School lunch menus and 11 to 12 year old children's food choice in three secondary schools in England—are the nutritional standards being met?

The feasibility and acceptability of a rewards system based on food purchasing behaviour in secondary school cashless canteens: the Eat4Treats (E4T) cluster feasibility, non-randomised, controlled intervention study

BACKGROUND

Using rewards may be an effective method to positively influence children's eating behaviour but evidence to date is limited, particularly in older children. The cashless canteen systems in schools provides a unique opportunity to implement a food-based reward scheme but intervention development work and feasibility testing is needed. The overall aim of the E4T feasibility study was to examine the feasibility and acceptability of implementing a rewards scheme based on the food purchasing behaviour of pupils in cashless canteens in secondary schools.

METHODS

A non-randomised, controlled, parallel-group cluster feasibility study conducted in four secondary schools (two intervention and two control) serving areas of the highest social deprivation in Northern Ireland. During the 4-month trial, pupils earned points for foods purchased at the school canteen, with better nutritional choices having a higher value. Pupils could exchange the points they earned for rewards (e.g. stationery, vouchers, sports equipment) via the E4T website. Qualitative and quantitative data was collected from year 9 and 10 pupils (boys and girls aged 12-14 years), teachers and canteen staff to address the feasibility questions.

RESULTS

Two intervention (one urban, one rural) and one control (urban) school completed the study. Seventy-one percent of 12-14-year-old pupils consented to take part; 1% of parents opted their child out of the study. Questionnaire completion rates were high (6 and 11% of questionnaires were partially completed at baseline and follow-up respectively). Collecting data on food consumed in the canteen was challenging logistically. Focus groups with pupils indicated that the overall concept of E4T was well received and there was a high degree of satisfaction with the rewards available. Pupils and teachers made several suggestions for improvements.

CONCLUSIONS

E4T was successfully implemented as a result of collaboration between schools, school canteens and cashless canteen providers working with a multidisciplinary research team. It was acceptable to pupils, teachers and canteen staff. The findings suggest a few areas for refining implementation and evaluation processes that would need to be considered in the design of a larger trial, particularly resources required to streamline implementation and ways to optimise pupil engagement.

TRIAL REGISTRATION

Under review with https://www.

CLINICALTRIALS

gov (retrospective registration-reg number and weblink to be added).

Associations between School Lunch and Obesity in Korean Children and Adolescents Based on the Korea National Health and Nutrition Examination Survey 2017-2019 Data: A Cross-Sectional Study

Obesity in children and adolescents is a serious global problem. In Korea, approximately 35% of students' daily nutrient intake is from school lunch (SL), and all schools provide SL. However, the association between SL and obesity remains controversial. This study examined this association and the daily nutrient intake according to lunch type in Korean children and adolescents. We analyzed 1736 individuals aged 7-18 from the Korea National Health and Nutrition Examination Survey (2017-2019), a cross-sectional study, using logistic regression analysis with odds ratios and 95% confidence intervals. The SL group had higher energy and greater phosphorus, potassium, vitamin A, carotene, vitamin B1, and niacin intake than the non-school lunch (NSL) and skipping lunch (SKL) groups. Protein intake was also higher in the SL group than in the NSL group. The SKL group had higher saturated fatty acid intake, and was thereby 2.5, 1.9, and 2.5 times more likely to have obesity, overweight and obesity, and central obesity (p = 0.0071, 0.0459, 0.0092), respectively, than the SL group. Therefore, the SL group consumed more appropriate nutrients than the NSL and SKL groups, and was less likely to become obese than the SKL group. More in-depth prospective studies are needed to elucidate the causal relationship between SL and obesity.

School lunch nutritional adequacy: what is served, consumed and wasted

OBJECTIVE

To determine nutritional adequacy of school lunch and to assess the impact of food waste on nutrient intake of primary schoolchildren.

DESIGN

The weighing method was used for evaluating initial servings and plate waste for lunch. Energy and nutritional contents of meals served, consumed and wasted were estimated using the software Food Processor Plus. The mean nutritional value of food served and consumed was compared with dietary guidelines.

SETTING

Portuguese public primary schools in the city of Porto.

PARTICIPANTS

All 525 fourth-grade children, aged from 9 to 10 years old, attending to twenty-one public primary schools.

RESULTS

Overall, school lunches served did not meet the dietary guidelines for energy and nutrients, as only 12·5 % of the evaluated meals were adequate for energy, 33·5 % for proteins, 11·9 % for carbohydrates and 57·1 % for lipids. The majority of meals served were below the age-specific lower limit, namely for energy (83·7 %) and carbohydrates (86·8 %). The only exception, also unbalanced, was observed for proteins, as 42·4 % of lunches served exceeded the recommended upper limit. Furthermore, lunches served and consumed by children did not meet the dietary guidelines for fibre and for the micronutrients evaluated. Children wasted 26 % of the energy content provided in lunches, corresponding to 91·5 kcal, 25 % of proteins and 29 % of carbohydrates supplied.

CONCLUSIONS

The lunches served and consumed by children at school canteens failed to meet nutritional standards. These results are not only a consequence of inadequate food portions served but also a result of the high plate waste values observed.

Feeding the food insecure in Britain: learning from the 2020 COVID-19 crisis

The lockdown in Britain has rendered a large proportion of the population economically vulnerable and has at least quadrupled demand for emergency food relief. This paper looks critically at response to the crisis from the government and the voluntary sector with respect to provision of emergency food. In doing so, it has exposed gaps in understanding of the vagaries of the food supply for certain population groups and systemic weaknesses in the current system of emergency food aid. We make recommendations for healthier governmental capacity to react to a food security crisis, better relationships between the government and the voluntary sector, and further research into the dietary constraints of the precariate. Importantly, the social system needs to be responsive to short-term changes in people’s income if people are not to fall into food insecurity.

Impact of the school lunch program on overweight and obesity among junior high school students: a nationwide study in Japan

BACKGROUND

Japan has experienced a low prevalence of childhood obesity. The Japanese nationwide school lunch program is suggested to have helped this phenomenon, but it has not been proven.

METHODS

From official statistics, we combined annual data for 2006-15 about the prefecture-level school lunch coverage rate for public junior high school students and the prefecture-level nutritional indicators calculated by randomly selected age-sex groups of 13-15-year olds: the percentage of overweight, obese or underweight children, who are 20% heavier, 30% heavier or 20% lighter than the standard weight by sex, age and height; and mean body weight (kg) or height (cm). We estimated the impact of the school lunch coverage rate on the nutritional indicators in subsequent years, adjusting for the lagged dependent variable and dummies for prefecture, age and year.

RESULTS

A 10 percentage point increase in the prefecture-level school lunch coverage rate significantly decreased the percentage of overweight (0.37%, 95% CI: 0.18-0.56) and obesity (0.23%, 0.10-0.37) in subsequent years among boys, but not among girls. No significant effect on the percentage of underweight or mean body weight/height was observed for either sex.

CONCLUSIONS

Appropriate nutritional intake through school lunch may be effective to reduce childhood obesity.

Composition of School Meals in Sweden, Finland, and Iceland: Official Guidelines and Comparison With Practice and Availability

BACKGROUND

Nutritious and attractive school meals can improve health equality and public health. Current official guidelines and recommendations on food and nutrient composition of school meals in 3 Nordic countries; Sweden, Finland, and Iceland, are described and compared with actual practice, ie, availability of foods and nutrients in served reference meals in 3 selected areas in each country.

METHODS

A country comparison was made between official guidelines, and actual practice was studied in participating schools. Reference portions of school meals (N = 170) provided in 24 compulsory schools were photographed and weighed. Food and nutrient availability were compared with official guidelines in each country.

RESULTS

Emphasis of recommendations on whole-grain bread in Sweden, whole grains in Finland, and fish in Iceland were reflected in food availability. The energy content of the meals provided was lower than guidelines and there was a large variation in energy content between days.

CONCLUSIONS

The guidelines regarding food availability were quite well followed, but the large variation in energy and nutrient content of provided school meals between days indicates a need for standardization.

What do Danish children eat, and does the diet meet the recommendations? Baseline data from the OPUS School Meal Study

A child's diet is an important determinant for later health, growth and development. In Denmark, most children in primary school bring their own packed lunch from home and attend an after-school care institution. The aim of the present study was to evaluate the food, energy and nutrient intake of Danish school children in relation to dietary guidelines and nutrient recommendations, and to assess the food intake during and outside school hours. In total, 834 children from nine public schools located in the eastern part of Denmark were included in this cross-sectional study and 798 children (95·7 %) completed the dietary assessment sufficiently (August–November 2011). The whole diet was recorded during seven consecutive days using the Web-based Dietary Assessment Software for Children (WebDASC). Compared with the food-based dietary guidelines and nutrient recommendations, 85 % of the children consumed excess amounts of red meat, 89 % consumed too much saturated fat, and 56 % consumed too much added sugar. Additionally 35 or 91 % of the children (depending on age group) consumed insufficient amounts of fruits and vegetables, 85 % consumed insufficient amounts of fish, 86 % consumed insufficient amounts of dietary fibre, 60 or 84 % had an insufficient Fe intake (depending on age group), and 96 % had an insufficient vitamin D intake. The study also showed that there is a higher intake of fruits and bread during school hours than outside school hours; this is not the case with, for example, fish and vegetables, and future studies should investigate strategies to increase fish and vegetable intake during school hours.

School nutrition guidelines: overview of the implementation and evaluation

Objective

To holistically evaluate the extent of implementation of dietary guidelines in schools and present various monitoring systems.

Design

The study comprises three methods: (i) a cross-sectional survey (process evaluation); (ii) an indicator-based evaluation (menu quality); and (iii) a 5 d weighed food record of school lunches (output evaluation).

Setting

Slovenian primary schools.

Subjects

A total 234 food-service managers from 488 schools completed a self-administrated questionnaire for process evaluation; 177 out of 194 randomly selected schools provided menus for menu quality evaluation; and 120 school lunches from twenty-four schools were measured and nutritionally analysed for output evaluation.

Results

The survey among food-service managers revealed high levels of implementation at almost all process evaluation areas of the guidelines. An even more successful implementation of these guidelines was found in relation to organization cultural issues as compared with technical issues. Differences found in some process evaluation areas were related to location, size and socio-economic characteristics of schools. Evaluation of school menu quality demonstrated that score values followed a normal distribution. Higher (better) nutrition scores were found in larger-sized schools and corresponding municipalities with higher socio-economic status. School lunches did not meet minimum recommendations for energy, carbohydrates or dietary fibre intake, nor for six vitamins and three (macro, micro and trace) elements.

Conclusions

The implementation of the guidelines was achieved differently at distinct levels. The presented multilevel evaluation suggests that different success in implementation might be attributed to different characteristics of individual schools. System changes might also be needed to support and improve implementation of the guidelines.

The relationship between school-level characteristics and implementation fidelity of a coordinated school health childhood obesity prevention intervention

BACKGROUND

Curtailing childhood obesity is a public health imperative. Although multicomponent school-based programs reduce obesity among children, less is known about the implementation fidelity of these interventions. This study examines process evaluation findings for the Healthy, Energetic Ready, Outstanding, Enthusiastic, Schools (HEROES) Initiative, a tri-state school-based childhood obesity prevention intervention based on the coordinated school health (CSH) model.

METHODS

Site visits were conducted that included key stakeholder interviews, observation, and document review. Scores were given for 8 domains, and a total implementation score was calculated. Two-way analyses of variance were conducted to examine the relationship of 4 school-level characteristics: elementary vs. middle/high schools, public vs. private schools, district vs. building level implementation, and socioeconomic status on each implementation area.

RESULTS

Overall, schools had high fidelity scores, although some domains were implemented more successfully than others. Three school-level characteristics were associated with 1 or more domains, with elementary schools and schools implementing at the building level consistently having higher implementation scores than their counterparts.

CONCLUSIONS

Process evaluation findings provide insight into successes and challenges schools implementing the CSH approach may encounter. Although preliminary, these findings on school-level characteristics establish a new area of research related to school-based childhood obesity prevention programs' implementation fidelity.

Predictors for Persistent Overweight, Deteriorated Weight Status, and Improved Weight Status During 18 Months in a School-Based Longitudinal Cohort

PURPOSE

To examine predictors for persistent overweight/obesity, deteriorated weight status, and improved weight status among students who participated in a school-based obesity prevention intervention from fall 2009 to spring 2011.

DESIGN

Longitudinal assessment of a school-based cohort was conducted to determine the characteristics of students who remained overweight/obese, improved their weight status, or showed deteriorated weight status during an 18-month period.

SETTING

Eleven schools in southern Indiana, northwestern Kentucky, and southeastern Illinois.

SUBJECTS

N = 5309 students in 4th through 12th grade.

MEASURES

Weight, height, and self-reported physical activity and nutrition behaviors of students were measured at baseline and 6, 12, and 18 months.

ANALYSIS

SAS 9.3 was employed to examine predictors for the three different weight categories using logistic regression.

RESULTS

Low socioeconomic status (SES) (adjusted odds ratio [AOR] = 1.56 and p < .001, AOR = 1.35 and p = .0069, respectively) and higher soda intake (AOR = 1.07 and p = .0016, AOR = 1.08 and p = .0278, respectively) increased the odds of belonging to persistent overweight/obesity (30.6%) and deteriorated weight status (6.9%), compared to the persistent nonoverweight status group.

CONCLUSION

While SES is an important determinant of weight category change, students' screen time and soda consumption may be important factors. Schools and families may be able to successfully focus on these modifiable risk factors, decreasing the burden of childhood obesity.

Adolescents' views about a proposed rewards intervention to promote healthy food choice in secondary school canteens

Using rewards may be an effective method to positively influence adolescent eating behaviour, but evidence regarding this approach is limited. The aim of this study was to explore young adolescent views about a proposed reward intervention associated with food choice in school canteens. Focus groups were held in 10 schools located in lower socioeconomic areas within Northern Ireland and involved 90 pupils aged 11-12 years (54 girls, 36 boys). Our findings indicated a high degree of acceptability for a reward scheme but there was major diversity in the type of rewards valued by pupils, largely defined by geographical area and socio-cultural differences. Pupils from rural areas tended to emphasize group-based and longer-term rewards, whereas pupils from urban-city schools tended to suggest individualistic and immediate rewards. The major factors influencing food choice were food price, value for money, taste and visual appearance. Pupils felt that factors outside of their control, such as being assigned to the second lunch sitting placed considerable constraints on their food choice. This research not only indicated a high degree of acceptability for a rewards-based intervention but also highlighted a number of socio-cultural and environmental factors that should be considered by researchers when developing such an intervention.

Meeting school food standards - students' food choice and free school meals

OBJECTIVE

To examine students’ school food choice in relation to school food standards and entitlement to free school meals (FSM).

DESIGN

Cross-sectional analysis of students’ school food choices.

SETTING

Two large secondary schools in Yorkshire, England.

SUBJECTS

Students (n 2660) aged 11–18 years.

RESULTS

Sandwiches and pizza were the most popular main food items: 40·4 % and 31·2 %, respectively, in School A; 48·3 % and 27·3 %, respectively, in School B. More nutritionally valuable ‘dishes of the day’ accounted for 8·7 % and 8·3 % of main foods for School A and School B, respectively. FSM students were more likely (P < 0·0 0 1) to choose main foods (School A: FSM 87·04 %, non-FSM 70·28 %; School B: FSM 75·43 %, non-FSM 56·13 %). Dishes of the day were chosen on a significantly greater (P < 0·0 0 1) percentage of days by FSM v. non-FSM students (School A: FSM 15·67 %, non-FSM 7·11 %; School B: FSM 19·42 %, non-FSM 5·17 %).

CONCLUSIONS

Despite the availability of nutritionally valuable dishes of the day, the most popular food items were sandwiches, pizza and desserts. FSM students were more likely to choose the more nutritionally valuable dish of the day. School food standards should be reassessed in light of students’ preferences.

Lunchtime food and nutrient intakes of secondary-school pupils; a comparison of school lunches and packed lunches following the introduction of mandatory food-based standards for school lunch

Objective

To compare the key differences between school lunches and packed lunches as eaten in eleven secondary schools in England, 21 months after the food-based standards for school lunch became mandatory, but before the introduction of nutrient-based standards.

Design

Data on 358 school lunches and 139 packed lunches were collected in May and June 2008 from pupils attending secondary schools in Sheffield, Manchester, Leicester City and Essex. Fieldwork was conducted over five consecutive school days at each school. Fieldworkers randomly selected five pupils taking a school lunch and five pupils bringing a packed lunch each day. All food and drink items chosen by pupils were weighed and recorded. Leftovers were also weighed.

Setting

Eleven state-maintained, co-educational secondary schools from four local authorities in England.

Subjects

Four hundred and ninety-seven pupils aged 11–16 years.

Results

Pupils taking school lunches, on average, had significantly higher intakes of energy, protein, carbohydrate, NSP, vitamin C, folate, Fe and Zn than pupils bringing a packed lunch to school. Mean intakes of protein, fat and vitamin C from both types of lunch met the nutrient-based standards and school lunches also met standards for carbohydrate, NSP and energy.

Conclusions

Nutrient intakes from school lunches were more favourable than those from packed lunches, but typically failed to meet nutrient-based standards for school food. A combination of continued improvements to school food, educating pupils to make healthier choices and policies to encourage pupils to eat at school or bring healthier packed lunches is needed.

Developing and applying a socio-ecological model to the promotion of healthy eating in the school

OBJECTIVE

To develop and apply a socio-ecological model (SEM) for healthy eating in school students, to better understand the association between factors at different levels of the SEM and pupils' dietary choices.

DESIGN

Student-level data, collected through anonymised questionnaires, included reported dietary choices and correlates to these; data on school approaches to food were collected through postal surveys. We used multilevel analysis to study the association of each level of the SEM on student dietary choice while controlling for factors found at other levels.

SETTING

Data were collected from secondary schools in Wales that were a part of the 2005/2006 Health Behaviour in School-aged Children (HBSC) study.

SUBJECTS

The final sample for analysis included data from 6693 students aged 11-16 years and 289 teachers from sixty-four secondary schools in Wales.

RESULTS

Student interpersonal factors, an individual's social environment, had a greater association with the dietary choices students made for lunch than student intrapersonal characteristics, those that reside within the person, which were found to have a greater association with the dietary choices made outside school. School organisational factors, such as rules and policies, had a greater association with whether students ate unhealthy foods, whereas the community nature of the school had a greater association with the choosing of healthy foods.

CONCLUSIONS

Using the SEM and multilevel analysis allowed us to study how factors were associated with the choice of different foods at different times of the day by students. Interventions can use an SEM to target specific correlates and change health outcomes in the school.

School meals in French secondary state schools: Do national recommendations lead to healthier nutrition on offer?

To improve the dietary offering in schools, the French authorities published recommendations on nutrition in 1999, which were then revised in 2007. The aim of the present study was to assess the nutritional offering in secondary school meals and the extent to which the recommendations promote balanced nutritional offerings. In 2005, a national survey was conducted on a representative sample of secondary schools, either administrated by the Ministry of Education (ES) or the Ministry of Agriculture (AS). Information on school-catering organisation and twenty consecutive meals was collected from each of the 707 secondary schools surveyed. Nutritional composition was estimated according to the French food composition database. Univariate and multivariate analyses were used to investigate the impact of food-group frequency guidelines (FFG) on nutritional offering. It was found that 15 and 26 % of ES and AS schools, respectively, had high compliance with the FFG, at lunch. Macronutrient content was unbalanced in ES school lunches in which 42·8 % lipids, 21·5 % proteins and 35·7 % carbohydrates contributed to the energy. Nevertheless, proper offerings in Fe, Ca and vitamin C content were observed. In addition, a lower offering in lipids and a higher offering in proteins, Ca, vitamin C and Fe were found when the FFG were applied (P < 0·001). Similar results were found for AS schools. This paper confirms the effectiveness of FFG in providing nutritionally balanced school meals. However, others measures such as nutrition promotion and actions to improve children's food habits have to be introduced to make the recommendations more effective and easier to understand.

Influence of life course socioeconomic position on older women's health behaviors: findings from the British Women's Heart and Health Study

OBJECTIVES

We examined the association between health behaviors and socioeconomic status (SES) in childhood and adult life.

METHODS

Self-reported diet, smoking, and physical activity were determined among 3523 women aged 60 to 79 years recruited from general practices in 23 British towns from 1999 through 2001.

RESULTS

The most affluent women reported eating more fruit, vegetables, chicken, and fish and less red or processed meat than did less affluent women. Affluent women were less likely to smoke and more likely to exercise. Life course SES did not influence the types of fat, bread, and milk consumed. Adult SES predicted consumption of all foods considered and predicted smoking and physical activity habits independently of childhood SES. Childhood SES predicted fruit and vegetable consumption independently of adult SES and, to a lesser extent, predicted physical activity. Downward social mobility over the life course was associated with poorer diets and reduced physical activity.

CONCLUSIONS

Among older women, healthful eating and physical activity were associated with both current and childhood SES. Interventions designed to improve social inequalities in health behaviors should be applied during both childhood and adult life.

Poverty-related factors associated with obesity prevention policies in Utah secondary schools

To address the childhood obesity epidemic, numerous national agencies have outlined specific school policy recommendations for nutrition and physical activity. The extent to which current policies differ by socioeconomic status and geographic location is yet to be determined. This cross-sectional study examined select school nutrition and physical activity policies by markers for poverty among 209 middle and high schools in Utah (82% response rate). The results show that students' opportunities to establish healthful dietary and physical activity patterns differed by economic circumstances and geographic location. Schools with the highest percentage of free and reduced-price lunch enrollment and schools in rural areas were both less likely to offer a variety of healthful foods outside of the school meal program (ie, competitive foods and drinks) and intramural activities or physical activity clubs. Schools with highest free and reduced-price lunch enrollment were more likely to allow the purchase of unhealthful snacks during lunchtimes than schools with low enrollment (28.4% vs 7.6%, P=0.01). Schools in rural communities were less likely to promote walking and bicycling to school compared with other locations (47.4% rural vs 67.1% urban and 63.6% suburban, P=0.06). Current school policies related to nutrition and physical activity may not be conducive to reducing the childhood overweight problem among children attending schools in areas with increased risk factors due to poverty or rural location in Utah.

The aetiology of childhood obesity: a review

Whilst the prevention of childhood obesity is the only viable, enduring, cost-effective solution to the obesity epidemic, effective methods for it remain elusive. Furthermore, strategies to influence obesogenic environments remain relatively unexplored. In order to be able to develop powerful population-level interventions and public health policies to prevent childhood obesity, it is important to understand its aetiology and those environments that are most amenable to measurable change. First, the present paper considers why we should be concerned about obesity in children, from both the perspective of the increased health risk to the individual and the high economic cost of treatment of obesity and related diseases, highlighting why the prevention of childhood obesity is important. Next, the determinants of health behaviour and the obesogenic environment are explored, which helps us to understand why the aetiology is so complex and that potential causal factors should not be considered in isolation, as the interaction between these factors is also important. The paper then considers the multi-factorial aetiology of childhood obesity and the rationale for the increasing trends in obesity that are evident, in order to understand what is changing in society and our children's behaviour that is triggering the positive energy balance leading to obesity. The review emphasises the need for multi-level approaches if we truly want to prevent childhood obesity. It also serves to highlight that there is a need to extend the current research base in order to build a well-founded framework to form the basis of a strategy for the prevention of childhood obesity.