Implementation of Competitive Food and Beverage Standards in a Sample of Massachusetts Schools: The NOURISH Study (Nutrition Opportunities to Understand Reforms Involving Student Health)

The Benefits and Challenges of Providing School Meals during the First Year of California's Universal School Meal Policy as Reported by School Foodservice Professionals

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

Competitive Foods' Nutritional Quality and Compliance with Smart Snacks Standards: An Analysis of a National Sample of U.S. Middle and High Schools

Snacks and beverages are often sold in addition to meals in U.S. schools ("competitive foods"), but their current nutritional quality and compliance with national Smart Snacks standards are unknown. This study assessed competitive foods in a national sample of 90 middle and high schools. Differences in compliance by school characteristics were measured using mixed methods analysis of variance. Overall, 80% of the schools in the sample sold competitive foods; but they were less commonly available in schools with universal free school meal (UFSM) policies. A total of 840 unique products were documented and, on average, 75% were compliant with Smart Snacks standards. A total of 56% aligned with recommended added sugar limits (<10% of calories); and 340 unique products (40%) aligned with both sugar and Smart Snacks standards. Approximately one-fifth of competitive foods contained synthetic dyes, and 31% of beverages contained artificial sweeteners. Smart Snacks standards compliance was greater when competitive foods were overseen by food service departments, in comparison with others (e.g., principals, student organizations, or outside vendors [77% vs. 59% compliance; p = 0.003]). Therefore, district wellness policies should consider requiring food service departments to oversee competitive foods. Federal and state policies should limit added sugars, artificial sweeteners, and synthetic dyes. This appears to be highly feasible, given the substantial number of products that meet these criteria. UFSM policies should also be considered to support healthier school meal environments more broadly.

Implementation of Universal School Meals during COVID-19 and beyond: Challenges and Benefits for School Meals Programs in Maine

School meals play a major role in supporting children’s diets and food security, and policies for universal school meals (USM) have the potential to contribute to positive child health outcomes. During the COVID-19 pandemic, schools provided free school meals to all students in the United States, but this national USM policy ended in school year (SY) 2022–2023; however, a few states have adopted policies to continue USM statewide for SY 2022–2023. Research examining the challenges and strategies for successful continuation of USM is essential, along with studying pandemic-related challenges that are likely to persist in schools. Therefore, we conducted a study in Maine (with a USM policy) to evaluate the impact of COVID-19 and the concurrent implementation of USM, as well as examine differences in implementation by school characteristics, throughout the state. A total of n = 43 school food authorities (SFAs) throughout Maine completed surveys. SFAs reported multiple benefits of USM including increased school meal participation; reductions in the perceived stigma for students from lower-income households and their families; and no longer experiencing unpaid meal charges and debt. SFAs also experienced challenges due to the COVID-19 pandemic, particularly regarding costs. When considering future challenges, most respondents were concerned with obtaining income information from families, product and ingredient availability, and the costs/financial sustainability of the school meal programs. Overall, USM may have multiple important benefits for students and schools, and other states should consider implementation of a USM policy.

Providing School Meals to All Students Free of Charge during the COVID-19 Pandemic and Beyond: Challenges and Benefits Reported by School Foodservice Professionals in California

Universal school meals (USM) have the potential to increase access to healthy food for millions of U.S. students. This study evaluated school food authorities’ (SFA) perspectives of federal USM in response to COVID-19 (school year (SY) 2021−22) and California’s upcoming USM policy in the SY 2022−23. In February 2022, all SFAs in California (n = 1116) were invited to complete an online survey. Descriptive statistics and logistic regression examining differences by school demographic characteristics were used. Five hundred and eighty-one SFAs completed the survey; 63% of them first implemented USM during the COVID-19 pandemic. Reported benefits included increased student meal participation (79.2%) and reduced stigma (39.7%). Top challenges included staffing (76.9%) and meal packaging/solid waste (67.4%). Nearly all SFAs reported pandemic-related challenges procuring the necessary types (88.9%) and amounts of foods (85.9%), and non-food supplies/equipment (82.6%). Over 40% reported that federal reimbursements were insufficient to cover costs. SFAs with <40% FRPM-eligible students and/or higher student enrollment reported more current challenges and future concerns than those with ≥40% FRPMs and lower student enrollment. The top resources requested to implement CA’s USM included additional facilities/equipment (83.8%), communications/marketing (76.1%), increasing meal participation (71.5%), and financial management (61.5%). Most California SFAs reported that implementing federal USM had the intended effect of feeding more children. This study’s findings may be useful to the several other U.S. states implementing universal school meals in the SY 2022−23, and to other states or countries considering adopting a USM policy in the future.

Are Nutrition Standards for Beverages in Schools Associated with Healthier Beverage Intakes among Adolescents in the US?

Under the U.S. Department of Agriculture's Smart Snacks in School standards, beverages sold in schools are restricted to water, flavored or unflavored non-fat milk or unflavored low-fat milk (and milk alternatives), and 100% fruit and vegetable juices; and, at the high school level, diet (≤10 kcal), low-calorie (≤60 kcal), and caffeinated beverages may also be sold. Using data from the School Nutrition and Meal Cost Study, this study examined whether secondary school student beverage consumption was associated with school-level à la carte and vending machine beverage availability, controlling for district, school, and student characteristics. On average, most beverages sold in middle schools (84.54%) and high schools (74.11%) were Smart Snacks compliant; while 24.06 percent of middle school students and 14.64 percent of high school students reported consuming non-compliant beverages, including non-compliant milk, fruit drinks, and sports or energy drinks. School beverage availability was not related to consumption among middle school students; however, high school students were less likely to consume non-compliant beverages when enrolled in schools that sold a higher proportion of compliant beverages (Range: OR = 0.97-0.98, 95% CI = 0.95, 1.00). Findings from this study build upon prior research illustrating the role that schools can play in influencing student dietary intake.

Association between Nutrition Policies and Student Body Mass Index

In response to concerns about childhood obesity, many US states have implemented policies to limit the sale of unhealthy foods and beverages (e.g., snacks, desserts, and sugary drinks) sold in competition with school meal programs (i.e., competitive foods) in order to improve the nutritional environment of schools and support student health. This study measured state-level competitive food and beverage policies that require foods and beverages sold in à la carte lines, vending machines, and school stores to meet strong nutrition standards and tested the hypothesis that students living in states with stronger laws would have lower body mass index (BMI)-for-age percentiles. BMI data from a national sample of 1625 students attending 284 schools from the School Nutrition and Meal Cost Study were linked to state laws coded as part of the National Wellness Policy Study. A survey-adjusted linear regression model accounting for student and school-level characteristics showed that stronger state nutrition policies were associated with lower student BMI scores (coefficient: -0.06, 95% CI: -0.12, -0.00). Additional models indicated that stronger state policies were significantly associated with fewer unhealthy foods and beverages available in schools. These findings suggest that strong regulations on competitive foods and beverages may lead to improvements in the nutritional quality of the school environment and student BMI. Thus, current federal standards regulating snacks in US schools (i.e., Smart Snacks) are an important element of a comprehensive strategy to improve the school nutrition environment and reduce rates of childhood obesity.

Meal Quality of Entrées That Can Be Sold as Competitive Foods in Schools and Potential Impact of the Proposed USDA Rollbacks

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

Interventions for increasing fruit and vegetable consumption in children aged five years and under

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.

Body Weight, Obesity Perception, and Actions to Achieve Desired Weight among Rural and Urban Ghanaian Adults

BACKGROUND

Accurate body weight perception is important to maintaining an ideal body weight. In Africa, a preference for a larger body size and its association with health and wellbeing has been well documented. It remains speculative if these perceptions have changed or improved and if differences exist among rural and urban dwellers. The main aim of this study was to assess the body weight and obesity perceptions among rural and urban Ghanaians.

METHODS

This cross-sectional study involved 565 participants. The Stunkard figure rating scale was used to assess the body weight perception of participants. Participants were to choose from the scale figures they perceived to represent their current body weight, desired body weight, ideal body weight, ideal look for a wealthy person, ideal look for a woman with children, and ideal look for a woman without children. Additionally, participants were asked to describe obesity and its threat to health in their terms. Responses of participants to the above questions are presented as frequencies. Differences between rural and urban participants as well as males and females with respect to the median figure chosen for each question were determined by Mann-Whitney U test.

RESULTS

The median age of participants was 40 (IQR 26). The prevalence of overweight and obesity observed among participants was 52.8%. The most frequently selected figure as current body image was figure 5 (23.5%). Figure 4 was most frequently chosen by both males (37.2%) and females (24.6%) as their desired body image (27.4%). Male participants (41.8%) chose figure 5 as ideal for their gender while females (27.4%) maintained figure 4 as ideal for their gender. Study participants associated overweight with wealth and childbirth, and attributed their current weights to hereditary (27%) and childbirth (27%). Most participants were not taking steps to achieve their desired body image, and only a few engaged in both dieting and exercise to lose weight. Majority of participants described obesity as the accumulation of fat (91.0%) and viewed it as a threat to health (91.0%). Differences were observed among rural and urban participants with regard to the figure chosen as ideal for a wealthy person.

CONCLUSION

Results from this study show an improvement in obesity perception and the acknowledgment of obesity as a threat to health. There was a desire for a normal-weight figure among study participants. Attribution of current body weight to hereditary and childbirth seems to be a hindrance to the implementation of actions to achieve this normal figure weight. Public health education, screening for overweight and obesity, creation of supportive food environments, and culture-sensitive interventions are promising to curbing the obesity menace.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

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.

Impact of the Food-Labeling and Advertising Law Banning Competitive Food and Beverages in Chilean Public Schools, 2014-2016

Objectives. To evaluate the impact of a national law banning sales of competitive food and beverages (CF&B) in schools on the availability of CF&B sold at school kiosks.Methods. This study was uncontrolled before and after study. We evaluated public schools in Santiago de Chile (n = 21; 78% response rate) in 2014 and 2016 (6 months after the law came into force). Trained personnel collected data on calories, total sugars, saturated fat, and sodium from food labels. The outcome was the percentage of foods exceeding the cutoff levels defined in the law and the mean difference between 2014 and 2016.Results. Foods exceeding any cutoffs decreased from 90.4% in 2014 to 15.0% in 2016. Solid products had a substantial reduction in calories, sugar, saturated fat, and sodium. Liquid products had a reduction in calories, total sugar, and saturated fat, whereas sodium increased. This was a result of changes in product mix.Conclusions. A ban on sales of CF&B reduced the availability of CF&B at Santiago's school kiosks. Further research should examine the impact of this ban on food intake and health outcomes.

The Impact of 1 Year of Healthier School Food Policies on Students' Diets During and Outside of the School Day

BACKGROUND

In 2012, Massachusetts implemented both the updated national school meal standards and comprehensive competitive food/beverage standards that closely align with current national requirements for school snacks.

OBJECTIVES

This study examines the impact of these combined standards on school meal and snack food selections, as well as food choices outside of school. In addition, this study examines the impact of these standards on nutrients consumed.

DESIGN

The NOURISH (Nutrition Opportunities to Understand Reforms Involving Student Health) Study was an observational cohort study conducted among students from spring 2012 to spring 2013.

PARTICIPANTS/SETTING

One hundred sixty students in 12 middle schools and high schools in Massachusetts completed two 24-hour recalls before (spring 2012) and after implementation (spring 2013) of the updated standards.

MAIN OUTCOME MEASURES

Changes in school meals, competitive food, and after-school snack selection, as well as nutrients consumed outside of school were examined.

STATISTICAL ANALYSES PERFORMED

Logistic regression and mixed-model analysis of variance were used to examine food selection and consumption.

RESULTS

After implementation, 13.6% more students chose a school meal (70.1% vs 56.5%; P=0.02). There were no differences in competitive food purchases but a significant decrease in the number of after-school unhealthy snacks consumed (0.69 [standard error=0.08] vs 1.02 [standard error=0.10]; P=0.009). During the entire day, students consumed, on average, 22 fewer grams of sugar daily after implementation compared with before implementation (86 g vs 108 g; P=0.002).

CONCLUSIONS

With the reduction in the number of unhealthy school snacks, significantly more students selected school meals. Students did not compensate for lack of unhealthy snacks in school by increased consumption of unhealthy snacks outside of school. This provides important new evidence that both national school meal and snack policies may improve daily diet quality and should remain strong.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

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.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

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.

Product reformulation and nutritional improvements after new competitive food standards in schools

OBJECTIVE

In 2012, Massachusetts enacted school competitive food and beverage standards similar to national Smart Snacks. These standards aim to improve the nutritional quality of competitive snacks. It was previously demonstrated that a majority of foods and beverages were compliant with the standards, but it was unknown whether food manufacturers reformulated products in response to the standards. The present study assessed whether products were reformulated after standards were implemented; the availability of reformulated products outside schools; and whether compliance with the standards improved the nutrient composition of competitive snacks.

DESIGN

An observational cohort study documenting all competitive snacks sold before (2012) and after (2013 and 2014) the standards were implemented.

SETTING

The sample included thirty-six school districts with both a middle and high school.

RESULTS

After 2012, energy, saturated fat, Na and sugar decreased and fibre increased among all competitive foods. By 2013, 8 % of foods were reformulated, as were an additional 9 % by 2014. Nearly 15 % of reformulated foods were look-alike products that could not be purchased at supermarkets. Energy and Na in beverages decreased after 2012, in part facilitated by smaller package sizes.

CONCLUSIONS

Massachusetts' law was effective in improving the nutritional content of snacks and product reformulation helped schools adhere to the law. This suggests fully implementing Smart Snacks standards may similarly improve the foods available in schools nationally. However, only some healthier reformulated foods were available outside schools.

A Community-Level Sodium Reduction Intervention, Boston, 2013-2015

OBJECTIVES

To evaluate a community-level sodium-reduction intervention in Boston, Massachusetts. Reducing sodium in the food offerings of community settings may help reduce hypertension disparities.

METHODS

We examined changes in the proportion of prepackaged foods with greater than 200 milligrams of sodium in 7 hospitals, 8 YMCAs, 4 community health centers, and 2 organizations serving homeless populations. Research assistants documented prepackaged items in cafeterias, kiosks, and vending machines before and after the intervention (2013-2015). We assessed intervention change via linear mixed models accounting for repeated observations.

RESULTS

There were 161 access points at baseline (4347 facings) and 171 (4996 facings) at follow-up. The percentage of prepackaged products with greater than 200 milligrams of sodium decreased from 29.0% at baseline to 21.5% at follow-up (P = .003). Changes were driven by improvements in hospital cafeterias and kiosks (P = .003). The percentage of products with greater than 200 milligrams of sodium in YMCA vending decreased 58% (from 27.2% to 11.5%; P = .017); other organizations had nonsignificant declines.

CONCLUSIONS

We found modest reductions in the percentage of higher-sodium prepackaged products across community institutions. Community-level interventions may increase availability of lower-sodium products in the food supply.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

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.

Healthier Standards for School Meals and Snacks: Impact on School Food Revenues and Lunch Participation Rates

INTRODUCTION

In 2012, the updated U.S. Department of Agriculture school meals standards and a competitive food law similar to the fully implemented version of the national Smart Snack standards went into effect in Massachusetts. This study evaluated the impact of these updated school meal standards and Massachusetts' comprehensive competitive food standards on school food revenues and school lunch participation.

METHODS

Revenue and participation data from 11 Massachusetts school districts were collected from 2011 to 2014 and analyzed in 2015 using multilevel modeling. The association between the change in compliance with the competitive food standards and revenues/participation was assessed using linear regression.

RESULTS

Schools experienced declines in school food revenues of $15.40/student in Year 1 from baseline (p=0.05), due to competitive food revenue losses. In schools with 3 years of data, overall revenues rebounded by the second year post-implementation. Additionally, by Year 2, school lunch participation increased by 15% (p=0.0006) among children eligible for reduced-price meals. Better competitive food compliance was inversely associated with school food revenues in the first year only; an absolute change in compliance by 10% was associated with a $9.78/student decrease in food revenues over the entire school year (p=0.04). No association was seen between the change in compliance and school meal participation.

CONCLUSIONS

Schools experienced initial revenue losses after implementation of the standards, yet longer-term school food revenues were not impacted and school meal participation increased among children eligible for reduced-price meals. Weakening the school meal or competitive food guidelines based on revenue concerns appears unwarranted.

How do we actually put smarter snacks in schools? NOURISH (Nutrition Opportunities to Understand Reforms Involving Student Health) conversations with food-service directors

OBJECTIVE

In autumn 2012, Massachusetts schools implemented comprehensive competitive food and beverage standards similar to the US Department of Agriculture's Smart Snacks in School standards. We explored major themes raised by food-service directors (FSD) regarding their school-district-wide implementation of the standards.

DESIGN

For this qualitative study, part of a larger mixed-methods study, compliance was measured via direct observation of foods and beverages during school site visits in spring 2013 and 2014, calculated to ascertain the percentage of compliant products available to students. Semi-structured interviews with school FSD conducted in each year were analysed for major implementation themes; those raised by more than two-thirds of participating school districts were explored in relationship to compliance.

SETTING

Massachusetts school districts (2013: n 26; 2014: n 21).

SUBJECTS

Data collected from FSD.

RESULTS

Seven major themes were raised by more than two-thirds of participating school districts (range 69-100 %): taking measures for successful transition; communicating with vendors/manufacturers; using tools to identify compliant foods and beverages; receiving support from leadership; grappling with issues not covered by the law; anticipating changes in sales of competitive foods and beverages; and anticipating changes in sales of school meals. Each theme was mentioned by the majority of more-compliant school districts (65-81 %), with themes being raised more frequently after the second year of implementation (range increase 4-14 %).

CONCLUSIONS

FSD in more-compliant districts were more likely to talk about themes than those in less-compliant districts. Identified themes suggest best-practice recommendations likely useful for school districts implementing the final Smart Snacks in School standards, effective July 2016.

Limited School Drinking Water Access for Youth

PURPOSE

Providing children and youth with safe, adequate drinking water access during school is essential for health. This study used objectively measured data to investigate the extent to which schools provide drinking water access that meets state and federal policies.

METHODS

We visited 59 middle and high schools in Massachusetts during spring 2012. Trained research assistants documented the type, location, and working condition of all water access points throughout each school building using a standard protocol. School food service directors (FSDs) completed surveys reporting water access in cafeterias. We evaluated school compliance with state plumbing codes and federal regulations and compared FSD self-reports of water access with direct observation; data were analyzed in 2014.

RESULTS

On average, each school had 1.5 (standard deviation: .6) water sources per 75 students; 82% (standard deviation: 20) were functioning and fewer (70%) were both clean and functioning. Less than half of the schools met the federal Healthy Hunger-Free Kids Act requirement for free water access during lunch; 18 schools (31%) provided bottled water for purchase but no free water. Slightly over half (59%) met the Massachusetts state plumbing code. FSDs overestimated free drinking water access compared to direct observation (96% FSD reported vs. 48% observed, kappa = .07, p = .17).

CONCLUSIONS

School drinking water access may be limited. In this study, many schools did not meet state or federal policies for minimum student drinking water access. School administrative staff may not accurately report water access. Public health action is needed to increase school drinking water access.

Impact of Nutrition Standards on Competitive Food Quality in Massachusetts Middle and High Schools

OBJECTIVES

To examine changes in competitive foods (items sold in à la carte lines, vending machines, and school stores that "compete" with school meals) in Massachusetts middle and high schools before and after implementation of a statewide nutrition law in 2012.

METHODS

We photographed n = 10 782 competitive foods and beverages in 36 Massachusetts school districts and 7 control state districts to determine availability and compliance with the law at baseline (2012), 1 year (2013), and 2 years (2014) after the policy (overall enrollment: 71 202 students). We examined availability and compliance trends over time.

RESULTS

By 2014, 60% of competitive foods and 79% of competitive beverages were compliant. Multilevel models showed an absolute 46.2% increase for foods (95% confidence interval = 36.2, 56.3) and 46.8% increase for beverages (95% confidence interval = 39.2, 54.4) in schools' alignment with updated standards from 2012 to 2014.

CONCLUSIONS

The law's implementation resulted in major improvements in the availability and nutritional quality of competitive foods and beverages, but schools did not reach 100% compliance. This law closely mirrors US Department of Agriculture Smart Snacks in School standards, suggesting that complying with strict nutrition standards is feasible, and schools may experience challenges and improvements over time.