Parent packs, child eats: Surprising results of Lunch is in the Bag's efficacy trial

The Quality of Lunches Brought from Home to School: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis, spanning studies published between 1995 and 2021, investigates various aspects of lunches brought from home (LBFH) to school by children. These meals, in contrast to those provided by the National School Lunch Program (NSLP), lack strict nutritional standards. Despite the availability of NSLP lunches, ∼40% of US children opt for LBFH. This review aims to assess the food content and nutritional quality of LBFH, their adherence to NSLP standards in terms of nutrition and cost, effectiveness of intervention programs designed to enhance their nutritional quality and parental and student perceptions of LBFH. The comprehensive literature search yielded 28 eligible papers, with 16 included in meta-analysis. LBFH commonly include fruits (50%), yet vegetables (17%) and dairy (25%) are less prevalent. They frequently contain snacks (50%), sweets (48%), and sugar-sweetened beverages (31%). Compared with school lunches, LBFH exhibit lower levels of calcium, protein, iron, fiber, and vitamin A, and higher levels of carbohydrates and saturated fat. Intervention programs had no effect on quality of LBFH. On average, LBFH ($1.81) cost slightly less than lunches served at school ($1.98), without accounting for free/reduced-price meals in the calculation. The cost of school lunch for pre-k and kindergarten children became $11.32, nearly 4 times higher than that of LBFH ($2.92), after replicating the meal at home and accounting for meal preparation time. Parents preferred LBFH over school lunches because of concerns related to the quality of school meals served. This study concludes that LBFH are generally less nutritious compared with lunches provided by NSLP. Future research needs to further explore ways to improve parent perception of NSLP. Especially with many states making free meals available to all children, identifying effective ways in promoting and increasing NSLP participation can ensure more children have access to nutritionally balanced and affordable lunches.

Assessing the scalability of healthy eating interventions within the early childhood education and care setting: secondary analysis of a Cochrane systematic review

OBJECTIVE

Early childhood education and care (ECEC) is a recommended setting for the delivery of health eating interventions 'at scale' (i.e. to large numbers of childcare services) to improve child public health nutrition. Appraisal of the 'scalability' (suitability for delivery at scale) of interventions is recommended to guide public health decision-making. This study describes the extent to which factors required to assess scalability are reported among ECEC-based healthy eating interventions.

DESIGN

Studies from a recent Cochrane systematic review assessing the effectiveness of healthy eating interventions delivered in ECEC for improving child dietary intake were included. The reporting of factors of scalability was assessed against domains outlined within the Intervention Scalability Assessment Tool (ISAT). The tool recommends decision makers consider the problem, the intervention, strategic and political context, effectiveness, costs, fidelity and adaptation, reach and acceptability, delivery setting and workforce, implementation infrastructure and sustainability. Data were extracted by one reviewer and checked by a second reviewer.

SETTING

ECEC.

PARTICIPANTS

Children 6 months to 6 years.

RESULTS

Of thirty-eight included studies, none reported all factors within the ISAT. All studies reported the problem, the intervention, effectiveness and the delivery workforce and setting. The lowest reported domains were intervention costs (13 % of studies) and sustainability (16 % of studies).

CONCLUSIONS

Findings indicate there is a lack of reporting of some key factors of scalability for ECEC-based healthy eating interventions. Future studies should measure and report such factors to support policy and practice decision makers when selecting interventions to be scaled-up.

Healthy eating interventions delivered in early childhood education and care settings for improving the diet of children aged six months to six years

BACKGROUND

Dietary intake during early childhood can have implications on child health and developmental trajectories. Early childhood education and care (ECEC) services are recommended settings to deliver healthy eating interventions as they provide access to many children during this important period. Healthy eating interventions delivered in ECEC settings can include strategies targeting the curriculum (e.g. nutrition education), ethos and environment (e.g. menu modification) and partnerships (e.g. workshops for families). Despite guidelines supporting the delivery of healthy eating interventions in this setting, little is known about their impact on child health.

OBJECTIVES

To assess the effectiveness of healthy eating interventions delivered in ECEC settings for improving dietary intake in children aged six months to six years, relative to usual care, no intervention or an alternative, non-dietary intervention. Secondary objectives were to assess the impact of ECEC-based healthy eating interventions on physical outcomes (e.g. child body mass index (BMI), weight, waist circumference), language and cognitive outcomes, social/emotional and quality-of-life outcomes. We also report on cost and adverse consequences of ECEC-based healthy eating interventions.

SEARCH METHODS

We searched eight electronic databases including CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, ERIC, Scopus and SportDiscus on 24 February 2022. We searched reference lists of included studies, reference lists of relevant systematic reviews, the World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov and Google Scholar, and contacted authors of relevant papers.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), including cluster-RCTs, stepped-wedge RCTs, factorial RCTs, multiple baseline RCTs and randomised cross-over trials, of healthy eating interventions targeting children aged six months to six years that were conducted within the ECEC setting. ECEC settings included preschools, nurseries, kindergartens, long day care and family day care. To be included, studies had to include at least one intervention component targeting child diet within the ECEC setting and measure child dietary or physical outcomes, or both.

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently screened titles and abstracts and extracted study data. We assessed risk of bias for all studies against 12 criteria within RoB 1, which allows for consideration of how selection, performance, attrition, publication and reporting biases impact outcomes. We resolved discrepancies via consensus or by consulting a third review author. Where we identified studies with suitable data and homogeneity, we performed meta-analyses using a random-effects model; otherwise, we described findings using vote-counting approaches and via harvest plots. For measures with similar metrics, we calculated mean differences (MDs) for continuous outcomes and risk ratios (RRs) for dichotomous outcomes. We calculated standardised mean differences (SMDs) for primary and secondary outcomes where studies used different measures. We applied GRADE to assess certainty of evidence for dietary, cost and adverse outcomes.

MAIN RESULTS

We included 52 studies that investigated 58 interventions (described across 96 articles). All studies were cluster-RCTs. Twenty-nine studies were large (≥ 400 participants) and 23 were small (< 400 participants). Of the 58 interventions, 43 targeted curriculum, 56 targeted ethos and environment, and 50 targeted partnerships. Thirty-eight interventions incorporated all three components. For the primary outcomes (dietary outcomes), we assessed 19 studies as overall high risk of bias, with performance and detection bias being most commonly judged as high risk of bias. ECEC-based healthy eating interventions versus usual practice or no intervention may have a positive effect on child diet quality (SMD 0.34, 95% confidence interval (CI) 0.04 to 0.65; P = 0.03, I2 = 91%; 6 studies, 1973 children) but the evidence is very uncertain. There is moderate-certainty evidence that ECEC-based healthy eating interventions likely increase children's consumption of fruit (SMD 0.11, 95% CI 0.04 to 0.18; P < 0.01, I2 = 0%; 11 studies, 2901 children). The evidence is very uncertain about the effect of ECEC-based healthy eating interventions on children's consumption of vegetables (SMD 0.12, 95% CI -0.01 to 0.25; P =0.08, I2 = 70%; 13 studies, 3335 children). There is moderate-certainty evidence that ECEC-based healthy eating interventions likely result in little to no difference in children's consumption of non-core (i.e. less healthy/discretionary) foods (SMD -0.05, 95% CI -0.17 to 0.08; P = 0.48, I2 = 16%; 7 studies, 1369 children) or consumption of sugar-sweetened beverages (SMD -0.10, 95% CI -0.34 to 0.14; P = 0.41, I2 = 45%; 3 studies, 522 children). Thirty-six studies measured BMI, BMI z-score, weight, overweight and obesity, or waist circumference, or a combination of some or all of these. ECEC-based healthy eating interventions may result in little to no difference in child BMI (MD -0.08, 95% CI -0.23 to 0.07; P = 0.30, I2 = 65%; 15 studies, 3932 children) or in child BMI z-score (MD -0.03, 95% CI -0.09 to 0.03; P = 0.36, I2 = 0%; 17 studies; 4766 children). ECEC-based healthy eating interventions may decrease child weight (MD -0.23, 95% CI -0.49 to 0.03; P = 0.09, I2 = 0%; 9 studies, 2071 children) and risk of overweight and obesity (RR 0.81, 95% CI 0.65 to 1.01; P = 0.07, I2 = 0%; 5 studies, 1070 children). ECEC-based healthy eating interventions may be cost-effective but the evidence is very uncertain (6 studies). ECEC-based healthy eating interventions may have little to no effect on adverse consequences but the evidence is very uncertain (3 studies). Few studies measured language and cognitive skills (n = 2), social/emotional outcomes (n = 2) and quality of life (n = 3).

AUTHORS' CONCLUSIONS

ECEC-based healthy eating interventions may improve child diet quality slightly, but the evidence is very uncertain, and likely increase child fruit consumption slightly. There is uncertainty about the effect of ECEC-based healthy eating interventions on vegetable consumption. ECEC-based healthy eating interventions may result in little to no difference in child consumption of non-core foods and sugar-sweetened beverages. Healthy eating interventions could have favourable effects on child weight and risk of overweight and obesity, although there was little to no difference in BMI and BMI z-scores. Future studies exploring the impact of specific intervention components, and describing cost-effectiveness and adverse outcomes are needed to better understand how to maximise the impact of ECEC-based healthy eating interventions.

Healthy eating interventions delivered in early childhood education and care settings for improving the diet of children aged six months to six years

BACKGROUND

Dietary intake during early childhood can have implications on child health and developmental trajectories. Early childhood education and care (ECEC) services are recommended settings to deliver healthy eating interventions as they provide access to many children during this important period. Healthy eating interventions delivered in ECEC settings can include strategies targeting the curriculum (e.g. nutrition education), ethos and environment (e.g. menu modification) and partnerships (e.g. workshops for families). Despite guidelines supporting the delivery of healthy eating interventions in this setting, little is known about their impact on child health.

OBJECTIVES

To assess the effectiveness of healthy eating interventions delivered in ECEC settings for improving dietary intake in children aged six months to six years, relative to usual care, no intervention or an alternative, non-dietary intervention. Secondary objectives were to assess the impact of ECEC-based healthy eating interventions on physical outcomes (e.g. child body mass index (BMI), weight, waist circumference), language and cognitive outcomes, social/emotional and quality-of-life outcomes. We also report on cost and adverse consequences of ECEC-based healthy eating interventions.

SEARCH METHODS

We searched eight electronic databases including CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, ERIC, Scopus and SportDiscus on 24 February 2022. We searched reference lists of included studies, reference lists of relevant systematic reviews, the World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov and Google Scholar, and contacted authors of relevant papers.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), including cluster-RCTs, stepped-wedge RCTs, factorial RCTs, multiple baseline RCTs and randomised cross-over trials, of healthy eating interventions targeting children aged six months to six years that were conducted within the ECEC setting. ECEC settings included preschools, nurseries, kindergartens, long day care and family day care. To be included, studies had to include at least one intervention component targeting child diet within the ECEC setting and measure child dietary or physical outcomes, or both.

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently screened titles and abstracts and extracted study data. We assessed risk of bias for all studies against 12 criteria within RoB 1, which allows for consideration of how selection, performance, attrition, publication and reporting biases impact outcomes. We resolved discrepancies via consensus or by consulting a third review author. Where we identified studies with suitable data and homogeneity, we performed meta-analyses using a random-effects model; otherwise, we described findings using vote-counting approaches and via harvest plots. For measures with similar metrics, we calculated mean differences (MDs) for continuous outcomes and risk ratios (RRs) for dichotomous outcomes. We calculated standardised mean differences (SMDs) for primary and secondary outcomes where studies used different measures. We applied GRADE to assess certainty of evidence for dietary, cost and adverse outcomes.  MAIN RESULTS: We included 52 studies that investigated 58 interventions (described across 96 articles). All studies were cluster-RCTs. Twenty-nine studies were large (≥ 400 participants) and 23 were small (< 400 participants). Of the 58 interventions, 43 targeted curriculum, 56 targeted ethos and environment, and 50 targeted partnerships. Thirty-eight interventions incorporated all three components. For the primary outcomes (dietary outcomes), we assessed 19 studies as overall high risk of bias, with performance and detection bias being most commonly judged as high risk of bias. ECEC-based healthy eating interventions versus usual practice or no intervention may have a positive effect on child diet quality (SMD 0.34, 95% confidence interval (CI) 0.04 to 0.65; P = 0.03, I2 = 91%; 6 studies, 1973 children) but the evidence is very uncertain. There is moderate-certainty evidence that ECEC-based healthy eating interventions likely increase children's consumption of fruit (SMD 0.11, 95% CI 0.04 to 0.18; P < 0.01, I2 = 0%; 11 studies, 2901 children). The evidence is very uncertain about the effect of ECEC-based healthy eating interventions on children's consumption of vegetables (SMD 0.12, 95% CI -0.01 to 0.25; P =0.08, I2 = 70%; 13 studies, 3335 children). There is moderate-certainty evidence that ECEC-based healthy eating interventions likely result in little to no difference in children's consumption of non-core (i.e. less healthy/discretionary) foods (SMD -0.05, 95% CI -0.17 to 0.08; P = 0.48, I2 = 16%; 7 studies, 1369 children) or consumption of sugar-sweetened beverages (SMD -0.10, 95% CI -0.34 to 0.14; P = 0.41, I2 = 45%; 3 studies, 522 children). Thirty-six studies measured BMI, BMI z-score, weight, overweight and obesity, or waist circumference, or a combination of some or all of these. ECEC-based healthy eating interventions may result in little to no difference in child BMI (MD -0.08, 95% CI -0.23 to 0.07; P = 0.30, I2 = 65%; 15 studies, 3932 children) or in child BMI z-score (MD -0.03, 95% CI -0.09 to 0.03; P = 0.36, I2 = 0%; 17 studies; 4766 children). ECEC-based healthy eating interventions may decrease child weight (MD -0.23, 95% CI -0.49 to 0.03; P = 0.09, I2 = 0%; 9 studies, 2071 children) and risk of overweight and obesity (RR 0.81, 95% CI 0.65 to 1.01; P = 0.07, I2 = 0%; 5 studies, 1070 children). ECEC-based healthy eating interventions may be cost-effective but the evidence is very uncertain (6 studies). ECEC-based healthy eating interventions may have little to no effect on adverse consequences but the evidence is very uncertain (3 studies). Few studies measured language and cognitive skills (n = 2), social/emotional outcomes (n = 2) and quality of life (n = 3).

AUTHORS' CONCLUSIONS

ECEC-based healthy eating interventions may improve child diet quality slightly, but the evidence is very uncertain, and likely increase child fruit consumption slightly. There is uncertainty about the effect of ECEC-based healthy eating interventions on vegetable consumption. ECEC-based healthy eating interventions may result in little to no difference in child consumption of non-core foods and sugar-sweetened beverages. Healthy eating interventions could have favourable effects on child weight and risk of overweight and obesity, although there was little to no difference in BMI and BMI z-scores. Future studies exploring the impact of specific intervention components, and describing cost-effectiveness and adverse outcomes are needed to better understand how to maximise the impact of ECEC-based healthy eating interventions.

Feeding and Activity Environments for Infants and Toddlers in Childcare Centers and Family Childcare Homes in Southeastern New England

Few studies have documented the food and physical activity (PA) environments of childcare settings caring for children <24 months of age, although they may be key contributors to developing child PA and diet patterns. We used an adapted Environment and Policy Assessment and Observation tool to assess the food and activity environments for infants and toddlers in childcare centers (n = 21) and family childcare homes (FCCH) (n = 20) and explored differences by childcare type. Many similarities were found between childcare site types; however, centers used more recommended feeding practices than FCCH (e.g., 100% of center providers talked with toddlers about feelings of hunger or fullness compared to 18% of family childcare providers (FCCP), p < 0.01). Differences in non-recommended feeding practices (e.g., spoon feeding, bottle propping and encouraging unhealthy foods) were mixed between childcare types. Toddlers in centers spent more time playing at higher PA levels than those in FCCH (61 vs. 13 min, p < 0.001). Screen time was observed in FCCH, but not in centers. Differences between childcare types may indicate differential influences on infant and toddler feeding and PA behaviors, which could predict disparate obesity risk. Future research should further observe these behaviors in a larger sample of centers and FCCH to inform childcare interventions and policies.

Intervención para modificar hábitos alimentarios en los refrigerios de escolares de una ciudad fronteriza México / Estados Unidos

El objetivo del presente estudio fue evaluar el efecto de una intervención en educación nutricional como estrategia para modificar la calidad de los refrigerios escolares de acuerdo con los estándares gubernamentales. Se evaluaron alumnos de 12 escuelas primarias públicas de nivel socioeconómico medio. Se formó un grupo intervención (GI) y un grupo control (GC), con seguimiento durante dos años. En ambos grupos se tomaron mediciones de peso, estatura y circunferencia de cintura. Se registró, durante cinco días consecutivos, los alimentos incluidos en la lonchera de los niños, previa firma de un consentimiento informado de los padres. Durante la intervención se realizaron pláticas sobre alimentación en el salón de clase para los escolares y a los padres de familia se les entregaron folletos sobre recomendaciones de un refrigerio adecuado. En el GC solo se entregaron folletos sin tener contacto con alumnos y padres de familia. Al final de la intervención, el GI disminuyó calorías (p = 0.001), proteínas (p = 0.01), carbohidratos (p = 0.008) y azúcar (p = 0.0001); mientras que en el GC disminuyó el contenido de carbohidratos y azúcar. Además, el GI aumentó el consumo de cereales integrales, verduras, frijoles y pan integral. En conclusión, la escuela es el lugar ideal para realizar intervenciones a largo plazo, sin embargo, es necesario promover la incorporación de profesionales de la salud (nutriólogos) con programas y actividades planeadas durante los seis años de primaria.

Gender Differences in Nutritional Quality and Consumption of Lunches Brought from Home to School

Gender difference in the lunches brought from home to school and the amount consumed by elementary and intermediate school students were examined using data collected from 12 schools in Texas. The amount and nutritional quality of food items brought and consumed was evaluated, by comparing the results to the 2012 school meal standards, and Dietary Reference Intakes (DRIs). Almost all lunches brought from home contained grain and meat/meat alternatives, and the amount brought and consumed exceeded the NSLP standards. The majority of students did not bring fruits, vegetables, and whole grain foods, but those who brought consumed most of what they brought. Among elementary school students, only 9% of boys and 14% of girls brought vegetables and the amount brought and consumed did not meet the standards. Although carbohydrate and protein consumption were adequate for boys and girls, the intakes of micronutrients and fiber did not meet the requirements across both genders at both school levels. Overall, lunches brought from home were not well balanced and did not meet NSLP standards and DRIs. It is imperative to identify strategies to improve the nutritional quality of lunches brought from home considering gender difference in food choice and educating parents and children on what is a healthy well-balanced lunch.

Food Photography as a Tool to Assess Type, Quantity, and Quality of Foods in Parent-Packed Lunches for Preschoolers

OBJECTIVE

Explore using food photography to assess packed lunches in a university-based Early Childhood Center and contextualize these photographs through parent interviews.

METHODS

An explanatory sequential design was used. Packed lunches were photographed to assess the type and quantity of foods offered and consumed by Child and Adult Food Care Program components (fruit, vegetable, grain, and protein) and quality of foods offered using the Healthy Meal Index. Parent interviews aimed to understand motivations and behaviors related to packing lunch.

RESULTS

Data were collected on 401 lunches. Only 16.2% of lunches met all Child and Adult Food Care Program requirements. Most lunches included fruit (84%) and grains (82%), whereas fewer included vegetables (44%). Portion sizes were large, especially for grains (2.7 ± 1.5 servings). In interviews (n = 24), parents expressed tension between offering healthful items and foods they knew their child would eat, as well as concern about children going hungry.

CONCLUSIONS AND IMPLICATIONS

Food photography is a feasible methodology to capture parent-packed lunches for preschoolers and may have utility in nutrition education, particularly related to age-appropriate portion sizes.

Cluster randomised controlled trial of an m-health intervention in centre-based childcare services to reduce the packing of discretionary foods in children's lunchboxes: study protocol for the 'SWAP IT Childcare' trial

INTRODUCTION

In many developed nations, including Australia, a substantial number of children aged under 5 years attend centre-based childcare services that require parents to pack food in lunchboxes. These lunchboxes often contain excessive amounts of unhealthy ('discretionary') foods. This study aims to assess the impact of a mobile health (m-health) intervention on reducing the packing of discretionary foods in children's childcare lunchboxes.

METHODS AND ANALYSIS

A cluster randomised controlled trial will be undertaken with parents from 18 centre-based childcare services in the Hunter New England region of New South Wales, Australia. Services will be randomised to receive either a 4-month m-health intervention called 'SWAP IT Childcare' or usual care. The development of the intervention was informed by the Behaviour Change Wheel model and will consist primarily of the provision of targeted information, lunchbox food guidelines and website links addressing parent barriers to packing healthy lunchboxes delivered through push notifications via an existing app used by childcare services to communicate with parents and carers. The primary outcomes of the trial will be energy (kilojoules) from discretionary foods packed in lunchboxes and the total energy (kilojoules), saturated fat (grams), total and added sugars (grams) and sodium (milligrams) from all foods packed in lunchboxes. Outcomes will be assessed by weighing and photographing all lunchbox food items at baseline and at the end of the intervention.

ETHICS AND DISSEMINATION

The study was approved by the Hunter New England Local Health District Human Ethics Committee (06/07/26/4.04) and ratified by the University of Newcastle, Human Research Ethics Committee (H-2008-0343). Evaluation and process data collected as part of the study will be disseminated in peer-reviewed publications and local, national and international presentations and will form part of PhD student theses.

TRIAL REGISTRATION NUMBER

ACTRN12618000133235; Pre-results.