara M Leak
- Division of Nutritional Sciences, Cornell University, Ithaca, NY
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Virgara R, Phillips A, Lewis LK, Baldock K, Wolfenden L, Ferguson T, Richardson M, Okely A, Beets M, Maher C. Interventions in outside-school hours childcare settings for promoting physical activity amongst schoolchildren aged 4 to 12 years. Cochrane Database Syst Rev 2021; 9:CD013380. [PMID: 34694005 PMCID: PMC8543676 DOI: 10.1002/14651858.cd013380.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Insufficient physical activity is one of four primary risk factors for non-communicable diseases such as stroke, heart disease, type 2 diabetes, cancer and chronic lung disease. As few as one in five children aged 5 to 17 years have the physical activity recommended for health benefits. The outside-school hours period contributes around 30% of children's daily physical activity and presents a key opportunity for children to increase their physical activity. Testing the effects of interventions in outside-school hours childcare settings is required to assess the potential to increase physical activity and reduce disease burden. OBJECTIVES To assess the effectiveness, cost-effectiveness and associated adverse events of interventions designed to increase physical activity in children aged 4 to 12 years in outside-school hours childcare settings. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, ERIC and SportsDISCUS to identify eligible trials on 18 August 2020. We searched two databases, three trial registries, reference lists of included trials and handsearched two physical activity journals in August 2020. We contacted first and senior authors on articles identified for inclusion for ongoing or unpublished potentially relevant trials in August 2020. SELECTION CRITERIA We included randomised controlled trials, including cluster-randomised controlled trials, of any intervention primarily aimed at increasing physical activity in children aged 4 to 12 years in outside-school hours childcare settings compared to usual care. To be eligible, the interventions must have been delivered in the context of an existing outside-school hours childcare setting (i.e. childcare that was available consistently throughout the school week/year), and not set up in the after-school period for the purpose of research. Two review authors independently screened titles and abstracts of identified papers with discrepancies resolved via a consensus discussion. A third review author was not required to resolve disagreements. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed the risk of bias of included trials with discrepancies resolved via a consensus discussion; a third review author was not required to resolve disagreements. For continuous measures of physical activity, we reported the mean difference (MD) with 95% confidence intervals (CIs) in random-effects models using the generic inverse variance method for each outcome. For continuous measures, when studies used different scales to measure the same outcome, we used standardised mean differences (SMDs). We conducted assessments of risk of bias of all outcomes and evaluated the certainty of evidence (GRADE approach) using standard Cochrane procedures. MAIN RESULTS We included nine trials with 4458 participants. Five trials examined the effectiveness of staff-based interventions to change practice in the outside-school hours childcare setting (e.g. change in programming, activities offered by staff, staff facilitation/training). Two trials examined the effectiveness of staff- and parent-based interventions (e.g. parent newsletters/telephone calls/messages or parent tool-kits in addition to staff-based interventions), one trial assessed staff- and child-based intervention (e.g. children had home activities to emphasise physical activity education learnt during outside-school hours childcare sessions in addition to staff-based interventions) and one trial assessed child-only based intervention (i.e. only children were targeted). We judged two trials as free from high risk of bias across all domains. Of those studies at high risk of bias, it was across domains of randomisation process, missing outcome data and measurement of the outcome. There was low-certainty evidence that physical activity interventions may have little to no effect on total daily moderate-to-vigorous physical activity compared to no intervention (MD 1.7 minutes, 95% CI -0.42 to 3.82; P = 0.12; 6 trials; 3042 children). We were unable to pool data on proportion of the OSHC session spent in moderate-to-vigorous physical activity in a meta-analysis. Both trials showed an increase in proportion of session spent in moderate-to-vigorous physical activity (moderate-certainty evidence) from 4% to 7.3% of session time; however, only one trial was statistically significant. There was low-certainty evidence that physical activity interventions may lead to little to no reduction in body mass index (BMI) as a measure of cardiovascular health, compared to no intervention (SMD -0.17, 95% CI -0.44 to 0.10; P = 0.22; 4 trials, 1684 children). Physical activity interventions that were delivered online were more cost-effective than in person. Combined results suggest that staff-and-parent and staff-and-child-based interventions may lead to a small increase in overall daily physical activity and a small reduction or no difference in BMI. Process evaluation was assessed differently by four of the included studies, with two studies reporting improvements in physical activity practices, one reporting high programme satisfaction and one high programme fidelity. The certainty of the evidence for these outcomes was low to moderate. Finally, there was very low-certainty evidence that physical activity interventions in outside-school hours childcare settings may increase cardiovascular fitness. No trials reported on quality of life or adverse outcomes. Trials reported funding from local government health grants or charitable funds; no trials reported industry funding. AUTHORS' CONCLUSIONS Although the review included nine trials, the evidence for how to increase children's physical activity in outside-school hours care settings remains limited, both in terms of certainty of evidence and magnitude of the effect. Of the types of interventions identified, when assessed using GRADE there was low-certainty evidence that multi-component interventions, with a specific physical activity goal may have a small increase in daily moderate-to-vigorous physical activity and a slight reduction in BMI. There was very low-certainty evidence that interventions increase cardiovascular fitness. By contrast there was moderate-certainty evidence that interventions were effective for increasing proportion of time spent in moderate-to-vigorous physical activity, and online training is cost-effective.
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Affiliation(s)
- Rosa Virgara
- Allied Health and Human Performance, Alliance for Research in Exercise Nutrition and Activity (ARENA), University of South Australia, Adelaide, Australia
| | - Anna Phillips
- Allied Health and Human Performance, University of South Australia, Adelaide, Australia
| | - Lucy K Lewis
- College of Nursing and Health Sciences, Flinders University, Bedford Park, Australia
| | - Katherine Baldock
- Allied Health and Human Performance, Alliance for Research in Exercise Nutrition and Activity (ARENA), University of South Australia, Adelaide, Australia
| | - Luke Wolfenden
- School of Medicine and Public Health, The University of Newcastle, Callaghan, Australia
| | - Ty Ferguson
- Allied Health and Human Performance, Alliance for Research in Exercise Nutrition and Activity (ARENA), University of South Australia, Adelaide, Australia
| | - Mandy Richardson
- Outside School Hours Care (OSHC) Service, St Pius X School, Windsor Gardens, Australia
| | - Anthony Okely
- Early Start Research Institute, University of Wollongong, Wollongong, Australia
| | - Michael Beets
- Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
| | - Carol Maher
- Allied Health and Human Performance, Alliance for Research in Exercise Nutrition and Activity (ARENA), University of South Australia, Adelaide, Australia
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Fayet‐Moore F, McConnell A, Petocz P, Cassettari T, Tuck K, Blumfield M, Warner M, Marshall S. Contribution of dietary snacking behaviours to discretionary energy intake and anthropometric measures in Australian adults: A comparison using an objective vs subjective definition for snacking. Nutr Diet 2020; 78:154-164. [DOI: 10.1111/1747-0080.12648] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 09/24/2020] [Accepted: 10/01/2020] [Indexed: 11/28/2022]
Affiliation(s)
| | | | - Peter Petocz
- Nutrition Research Australia Sydney New South Wales Australia
| | - Tim Cassettari
- Nutrition Research Australia Sydney New South Wales Australia
| | - Kate Tuck
- Nutrition Research Australia Sydney New South Wales Australia
| | | | - Molly Warner
- Nutrition Research Australia Sydney New South Wales Australia
| | - Skye Marshall
- Nutrition Research Australia Sydney New South Wales Australia
- Bond University Nutrition and Dietetics Research Group, Faculty of Health Sciences and Medicine Bond University Gold Coast Queensland Australia
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Hodder RK, O'Brien KM, Tzelepis F, Wyse RJ, Wolfenden L. Interventions for increasing fruit and vegetable consumption in children aged five years and under. Cochrane Database Syst Rev 2020; 5:CD008552. [PMID: 32449203 PMCID: PMC7273132 DOI: 10.1002/14651858.cd008552.pub7] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Insufficient consumption of fruits and vegetables in childhood increases the risk of future non-communicable diseases, including cardiovascular disease. Testing the effects of interventions to increase consumption of fruit and vegetables, including those focused on specific child-feeding strategies or broader multicomponent interventions targeting the home or childcare environment is required to assess the potential to reduce this disease burden. OBJECTIVES To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 January 2020. We searched Proquest Dissertations and Theses in November 2019. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included trials to identify further potentially relevant trials. SELECTION CRITERIA We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed the risks of bias of included trials; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures. MAIN RESULTS We included 80 trials with 218 trial arms and 12,965 participants. Fifty trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Fifteen trials examined the impact of parent nutrition education only in increasing child fruit and vegetable intake. Fourteen trials examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. Two trials examined the effect of a nutrition education intervention delivered to children in increasing child fruit and vegetable intake. One trial examined the impact of a child-focused mindfulness intervention in increasing vegetable intake. We judged 23 of the 80 included trials as free from high risks of bias across all domains. Performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining trials. There is low-quality evidence that child-feeding practices versus no intervention may have a small positive effect on child vegetable consumption, equivalent to an increase of 5.30 grams as-desired consumption of vegetables (SMD 0.50, 95% CI 0.29 to 0.71; 19 trials, 2140 participants; mean post-intervention follow-up = 8.3 weeks). Multicomponent interventions versus no intervention has a small effect on child consumption of fruit and vegetables (SMD 0.32, 95% CI 0.09 to 0.55; 9 trials, 2961 participants; moderate-quality evidence; mean post-intervention follow-up = 5.4 weeks), equivalent to an increase of 0.34 cups of fruit and vegetables a day. It is uncertain whether there are any short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.13, 95% CI -0.02 to 0.28; 11 trials, 3050 participants; very low-quality evidence; mean post-intervention follow-up = 13.2 weeks). We were unable to pool child nutrition education interventions in meta-analysis; both trials reported a positive intervention effect on child consumption of fruit and vegetables (low-quality evidence). Very few trials reported long-term effectiveness (6 trials), cost effectiveness (1 trial) or unintended adverse consequences of interventions (2 trials), limiting our ability to assess these outcomes. Trials reported receiving governmental or charitable funds, except for four trials reporting industry funding. AUTHORS' CONCLUSIONS Despite identifying 80 eligible trials of various intervention approaches, the evidence for how to increase children's fruit and vegetable consumption remains limited in terms of quality of evidence and magnitude of effect. Of the types of interventions identified, there was moderate-quality evidence that multicomponent interventions probably lead to, and low-quality evidence that child-feeding practice may lead to, only small increases in fruit and vegetable consumption in children aged five years and under. It is uncertain whether parent nutrition education or child nutrition education interventions alone are effective in increasing fruit and vegetable consumption in children aged five years and under. Our confidence in effect estimates for all intervention approaches, with the exception of multicomponent interventions, is limited on the basis of the very low to low-quality evidence. Long-term follow-up of at least 12 months is required and future research should adopt more rigorous methods to advance the field. This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.
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Affiliation(s)
- Rebecca K Hodder
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
- Priority Research Centre in Health and Behaviour, University of Newcastle, Callaghan, Australia
| | - Kate M O'Brien
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
- Priority Research Centre in Health and Behaviour, University of Newcastle, Callaghan, Australia
| | - Flora Tzelepis
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
- Priority Research Centre in Health and Behaviour, University of Newcastle, Callaghan, Australia
| | - Rebecca J Wyse
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
- Priority Research Centre in Health and Behaviour, University of Newcastle, Callaghan, Australia
| | - Luke Wolfenden
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
- Priority Research Centre in Health and Behaviour, University of Newcastle, Callaghan, Australia
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Club Fit: Development of a Physical Activity and Healthy Eating Intervention at a Boys & Girls Club After School Program. J Prim Prev 2020; 41:153-170. [DOI: 10.1007/s10935-020-00582-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Hodder RK, O'Brien KM, Stacey FG, Tzelepis F, Wyse RJ, Bartlem KM, Sutherland R, James EL, Barnes C, Wolfenden L. Interventions for increasing fruit and vegetable consumption in children aged five years and under. Cochrane Database Syst Rev 2019; 2019:CD008552. [PMID: 31697869 PMCID: PMC6837849 DOI: 10.1002/14651858.cd008552.pub6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Insufficient consumption of fruits and vegetables in childhood increases the risk of future non-communicable diseases, including cardiovascular disease. Interventions to increase consumption of fruit and vegetables, such as those focused on specific child-feeding strategies and parent nutrition education interventions in early childhood may therefore be an effective strategy in reducing this disease burden. OBJECTIVES To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 August 2019. We searched Proquest Dissertations and Theses in May 2019. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included trials to identify further potentially relevant trials. SELECTION CRITERIA We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed the risks of bias of included trials; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures. MAIN RESULTS We included 78 trials with 214 trial arms and 13,746 participants. Forty-eight trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Fifteen trials examined the impact of parent nutrition education in increasing child fruit and vegetable intake. Fourteen trials examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. Two trials examined the effect of a nutrition education intervention delivered to children in increasing child fruit and vegetable intake. One trial examined the impact of a child-focused mindfulness intervention in increasing vegetable intake. We judged 20 of the 78 included trials as free from high risks of bias across all domains. Performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining trials. There is very low-quality evidence that child-feeding practices versus no intervention may have a small positive effect on child vegetable consumption equivalent to an increase of 4.45 g as-desired consumption of vegetables (SMD 0.42, 95% CI 0.23 to 0.60; 18 trials, 2004 participants; mean post-intervention follow-up = 8.2 weeks). Multicomponent interventions versus no intervention has a small effect on child consumption of fruit and vegetables (SMD 0.34, 95% CI 0.10 to 0.57; 9 trials, 3022 participants; moderate-quality evidence; mean post-intervention follow-up = 5.4 weeks), equivalent to an increase of 0.36 cups of fruit and vegetables per day. It is uncertain whether there are any short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.12, 95% CI -0.03 to 0.28; 11 trials, 3078 participants; very low-quality evidence; mean post-intervention follow-up = 13.2 weeks). We were unable to pool child nutrition education interventions in meta-analysis; both trials reported a positive intervention effect on child consumption of fruit and vegetables (low-quality evidence). Very few trials reported long-term effectiveness (6 trials), cost effectiveness (1 trial) and unintended adverse consequences of interventions (2 trials), limiting their assessment. Trials reported receiving governmental or charitable funds, except for four trials reporting industry funding. AUTHORS' CONCLUSIONS Despite identifying 78 eligible trials of various intervention approaches, the evidence for how to increase children's fruit and vegetable consumption remains limited. There was very low-quality evidence that child-feeding practice may lead to, and moderate-quality evidence that multicomponent interventions probably lead to small increases in fruit and vegetable consumption in children aged five years and younger. It is uncertain whether parent nutrition education interventions are effective in increasing fruit and vegetable consumption in children aged five years and younger. Given that the quality of the evidence is very low or low, future research will likely change estimates and conclusions. Long-term follow-up of at least 12 months is required and future research should adopt more rigorous methods to advance the field. This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.
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Affiliation(s)
- Rebecca K Hodder
- Hunter New England Local Health DistrictHunter New England Population HealthLocked Bag 10WallsendAustralia2287
- University of NewcastleSchool of Medicine and Public HealthCallaghanAustralia
- Hunter Medical Research InstituteNew LambtonAustralia
- University of NewcastlePriority Research Centre in Health and BehaviourCallaghanAustralia
| | - Kate M O'Brien
- Hunter New England Local Health DistrictHunter New England Population HealthLocked Bag 10WallsendAustralia2287
- University of NewcastleSchool of Medicine and Public HealthCallaghanAustralia
- Hunter Medical Research InstituteNew LambtonAustralia
- University of NewcastlePriority Research Centre in Health and BehaviourCallaghanAustralia
| | - Fiona G Stacey
- University of NewcastleSchool of Medicine and Public HealthCallaghanAustralia
- Hunter Medical Research InstituteNew LambtonAustralia
- University of NewcastlePriority Research Centre in Health and BehaviourCallaghanAustralia
- University of NewcastlePriority Research Centre in Physical Activity and NutritionCallaghanAustralia
| | - Flora Tzelepis
- University of NewcastleSchool of Medicine and Public HealthCallaghanAustralia
- Hunter Medical Research InstituteNew LambtonAustralia
- University of NewcastlePriority Research Centre in Health and BehaviourCallaghanAustralia
| | - Rebecca J Wyse
- University of NewcastleSchool of Medicine and Public HealthCallaghanAustralia
- Hunter Medical Research InstituteNew LambtonAustralia
- University of NewcastlePriority Research Centre in Health and BehaviourCallaghanAustralia
| | - Kate M Bartlem
- University of NewcastleSchool of PsychologyUniversity DriveCallaghanNew South WalesAustralia2308
| | - Rachel Sutherland
- Hunter New England Local Health DistrictHunter New England Population HealthLocked Bag 10WallsendAustralia2287
- University of NewcastleSchool of Medicine and Public HealthCallaghanAustralia
- Hunter Medical Research InstituteNew LambtonAustralia
- University of NewcastlePriority Research Centre in Health and BehaviourCallaghanAustralia
| | - Erica L James
- University of NewcastleSchool of Medicine and Public HealthCallaghanAustralia
- Hunter Medical Research InstituteNew LambtonAustralia
| | - Courtney Barnes
- Hunter New England Local Health DistrictHunter New England Population HealthLocked Bag 10WallsendAustralia2287
- University of NewcastleSchool of Medicine and Public HealthCallaghanAustralia
- Hunter Medical Research InstituteNew LambtonAustralia
- University of NewcastlePriority Research Centre in Health and BehaviourCallaghanAustralia
| | - Luke Wolfenden
- Hunter New England Local Health DistrictHunter New England Population HealthLocked Bag 10WallsendAustralia2287
- University of NewcastleSchool of Medicine and Public HealthCallaghanAustralia
- Hunter Medical Research InstituteNew LambtonAustralia
- University of NewcastlePriority Research Centre in Health and BehaviourCallaghanAustralia
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Helmick M, Esmond AC, Hedrick V, Zoellner J, You W, Hill JL. The Adoption of the Healthy Eating Standards in Local Afterschool Programs Does Not Improve Quality of Snacks. THE JOURNAL OF SCHOOL HEALTH 2019; 89:809-817. [PMID: 31397496 DOI: 10.1111/josh.12822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Revised: 01/23/2018] [Accepted: 04/22/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES In 2011, the National Afterschool Association adopted the Healthy Eating and Physical Activity (HEPA) standards to address snack quality and physical activity in afterschool programs. Although research has indicated promise in the adoption of these policies by national organizations, less is known about local adoption, implementation, and effectiveness. In this study, we aimed to compare the quality of snacks served at program sites pre- and post-adoption and to determine the quality of non-program snacks compared to program snacks. METHODS An interrupted time series design was used to measure snack quality and consumption at 3 policy adopting sites and 2 non-policy adopting sites that served as a comparison control. Trained research staff collected snack type, brand, and amount consumed using a modified quarter-waste method. Analysis on nutrient content of snacks was completed using Nutrition Data System for Research software. RESULTS Adoption of the HEPA standards among policy adopting sites did not result in significantly better snack quality. Across all sites, program snacks were healthier than non-program snacks. CONCLUSION Pursuing additional components of the HEPA standards related to implementation may be necessary to significantly improve snack quality. Environmental supports such as limiting the amount of non-program snacks available onsite may improve snack quality.
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Affiliation(s)
- Meagan Helmick
- Radford University Carilion, 101 Elm Ave SE, Roanoke, VA 24013
| | | | - Valisa Hedrick
- 295 West Campus Drive, 338 Wallace Hall, Blacksburg, VA 24061
| | | | - Wen You
- 250 Drillfield Drive, 304 Hutcheson Hall, Blacksburg, VA 24061
| | - Jennie L Hill
- University of Nebraska Medical Center, 984395 Nebraska Medical Center, Omaha, NE 68198
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von Philipsborn P, Stratil JM, Burns J, Busert LK, Pfadenhauer LM, Polus S, Holzapfel C, Hauner H, Rehfuess E. Environmental interventions to reduce the consumption of sugar-sweetened beverages and their effects on health. Cochrane Database Syst Rev 2019; 6:CD012292. [PMID: 31194900 PMCID: PMC6564085 DOI: 10.1002/14651858.cd012292.pub2] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Frequent consumption of excess amounts of sugar-sweetened beverages (SSB) is a risk factor for obesity, type 2 diabetes, cardiovascular disease and dental caries. Environmental interventions, i.e. interventions that alter the physical or social environment in which individuals make beverage choices, have been advocated as a means to reduce the consumption of SSB. OBJECTIVES To assess the effects of environmental interventions (excluding taxation) on the consumption of sugar-sweetened beverages and sugar-sweetened milk, diet-related anthropometric measures and health outcomes, and on any reported unintended consequences or adverse outcomes. SEARCH METHODS We searched 11 general, specialist and regional databases from inception to 24 January 2018. We also searched trial registers, reference lists and citations, scanned websites of relevant organisations, and contacted study authors. SELECTION CRITERIA We included studies on interventions implemented at an environmental level, reporting effects on direct or indirect measures of SSB intake, diet-related anthropometric measures and health outcomes, or any reported adverse outcome. We included randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after (CBA) and interrupted-time-series (ITS) studies, implemented in real-world settings with a combined length of intervention and follow-up of at least 12 weeks and at least 20 individuals in each of the intervention and control groups. We excluded studies in which participants were administered SSB as part of clinical trials, and multicomponent interventions which did not report SSB-specific outcome data. We excluded studies on the taxation of SSB, as these are the subject of a separate Cochrane Review. DATA COLLECTION AND ANALYSIS Two review authors independently screened studies for inclusion, extracted data and assessed the risks of bias of included studies. We classified interventions according to the NOURISHING framework, and synthesised results narratively and conducted meta-analyses for two outcomes relating to two intervention types. We assessed our confidence in the certainty of effect estimates with the GRADE framework as very low, low, moderate or high, and presented 'Summary of findings' tables. MAIN RESULTS We identified 14,488 unique records, and assessed 1030 in full text for eligibility. We found 58 studies meeting our inclusion criteria, including 22 RCTs, 3 NRCTs, 14 CBA studies, and 19 ITS studies, with a total of 1,180,096 participants. The median length of follow-up was 10 months. The studies included children, teenagers and adults, and were implemented in a variety of settings, including schools, retailing and food service establishments. We judged most studies to be at high or unclear risk of bias in at least one domain, and most studies used non-randomised designs. The studies examine a broad range of interventions, and we present results for these separately.Labelling interventions (8 studies): We found moderate-certainty evidence that traffic-light labelling is associated with decreasing sales of SSBs, and low-certainty evidence that nutritional rating score labelling is associated with decreasing sales of SSBs. For menu-board calorie labelling reported effects on SSB sales varied.Nutrition standards in public institutions (16 studies): We found low-certainty evidence that reduced availability of SSBs in schools is associated with decreased SSB consumption. We found very low-certainty evidence that improved availability of drinking water in schools and school fruit programmes are associated with decreased SSB consumption. Reported associations between improved availability of drinking water in schools and student body weight varied.Economic tools (7 studies): We found moderate-certainty evidence that price increases on SSBs are associated with decreasing SSB sales. For price discounts on low-calorie beverages reported effects on SSB sales varied.Whole food supply interventions (3 studies): Reported associations between voluntary industry initiatives to improve the whole food supply and SSB sales varied.Retail and food service interventions (7 studies): We found low-certainty evidence that healthier default beverages in children's menus in chain restaurants are associated with decreasing SSB sales, and moderate-certainty evidence that in-store promotion of healthier beverages in supermarkets is associated with decreasing SSB sales. We found very low-certainty evidence that urban planning restrictions on new fast-food restaurants and restrictions on the number of stores selling SSBs in remote communities are associated with decreasing SSB sales. Reported associations between promotion of healthier beverages in vending machines and SSB intake or sales varied.Intersectoral approaches (8 studies): We found moderate-certainty evidence that government food benefit programmes with restrictions on purchasing SSBs are associated with decreased SSB intake. For unrestricted food benefit programmes reported effects varied. We found moderate-certainty evidence that multicomponent community campaigns focused on SSBs are associated with decreasing SSB sales. Reported associations between trade and investment liberalisation and SSB sales varied.Home-based interventions (7 studies): We found moderate-certainty evidence that improved availability of low-calorie beverages in the home environment is associated with decreased SSB intake, and high-certainty evidence that it is associated with decreased body weight among adolescents with overweight or obesity and a high baseline consumption of SSBs.Adverse outcomes reported by studies, which may occur in some circumstances, included negative effects on revenue, compensatory SSB consumption outside school when the availability of SSBs in schools is reduced, reduced milk intake, stakeholder discontent, and increased total energy content of grocery purchases with price discounts on low-calorie beverages, among others. The certainty of evidence on adverse outcomes was low to very low for most outcomes.We analysed interventions targeting sugar-sweetened milk separately, and found low- to moderate-certainty evidence that emoticon labelling and small prizes for the selection of healthier beverages in elementary school cafeterias are associated with decreased consumption of sugar-sweetened milk. We found low-certainty evidence that improved placement of plain milk in school cafeterias is not associated with decreasing sugar-sweetened milk consumption. AUTHORS' CONCLUSIONS The evidence included in this review indicates that effective, scalable interventions addressing SSB consumption at a population level exist. Implementation should be accompanied by high-quality evaluations using appropriate study designs, with a particular focus on the long-term effects of approaches suitable for large-scale implementation.
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Affiliation(s)
- Peter von Philipsborn
- Ludwig‐Maximilians‐University MunichInstitute for Medical Informatics, Biometry and Epidemiology, Pettenkofer School of Public HealthMarchioninistr. 15MunichBavariaGermany81377
| | - Jan M Stratil
- Ludwig‐Maximilians‐University MunichInstitute for Medical Informatics, Biometry and Epidemiology, Pettenkofer School of Public HealthMarchioninistr. 15MunichBavariaGermany81377
| | - Jacob Burns
- Ludwig‐Maximilians‐University MunichInstitute for Medical Informatics, Biometry and Epidemiology, Pettenkofer School of Public HealthMarchioninistr. 15MunichBavariaGermany81377
| | - Laura K Busert
- University College LondonGreat Ormond Street Institute of Child HealthLondonUK
| | - Lisa M Pfadenhauer
- Ludwig‐Maximilians‐University MunichInstitute for Medical Informatics, Biometry and Epidemiology, Pettenkofer School of Public HealthMarchioninistr. 15MunichBavariaGermany81377
| | - Stephanie Polus
- Ludwig‐Maximilians‐University MunichInstitute for Medical Informatics, Biometry and Epidemiology, Pettenkofer School of Public HealthMarchioninistr. 15MunichBavariaGermany81377
| | - Christina Holzapfel
- School of Medicine, Technical University of MunichInstitute of Nutritional Medicine, Else Kroener‐Fresenius Centre for Nutritional MedicineMunichGermany
| | - Hans Hauner
- School of Medicine, Technical University of MunichInstitute of Nutritional Medicine, Else Kroener‐Fresenius Centre for Nutritional MedicineMunichGermany
| | - Eva Rehfuess
- Ludwig‐Maximilians‐University MunichInstitute for Medical Informatics, Biometry and Epidemiology, Pettenkofer School of Public HealthMarchioninistr. 15MunichBavariaGermany81377
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9
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Hodder RK, O'Brien KM, Stacey FG, Wyse RJ, Clinton‐McHarg T, Tzelepis F, James EL, Bartlem KM, Nathan NK, Sutherland R, Robson E, Yoong SL, Wolfenden L. Interventions for increasing fruit and vegetable consumption in children aged five years and under. Cochrane Database Syst Rev 2018; 5:CD008552. [PMID: 29770960 PMCID: PMC6373580 DOI: 10.1002/14651858.cd008552.pub5] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Insufficient consumption of fruits and vegetables in childhood increases the risk of future non-communicable diseases, including cardiovascular disease. Interventions to increase consumption of fruit and vegetables, such as those focused on specific child-feeding strategies and parent nutrition education interventions in early childhood may therefore be an effective strategy in reducing this disease burden. OBJECTIVES To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 January 2018. We searched Proquest Dissertations and Theses in November 2017. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included studies to identify further potentially relevant trials. SELECTION CRITERIA We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed the risks of bias of included studies; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures. MAIN RESULTS We included 63 trials with 178 trial arms and 11,698 participants. Thirty-nine trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Fourteen trials examined the impact of parent nutrition education in increasing child fruit and vegetable intake. Nine studies examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. One study examined the effect of a nutrition education intervention delivered to children in increasing child fruit and vegetable intake.We judged 14 of the 63 included trials as free from high risks of bias across all domains; performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining studies.There is very low quality evidence that child-feeding practices versus no intervention may have a small positive effect on child vegetable consumption equivalent to an increase of 3.50 g as-desired consumption of vegetables (SMD 0.33, 95% CI 0.13 to 0.54; participants = 1741; studies = 13). Multicomponent interventions versus no intervention may have a very small effect on child consumption of fruit and vegetables (SMD 0.35, 95% CI 0.04 to 0.66; participants = 2009; studies = 5; low-quality evidence), equivalent to an increase of 0.37 cups of fruit and vegetables per day. It is uncertain whether there are any short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.12, 95% CI -0.03 to 0.28; participants = 3078; studies = 11; very low-quality evidence).Insufficient data were available to assess long-term effectiveness, cost effectiveness and unintended adverse consequences of interventions. Studies reported receiving governmental or charitable funds, except for four studies reporting industry funding. AUTHORS' CONCLUSIONS Despite identifying 63 eligible trials of various intervention approaches, the evidence for how to increase children's fruit and vegetable consumption remains limited. There was very low- and low-quality evidence respectively that child-feeding practice and multicomponent interventions may lead to very small increases in fruit and vegetable consumption in children aged five years and younger. It is uncertain whether parent nutrition education interventions are effective in increasing fruit and vegetable consumption in children aged five years and younger. Given that the quality of the evidence is very low or low, future research will likely change estimates and conclusions. Long-term follow-up is required and future research should adopt more rigorous methods to advance the field.This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.
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Affiliation(s)
- Rebecca K Hodder
- Hunter New England Local Health DistrictHunter New England Population HealthLocked Bag 10WallsendAustralia2287
| | - Kate M O'Brien
- Hunter New England Local Health DistrictHunter New England Population HealthLocked Bag 10WallsendAustralia2287
| | - Fiona G Stacey
- University of Newcastle, Hunter Medical Research Institute, Priority
Research Centre in Health Behaviour, and Priority Research Centre in
Physical Activity and NutritionSchool of Medicine and Public HealthCallaghanAustralia2287
| | - Rebecca J Wyse
- University of NewcastleSchool of Medicine and Public HealthCallaghanAustralia2308
| | - Tara Clinton‐McHarg
- University of NewcastleSchool of Medicine and Public HealthCallaghanAustralia2308
| | - Flora Tzelepis
- University of NewcastleSchool of Medicine and Public HealthCallaghanAustralia2308
| | - Erica L James
- University of Newcastle, Hunter Medical Research InstituteSchool of Medicine and Public HealthUniversity DriveCallaghanAustralia2308
| | - Kate M Bartlem
- University of NewcastleSchool of PsychologyUniversity DriveCallaghanAustralia2308
| | - Nicole K Nathan
- Hunter New England Local Health DistrictHunter New England Population HealthLocked Bag 10WallsendAustralia2287
| | - Rachel Sutherland
- Hunter New England Local Health DistrictHunter New England Population HealthLocked Bag 10WallsendAustralia2287
| | - Emma Robson
- Hunter New England Local Health DistrictHunter New England Population HealthLocked Bag 10WallsendAustralia2287
| | - Sze Lin Yoong
- Hunter New England Local Health DistrictHunter New England Population HealthLocked Bag 10WallsendAustralia2287
| | - Luke Wolfenden
- University of NewcastleSchool of Medicine and Public HealthCallaghanAustralia2308
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10
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Hodder RK, Stacey FG, O'Brien KM, Wyse RJ, Clinton‐McHarg T, Tzelepis F, James EL, Bartlem KM, Nathan NK, Sutherland R, Robson E, Yoong SL, Wolfenden L. Interventions for increasing fruit and vegetable consumption in children aged five years and under. Cochrane Database Syst Rev 2018; 1:CD008552. [PMID: 29365346 PMCID: PMC6491117 DOI: 10.1002/14651858.cd008552.pub4] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Insufficient consumption of fruits and vegetables in childhood increases the risk of future chronic diseases, including cardiovascular disease. OBJECTIVES To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE and Embase to identify eligible trials on 25 September 2017. We searched Proquest Dissertations and Theses and two clinical trial registers in November 2017. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included studies to identify further potentially relevant trials. SELECTION CRITERIA We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed the risks of bias of included studies; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures. MAIN RESULTS We included 55 trials with 154 trial arms and 11,108 participants. Thirty-three trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Thirteen trials examined the impact of parent nutrition education in increasing child fruit and vegetable intake. Eight studies examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. One study examined the effect of a nutrition intervention delivered to children in increasing child fruit and vegetable intake.We judged 14 of the 55 included trials as free from high risks of bias across all domains; performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining studies.Meta-analysis of trials examining child-feeding practices versus no intervention revealed a positive effect on child vegetable consumption (SMD 0.38, 95% confidence interval (CI) 0.15 to 0.61; n = 1509; 11 studies; very low-quality evidence), equivalent to a mean difference of 4.03 g of vegetables. There were no short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.11, 95% CI -0.05 to 0.28; n = 3023; 10 studies; very low-quality evidence) or multicomponent interventions versus no intervention (SMD 0.28, 95% CI -0.06 to 0.63; n = 1861; 4 studies; very low-quality evidence).Insufficient data were available to assess long-term effectiveness, cost effectiveness and unintended adverse consequences of interventions. Studies reported receiving governmental or charitable funds, except for three studies reporting industry funding. AUTHORS' CONCLUSIONS Despite identifying 55 eligible trials of various intervention approaches, the evidence for how to increase children's fruit and vegetable consumption remains sparse. There was very low-quality evidence that child-feeding practice interventions are effective in increasing vegetable consumption in children aged five years and younger, however the effect size was very small and long-term follow-up is required. There was very low-quality evidence that parent nutrition education and multicomponent interventions are not effective in increasing fruit and vegetable consumption in children aged five years and younger. All findings should be considered with caution, given most included trials could not be combined in meta-analyses. Given the very low-quality evidence, future research will very likely change estimates and conclusions. Such research should adopt more rigorous methods to advance the field.This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.
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Affiliation(s)
- Rebecca K Hodder
- Hunter New England Local Health DistrictHunter New England Population HealthLocked Bag 10WallsendAustralia2287
| | - Fiona G Stacey
- University of Newcastle, Hunter Medical Research Institute, Priority Research Centre in Health Behaviour, and Priority Research Centre in Physical Activity and NutritionSchool of Medicine and Public HealthCallaghanAustralia2287
| | - Kate M O'Brien
- Hunter New England Local Health DistrictHunter New England Population HealthLocked Bag 10WallsendAustralia2287
| | - Rebecca J Wyse
- University of NewcastleSchool of Medicine and Public HealthCallaghanAustralia2308
| | - Tara Clinton‐McHarg
- University of NewcastleSchool of Medicine and Public HealthCallaghanAustralia2308
| | - Flora Tzelepis
- University of NewcastleSchool of Medicine and Public HealthCallaghanAustralia2308
| | - Erica L James
- University of Newcastle, Hunter Medical Research InstituteSchool of Medicine and Public HealthUniversity DriveCallaghanAustralia2308
| | - Kate M Bartlem
- University of NewcastleSchool of PsychologyUniversity DriveCallaghanAustralia2308
| | - Nicole K Nathan
- Hunter New England Local Health DistrictHunter New England Population HealthLocked Bag 10WallsendAustralia2287
| | - Rachel Sutherland
- Hunter New England Local Health DistrictHunter New England Population HealthLocked Bag 10WallsendAustralia2287
| | - Emma Robson
- Hunter New England Local Health DistrictHunter New England Population HealthLocked Bag 10WallsendAustralia2287
| | - Sze Lin Yoong
- Hunter New England Local Health DistrictHunter New England Population HealthLocked Bag 10WallsendAustralia2287
| | - Luke Wolfenden
- University of NewcastleSchool of Medicine and Public HealthCallaghanAustralia2308
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Hodder RK, Stacey FG, Wyse RJ, O'Brien KM, Clinton‐McHarg T, Tzelepis F, Nathan NK, James EL, Bartlem KM, Sutherland R, Robson E, Yoong SL, Wolfenden L. Interventions for increasing fruit and vegetable consumption in children aged five years and under. Cochrane Database Syst Rev 2017; 9:CD008552. [PMID: 28945919 PMCID: PMC6483688 DOI: 10.1002/14651858.cd008552.pub3] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Insufficient consumption of fruits and vegetables in childhood increases the risk of future chronic diseases, including cardiovascular disease. OBJECTIVES To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE, Embase Classic and Embase to identify eligible trials on 30 September 2016. We searched CINAHL and PsycINFO in July 2016, Proquest Dissertations and Theses in November 2016 and three clinical trial registers in November 2016 and June 2017. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included studies to identify further potentially relevant trials. SELECTION CRITERIA We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed the risks of bias of included studies; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures.We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures. MAIN RESULTS We included 50 trials with 137 trial arms and 10,267 participants. Thirty trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Eleven trials examined the impact of parent nutrition education in increasing child fruit and vegetable intake. Eight studies examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. One study examined the effect of a nutrition intervention delivered to children in increasing child fruit and vegetable intake.Thirteen of the 50 included trials were judged as free from high risks of bias across all domains; performance, detection and attrition bias were the most common domains judged at high risk of bias of remaining studies.Meta-analysis of trials examining child-feeding practices versus no intervention revealed a positive effect on child vegetable consumption (SMD 0.38, 95% CI 0.15 to 0.61; n = 1509; 11 studies; very low-quality evidence), equivalent to a mean difference of 4.03 grams of vegetables. There were no short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.11, 95% CI -0.05 to 0.28; n = 3023; 10 studies; very low-quality evidence) or multicomponent interventions versus no intervention (SMD 0.28, 95% CI -0.06 to 0.63; n = 1861; 4 studies; very low-quality evidence).Insufficient data were available to assess long-term effectiveness, cost effectiveness and unintended adverse consequences of interventions.Studies reported receiving governmental or charitable funds, except for two studies reporting industry funding. AUTHORS' CONCLUSIONS Despite identifying 50 eligible trials of various intervention approaches, the evidence for how to increase fruit and vegetable consumption of children remains sparse. There was very low-quality evidence child-feeding practice interventions are effective in increasing vegetable consumption of children aged five years and younger, however the effect size was very small and long-term follow-up is required. There was very low-quality evidence that parent nutrition education and multicomponent interventions are not effective in increasing fruit and vegetable consumption of children aged five years and younger. All findings should be considered with caution, given most included trials could not be combined in meta-analyses. Given the very low-quality evidence, future research will very likely change estimates and conclusions. Such research should adopt more rigorous methods to advance the field.This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.
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Affiliation(s)
- Rebecca K Hodder
- Hunter New England Local Health DistrictHunter New England Population HealthLocked Bag 10WallsendAustralia2287
| | - Fiona G Stacey
- University of Newcastle, Hunter Medical Research Institute, Priority Research Centre in Health Behaviour, and Priority Research Centre in Physical Activity and NutritionSchool of Medicine and Public HealthCallaghanAustralia2287
| | - Rebecca J Wyse
- University of NewcastleSchool of Medicine and Public HealthCallaghanAustralia2308
| | | | - Tara Clinton‐McHarg
- University of NewcastleSchool of Medicine and Public HealthCallaghanAustralia2308
| | - Flora Tzelepis
- University of NewcastleSchool of Medicine and Public HealthCallaghanAustralia2308
| | - Nicole K Nathan
- Hunter New England Local Health DistrictHunter New England Population HealthLocked Bag 10WallsendAustralia2287
| | - Erica L James
- University of Newcastle, Hunter Medical Research InstituteSchool of Medicine and Public HealthUniversity DriveCallaghanAustralia2308
| | - Kate M Bartlem
- University of NewcastleSchool of PsychologyUniversity DriveCallaghanAustralia2308
| | - Rachel Sutherland
- Hunter New England Local Health DistrictHunter New England Population HealthLocked Bag 10WallsendAustralia2287
| | - Emma Robson
- Hunter New England Local Health DistrictHunter Population HealthLocked Bag 10WallsendAustralia
| | - Sze Lin Yoong
- Hunter New England Local Health DistrictHunter New England Population HealthLocked Bag 10WallsendAustralia2287
| | - Luke Wolfenden
- University of NewcastleSchool of Medicine and Public HealthCallaghanAustralia2308
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Beets MW, Weaver RG, Turner-McGrievy G, Huberty J, Moore JB, Ward DS, Freedman DA, Beighle A. Two-Year Healthy Eating Outcomes: An RCT in Afterschool Programs. Am J Prev Med 2017; 53:316-326. [PMID: 28532659 PMCID: PMC5562516 DOI: 10.1016/j.amepre.2017.03.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 02/10/2017] [Accepted: 03/08/2017] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Across the U.S., afterschool programs (ASPs, 3:00pm-6:00pm) are trying to achieve nationally endorsed nutrition standards (Healthy Eating Standards) calling for fruits/vegetables and water to be served every day, while eliminating sugar-sweetened beverages and foods. The purpose of this study was to evaluate the 2-year changes in the types of foods and beverages served during a community-based intervention designed to achieve the Healthy Eating Standards. STUDY DESIGN Randomized delayed treatment trial with an immediate (1-year baseline and 2-year intervention) or delayed (2-year baseline and 1-year intervention) group. SETTING/PARTICIPANTS Twenty ASPs serving 1,700 children (aged 5-12 years) were recruited, with baseline occurring spring 2013, and outcome assessment occurring spring 2014 and 2015. INTERVENTION The multistep intervention, Strategies To Enhance Practice for Healthy Eating, assisted ASP leaders/staff to serve foods/beverages that meet the nutrition standards. MAIN OUTCOME MEASURES The foods and beverages served for snack were observed directly. RESULTS Compared with non-intervention years, both the immediate and delayed groups increased the number of days/week that fruits/vegetables (0.6 vs 1.7 days/week and 0.6 vs 4.4 days/week, OR=3.80, 95% CI=1.45, 9.95) and water (2.3 vs 3.7 days/week and 2.7 vs 4.8 days/week, OR=4.65, 95% CI=1.69, 12.79) were served. Sugar-sweetened beverages were almost eliminated by post-assessment (1.2 vs 0.2 days/week and 3.2 vs 0.0 days/week, OR=0.05, 95% CI=0.02, 0.13). Only the immediate group decreased the number of days/week desserts were served (2.9 vs 0.6 days/week, OR=0.10, 95% CI=0.03, 0.33). Implementation barriers for the delayed group included once/month delivery schedules for fruits/vegetables and limited storage space for foods meeting the Healthy Eating Standards. CONCLUSIONS Improvements in the foods/beverages served in ASPs can be made, yet were hindered by structural barriers related to procurement and storage of perishable foods. Additional efforts are needed to support ASPs as they work toward fully achieving the Healthy Eating Standards.
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Affiliation(s)
- Michael W Beets
- Arnold School of Public Health, University of South Carolina, Columbia, South Carolina.
| | - R Glenn Weaver
- Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | | | - Jennifer Huberty
- School of Nutrition and Health Promotion, Arizona State University, Phoenix, Arizona
| | - Justin B Moore
- Family and Community Medicine, Wake Forest School of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Dianne S Ward
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, Chapel Hill, North Carolina
| | - Darcy A Freedman
- Department of Epidemiology and Biostatistics, Case Western Reserve University, Cleveland, Ohio
| | - Aaron Beighle
- College of Education, University of Kentucky, Lexington, Kentucky
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Kenney EL, Lee RM, Brooks CJ, Cradock AL, Gortmaker SL. What Do Children Eat in the Summer? A Direct Observation of Summer Day Camps That Serve Meals. J Acad Nutr Diet 2017; 117:1097-1103. [PMID: 28330733 DOI: 10.1016/j.jand.2017.01.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 01/24/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND More than 14 million children in the United States attend summer camp annually, yet little is known about the food environment in day camps. OBJECTIVE Our aim was to describe the nutritional quality of meals served to, brought by, and consumed by children attending summer day camps serving meals and snacks, and to describe camp water access. DESIGN We conducted a cross-sectional study. PARTICIPANTS/SETTINGS Participants were 149 children attending five summer camps in Boston, MA, in 2013. MAIN OUTCOME MEASURES Foods and beverages served were observed for 5 consecutive days. For 2 days, children's dietary intake was directly observed using a validated protocol. Outcome measures included total energy (kilocalories) and servings of different types of foods and beverages served and consumed during breakfast, lunch, and snack. STATISTICAL ANALYSES PERFORMED Mean total energy, trans fats, sodium, sugar, and fiber served per meal were calculated across the camps, as were mean weekly frequencies of serving fruits, vegetables, meat/meat alternates, grains, milk, 100% juice, sugar-sweetened beverages, whole grains, red/highly processed meats, grain-based desserts, and salty snacks. Mean consumption was calculated per camper per day. RESULTS Camps served a mean (standard deviation) of 647.7 (134.3) kcal for lunch, 401.8 (149.6) kcal for breakfast, and 266.4 (150.8) kcal for snack. Most camps served red/highly processed meats, salty snacks, and grain-based desserts frequently, and rarely served vegetables or water. Children consumed little (eg, at lunch, 36.5% of fruit portions, 35.0% of meat/meat alternative portions, and 37.6% of milk portions served) except for salty snacks (66.9% of portions) and grain-based desserts (64.1% of portions). Sugar-sweetened beverages and salty snacks were frequently brought to camp. One-quarter of campers drank nothing throughout the entire camp day. CONCLUSIONS The nutritional quality of foods and beverages served at summer day camps could be improved. Future studies should assess barriers to consumption of healthy foods and beverages in these settings.
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Weaver RG, Moore JB, Turner-McGrievy B, Saunders R, Beighle A, Khan MM, Chandler J, Brazendale K, Randell A, Webster C, Beets MW. Identifying Strategies Programs Adopt to Meet Healthy Eating and Physical Activity Standards in Afterschool Programs. HEALTH EDUCATION & BEHAVIOR 2016; 44:536-547. [PMID: 27852666 DOI: 10.1177/1090198116676252] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The YMCA of USA has adopted Healthy Eating and Physical Activity (HEPA) Standards for its afterschool programs (ASPs). Little is known about strategies YMCA ASPs are implementing to achieve Standards and these strategies' effectiveness. AIMS (1) Identify strategies implemented in YMCA ASPs and (2) evaluate the relationship between strategy implementation and meeting Standards. METHOD HEPA was measured via accelerometer (moderate-to-vigorous-physical-activity [MVPA]) and direct observation (snacks served) in 20 ASPs. Strategies were identified and mapped onto a capacity building framework ( Strategies To Enhance Practice [STEPs]). Mixed-effects regression estimated increases in HEPA outcomes as implementation increased. Model-implied estimates were calculated for high (i.e., highest implementation score achieved), moderate (median implementation score across programs), and low (lowest implementation score achieved) implementation for both HEPA separately. RESULTS Programs implemented a variety of strategies identified in STEPs. For every 1-point increase in implementation score 1.45% (95% confidence interval = 0.33% to 2.55%, p ≤ .001) more girls accumulated 30 min/day of MVPA and fruits and/or vegetables were served on 0.11 more days (95% confidence interval = 0.11-0.45, p ≤ .01). Relationships between implementation and other HEPA outcomes did not reach statistical significance. Still regression estimates indicated that desserts are served on 1.94 fewer days (i.e., 0.40 vs. 2.34) in the highest implementing program than the lowest implementing program and water is served 0.73 more days (i.e., 2.37 vs. 1.64). CONCLUSIONS Adopting HEPA Standards at the national level does not lead to changes in routine practice in all programs. Practical strategies that programs could adopt to more fully comply with the HEPA Standards are identified.
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