The implementation and effectiveness of school-based nutrition promotion programmes using a health-promoting schools approach: a systematic review

Prevalence of Metabolic Syndrome Based on Activity Type and Dietary Habits in Extremely Low-Income Individuals

A high prevalence of metabolic syndrome (MS) and cardiovascular disease among low-income individuals has often been reported. However, there is still a lack of research on the relationship between basic livelihood security (BLS) and MS. This study investigated the prevalence of MS according to activity type, dietary habits, and the nutrient intake characteristics of individuals receiving BLS. Data from 14,803 men and 20,299 women were analyzed to assess the association between receiving BLS and MS. The associations between MS and various factors were analyzed separately in men and women by logistic regression analysis. In this cohort, 5.9% of men and 6.8% of women received BLS; of these, 46.9% and 47.7% had MS, respectively. High caloric intake, low-frequency breakfast consumption, and no nutritional education were associated with MS in both men and women. Among those with a low-frequency walking habit and strength training activity type, MS increased by 1.58 and 1.57 times in men and by 1.47 and 2.16 times in women, respectively. Men who were sedentary for 8 h or more had an increased risk of MS, but there was no association between these in women. BLS nutritional intake characteristics were high in carbohydrates and fat and low in dietary fiber and vitamin C (p < 0.05). In conclusion, establishing a healthy eating pattern through nutritional education and increasing walking and strength training may reduce the risk of MS.

Qualitative multi-stakeholder evaluation of the adoption, implementation and sustainment of the school-based dietary intervention "Jump-in"

BACKGROUND

Comprehensive school-based programs applying the WHO Health Promoting School Model have the potential to initiate and sustain behavior change and impact health. However, since they often include intervention efforts on a school's policies, physical environment, curriculum, health care and involving parents and communities, they significantly 'intrude' on a complex system that is aimed primarily at education, not health promotion. More insights into and concrete strategies are therefore needed regarding their adoption, implementation, and sustainment processes to address the challenge to sustainable implementation of HPS initiatives in a primarily educational setting. This study consequently evaluates adoption, implementation and sustainment processes of Amsterdam's Jump-in healthy nutrition HPS intervention from a multi-stakeholder perspective.

METHODS

We conducted semi-structured interviews and focus groups with all involved stakeholders (n = 131), i.e., Jump-in health promotion professionals (n = 5), school principals (n = 7), at-school Jump-in coordinators (n = 7), teachers (n = 20), parents (n = 50, 9 groups) and children (n = 42, 7 groups) from 10 primary schools that enrolled in Jump-in in the school year 2016-2017. Included schools had a higher prevalence of overweight and/or obesity than the Dutch average and they were all located in Amsterdam's low-SEP neighborhoods. Data were analyzed using a directed content analysis, in which the Determinants of Innovation Model was used for obtaining theory-based predetermined codes, supplemented with new codes emerging from the data.

RESULTS

During intervention adoption, all stakeholders emphasized the importance of parental support, and accompanying workshops and promotional materials. Additionally, parents and teachers indicated that a shared responsibility for children's health and nuanced framing of health messages were important. During implementation, all stakeholders needed clear guidelines and support structures. Teachers and children highlighted the importance of peer influence, social norms, and uniform application of guidelines. School staff also found further tailoring of the intervention and dealing with financial constraints important. For long-term intervention sustainment, incorporating the intervention policies into the school statutes was crucial according to health promotion professionals.

CONCLUSIONS

This qualitative evaluation provides valuable insights into factors influencing the adoption, implementation, and sustainment processes of dietary interventions, such as the importance of transparent and consistent intervention guidelines, clear communication regarding the rationale behind intervention guidelines, and, stakeholders' involvement in decision-making.

Association Between Dietary Patterns and Bullying Among Adolescents in Sao Paulo-Brazil

Previous studies have assessed the association between food consumption and bullying perpetration, but most of them have not broadly assessed food consumption, neither the distinction between forms of bullying. The aim of the study was to evaluate the association between dietary patterns with bullying roles and its different types of bullying perpetration among adolescents. Data on a representative sample of ninth-grade students (N = 2,163; mean age = 14.8 years) taken from Sao Paulo Project for the social development of children and adolescents (SP-PROSO) were used. The independent variables were healthy and unhealthy dietary patterns obtained by exploratory factor analysis. The dependent variables were bullying role (victim-only, bully-only, bully-victim) and bullying perpetration (any type, social exclusion, psychological/verbal aggression, physical aggression, property destruction, sexual harassment). Multinomial and logistic regression models were performed for the total sample and stratified by sex (only for association with sexual harassment), adjusting for covariates. Adolescents who engaged in a healthy dietary pattern were less likely to be bullies (RR 0.67 [0.49, 0.92]), while adolescents with an unhealthy dietary pattern were more likely to be bully-victims (RR 1.29 [1.12, 1.48]). Unhealthy dietary pattern was associated with any type of bullying perpetration (OR 1.24 [1.12, 1.38]), mainly with sexual harassment and physical aggression. Boys who had an unhealthy dietary pattern were more likely to sexually harass another adolescent (OR 2.10 [1.20, 3.66]). In conclusion, adolescents who had a healthy dietary pattern were less likely to perpetrate bullying. Unhealthy dietary pattern was associated with bullying perpetration, especially with sexual harassment by boys.

Impact and process evaluation of a primary-school Food Education and Sustainability Training (FEAST) program in 10-12-year-old children in Australia: pragmatic cluster non-randomized controlled trial

BACKGROUND

Environmentally sustainable food initiatives accompanying nutrition education, such as the Food Education and Sustainability Training (FEAST) program, have gained traction in school settings. The aim of this trial was to conduct an impact and process evaluation of FEAST, to evaluate its effect on children's fruit and vegetable (F&V) intakes, and secondary outcomes: F&V variety consumed, nutrition knowledge, food preparation/cooking skills, self-efficacy and behaviours, food waste knowledge and behaviours, and food production knowledge.

METHODS

FEAST was a 10-week curriculum-aligned program, designed to educate children about healthy eating, food waste, and sustainability, while teaching cooking skills. It was implemented by classroom teachers, face-to-face and online, during COVID-19 school closures, in Australia in 2021. A custom designed survey was used to collect baseline and post-intervention data from students. Generalised linear mixed models (GLMM) estimated group differences in pre-post changes for primary and secondary outcomes. Surveys were also administered to students and teachers to evaluate intervention implementation.

RESULTS

Twenty schools participated and self-selected to be either intervention schools (n = 10) or wait-list control (WLC) schools (n = 10). A total of 977, 5th and 6th grade children participated in the trial with a mean age of 11.1 years (SD ± 0.7). The FEAST intervention, compared to WLC, did not result in significant increases in primary outcomes nor secondary outcomes. The process evaluation revealed FEAST was well-received by students and teachers, but COVID-19 school closures hindered implementation fidelity with a less intense program delivered under the constraints of pandemic lockdowns.

CONCLUSIONS

This is the first cluster non-randomized controlled trial designed to independently evaluate FEAST in the primary-school setting. No evidence was found for improved F&V intakes in children, nor secondary outcomes. However, the positive process evaluation results suggest that further trials of the program are warranted. If implemented as originally designed (pre-pandemic), with increased duration and complemented by supporting school policies, such programs have the potential to improve children's daily F&V intakes, cooking skills and food waste behaviours. This would support the Australian curriculum and contribute to: health promotion within schools and sustainable schools initiatives, the national agenda to reduce food waste and sustainable development goals. AUSTRALIAN AND NEW ZEALAND CLINICAL TRIALS REGISTRY: [ACTRN12620001347954]- Registered prospectively on 14/12/2020.

Identifying barriers and facilitators to increase fibre intakes in UK primary school children and exploring the acceptability of intervention components: a UK qualitative study

OBJECTIVE

Within the UK, dietary fibre intakes are well below recommended intakes and associated with increased risk of obesity. This study aimed to explore the views of parents and children on barriers and facilitators to increasing fibre intakes and improving diets, alongside investigating the appropriateness of intervention components to overcome modifiable barriers.

DESIGN

Qualitative study including semi-structured interviews and focus groups informed by the Theoretical Domains Framework (TDF) and the Capability-Opportunity-Motivation-Behaviour (COM-B) model.

PARTICIPANTS

Year 5 children (aged 9-10-years) and parents, recruited through London primary schools.

RESULTS

A total of twenty-four participants (eleven parents and thirteen children) took part. Five key themes were identified as barriers and facilitators, namely lack of (and improving) knowledge, social factors (including parent-child conflicts, limited time for food preparation, influence of peer and family members), current eating habits, influence of the school, community and home environment in shaping eating behaviours, and the importance of choice and variety in finding foods that are healthy and tasty. Parents strongly supported school-based dietary interventions to enable consistent messaging at home and school and help support dietary behaviour change. Practical sessions (such as workshops to strengthen knowledge, taste tests and food swap ideas) were supported by parents and children.

CONCLUSIONS

By using a theory-driven approach to explore the barriers and facilitators to increasing fibre intake, this research identified important themes and modifiable barriers to behaviour change and identifies acceptable intervention components to overcome barriers and bring about sustained dietary behaviour change in primary school children.

Feasibility and impact of school-based nutrition education interventions on the diets of adolescent girls in Ethiopia: a non-masked, cluster-randomised, controlled trial

BACKGROUND

Adolescence is a critical period of physical and psychological development, especially for girls, because poor nutrition can affect their wellbeing as well as that of their children. We aimed to assess the feasibility and impact of a package of nutrition education interventions delivered through public primary schools on the diets of adolescent girls in Ethiopia.

METHODS

In this non-masked, cluster-randomised, controlled trial, primary schools (clusters) in the Southern Nations, Nationalities, and People's Region and Somali region of Ethiopia were randomly allocated to the intervention group (nutrition information provided during flag ceremonies, classroom lessons, school club meetings, peer group mentoring, BMI measurement and counselling, and parent-teacher meetings) or the control group (standard academic curriculum on health and nutrition) by use of computer-generated pseudo-random numbers. Duration of the school-based interventions was 4 months, and the key messages were related to dietary diversity (eating a variety of foods), energy adequacy (eating breakfast and healthy snacks), and healthy food choices (avoiding junk foods). Adolescent girls were eligible for participation if aged 10-14 years and enrolled in grades 4-8 in a study school. Data were collected with two independent cross-sectional surveys: baseline before the start of implementation and endline 1·5 years later. The primary outcome of impact was dietary diversity score, defined as the number of food groups (out of ten) consumed over the previous 24 h using a list-based method, and minimum dietary diversity, defined as the proportion of girls who consumed foods from at least five of the ten food groups, in the intention-to-treat population. We also assessed intervention exposure as a measure of feasibility. We estimated intervention effects using linear regression models for mean differences at endline, with SEs clustered at the school level, and controlled for adolescent age, region, household food security, and wealth. The trial is registered with ClinicalTrials.Gov, NCT04121559, and is complete.

FINDINGS

27 primary schools were randomly allocated to the intervention group and 27 to the control group. Between March 22 and April 29, 2021, 536 adolescent girls participated in the endline survey (270 in the intervention group and 266 in the control group), with median age of 13·3 years (IQR 12·1-14·0). At endline, the dietary diversity score was 5·37 (SD 1·66) food groups in the intervention group and 3·98 (1·43) food groups in the control group (adjusted mean difference 1·33, 95% CI 0·90-1·75, p<0·0001). Increased minimum dietary diversity was also associated with the intervention (182 [67%] of 270 in the intervention group vs 76 [29%] of 266 in the control group; adjusted odds ratio 5·37 [95% CI 3·04-9·50], p<0·0001). 256 (95%) of 270 adolescent girls in the intervention group were exposed to at least one of the five in-school intervention components.

INTERPRETATION

Integrating nutrition interventions into primary schools in Ethiopia was feasible and increased dietary diversity incrementally among adolescent girls, but could be limited in changing other food choice behaviours, such as junk food consumption, based on nutrition education alone.

FUNDING

Bill & Melinda Gates Foundation.

Applying the Integrated Sustainability Framework to explore the long-term sustainability of nutrition education programmes in schools: a systematic review

OBJECTIVE

This review aimed to identify and synthesise the enablers and barriers that influence the long-term (≥ 2 years) sustainment of school-based nutrition programmes.

DESIGN

Four databases (PubMed, Cochrane Library, Embase and Scopus) were searched to identify studies reporting on the international literature relating to food and nutrition programmes aimed at school-age (5-14 years) children that had been running for ≥ 2 years (combined intervention and follow-up period). Eligible studies were analysed using the Integrated Sustainability Framework (ISF), which involved deductive coding of programme enablers and barriers. A quality assessment was completed, using the Mixed-Methods Appraisal Tool and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

SETTING

International school-based nutrition programmes.

SUBJECTS

Individuals involved with the implementation of school-based nutrition programmes.

RESULTS

From the 7366 articles identified, thirteen studies (seven qualitative, five mixed methods and one quantitative descriptive) were included, from which the enablers and barriers of eleven different nutrition-related programmes were analysed. Thirty-four factors across the five domains of the ISF were identified that influenced the sustained implementation of programmes. The most common barrier was a lack of organisational readiness and resources, whereas the most common enabler was having adequate external partnerships and a supportive environment.

CONCLUSIONS

These findings have application during the initiation and implementation phases of school-based nutrition programmes. Paying attention to the 'outer contextual factors' of the ISF including the establishment and maintenance of robust relationships across whole of government systems, local institutions and funding bodies are crucial for programme sustainment.

A randomised controlled school-based nutritional intervention in five Middle Eastern countries: Ajyal Salima improved students' dietary and physical activity habits

OBJECTIVE

The purpose of this study was to measure the impact of the Ajyal Salima school intervention on nutrition and physical activity outcomes in children aged 9–11 years.

DESIGN

The study was a 1-year cluster-randomised controlled trial. Ajyal Salima used a multi-component approach including classroom activities, family programme and food service adaptation. Outcomes included daily intake of breakfast, frequency of healthy and unhealthy food consumption, frequency of physical activity, knowledge score and self-efficacy score. Intervention and control groups were compared for all main outcomes and a post-intervention qualitative evaluation assessed strengths and limitations of the intervention components.

SETTING

Schools in five countries – Lebanon, Jordan, Palestine, Saudi Arabia and Bahrain.

PARTICIPANTS

Schools were selected by Ministries of Health and Education within their jurisdictions. Forty-five intervention schools (6052 students) and forty-six control schools (6200 students) were included in the analysis.

RESULTS

The intervention group had a significantly higher odds of consuming breakfast daily (OR 95 % CI = 1·60, 1·35, 1·90), consuming healthy foods (OR 95 % CI = 1·60, 1·39, 1·84) and a decreased odds of consuming unhealthy foods and sweetened beverages (OR, 95 % CI = 0·70, 0·60, 0·81). Additionally, school children in the intervention group, as compared with the control group, were 47 % more likely to exercise outside school hours (OR 95 % CI = 1·47, 1·23, 1·76). Lastly, children in the intervention group had a significantly improved nutritional knowledge score and improved self-efficacy by 1·3 score unit and 1·1 score unit, respectively.

CONCLUSIONS

The Ajyal Salima intervention led to significant improvements in dietary and physical activity habits among school children and increased nutritional knowledge scores.

Capturing the whole-school food environment in primary schools

OBJECTIVE

The school food environment (SFE) is an ideal setting for encouraging healthy dietary behaviour. We aimed to develop an instrument to assess whole-SFE, test the instrument in the school setting and demonstrate its use to make food environment recommendations.

DESIGN

SFE literature and UK school food guidance were searched to inform instrument items. The instrument consisted of (i) an observation proforma capturing canteen areas systems, food presentation and monitoring of food intake and (ii) a questionnaire assessing food policies, provision and activities. The instrument was tested in schools and used to develop SFE recommendations. Descriptive analyses enabled narrative discussion.

SETTING

Primary schools.

PARTICIPANTS

An observation was undertaken at schools in urban and rural geographical regions of Northern Ireland of varying socio-economic status (n 18). School senior management completed the questionnaire with input from school caterers (n 16).

RESULTS

The instrument captured desired detail and potential instrument modifications were identified. SFE varied. Differences existed between food policies and how policies were implemented and monitored. At many schools, there was scope to enhance physical eating environments (n 12, 67 %) and food presentation (n 15, 83 %); emphasise healthy eating through food activities (n 7, 78 %) and increase parental engagement in school food (n 9, 56 %).

CONCLUSIONS

The developed instrument can measure whole-SFE in primary schools and also enabled identification of recommendations to enhance SFE. Further assessment and adaptation of the instrument are required to enable future use as a research tool or for self-assessment use by schools.

Strategies to Improve Physical Activity and Nutrition Behaviours in Children and Adolescents: A Review

Despite widespread acknowledgement of the multifarious health benefits of physical activity (PA), including prevention and control of obesity, an overwhelming majority of children and adolescents are not sufficiently active to realise such benefits. Concurrently, young people are significantly impacted by the rapid global rise of sedentarism, and suboptimal dietary patterns during key phases of development. Regrettably, the cumulative effects of unhealthy behaviours during the growing years predisposes young people to the early stages of several chronic conditions, including obesity. Clear and consistent approaches are urgently needed to improve eating and activity behaviours of children and adolescents. Based on existing evidence of "best bets" to prevent and control obesity and its comorbidities, we present a set of non-negotiable strategies as a 'road map' to achieving prevention and improving the health of children and adolescents.

School health promotion and the consumption of water and sugar-sweetened beverages in secondary schools: a cross-sectional multilevel study

BACKGROUND

Overweight among adolescents remains a serious concern worldwide and can have major health consequences in later life, such as cardiovascular diseases and cancer. Still, 33% of secondary school adolescents in the Netherlands consume sugar-sweetened beverages daily and over 26% do not consume water every day. The Dutch Healthy School program was developed to support schools in stimulating healthier lifestyles by focusing on health education, school environments, identifying students' health problems, and school policy. We examined the variation between secondary schools regarding the daily consumption of water and sugar-sweetened beverages and whether this variation can be explained by differences between schools regarding Healthy School certification, general school characteristics, and the school population.

METHODS

We performed a cross-sectional multilevel study. We used data from the national Youth Health Monitor of 2019 on secondary schools (grades 8 and 10, age range about 12 to 18 years) of seven Public Health Services and combined these with information regarding Healthy School certification and general school- and school population characteristics. Our outcomes were daily consumption of water and sugar-sweetened beverages. In total, data from 51,901 adolescents from 191 schools were analysed. We calculated the intraclass correlation to examine the variation between schools regarding our outcomes. Thereafter, we examined whether we could explain this variation by the included characteristics.

RESULTS

The school-level explained 4.53% of the variation in the consumption of water and 2.33% of the variation in the consumption of sugar-sweetened beverages. This small variation in water and sugar-sweetened consumption could not be explained by Healthy School certification, yet some general school- and school population characteristics did: the proportion of the school population with at least one parent with high educational attainment, the educational track of the adolescents, urbanicity (only for water consumption) and school type (only for sugar-sweetened beverages consumption).

CONCLUSIONS

The low percentages of explained variation indicate that school-level characteristics in general (including Healthy School certification) do not matter substantially for the daily consumption of water and sugar-sweetened beverages. Future research should examine whether school health promotion can contribute to healthier lifestyles, and if so, under which level of implementation and school conditions.

Assessing Sustainability Priorities of U.S. Food Hub Managers: Results from a National Survey

Food hubs have emerged as innovative alternatives to the conventional United States food system. As aggregators of small local farms, food hubs hold the potential to transform food production, distribution, and consumption, while fostering environmental sustainability and social equity. However, assessing their contributions to environmental sustainability and social equity is challenging due to the diverse structures and practices of U.S. food hubs. This study presents the findings of a national survey of food hub managers conducted in 2022 to assess the sustainability objectives and practices of food hubs across the United States. Our survey questions were designed based on a comprehensive framework of social and environmental sustainability criteria. Our results reveal that food hubs make valuable contributions in supporting small producers and providing healthy local food options. However, there is room for improvement in their environmental sustainability practices, as they only meet 47% of the defined environmental sustainability goals. Addressing food insecurity is a high priority for food hubs, although not their top priority, and many offer fresh food access to low-income households. Food hubs also contribute to environmental sustainability by reducing food transportation, promoting healthy food production methods, and minimizing waste. While food hubs meet 67% of the defined social sustainability goals, there are opportunities for improvement in reaching important institutional stakeholders and enhancing consumer education on healthy nutrition and lifestyles. Expanding technical assistance for farmers is also critical. By addressing these opportunities for improvement, food hubs can drive progress towards a more resilient and equitable food system in the United States.

Understanding school food systems to support the development and implementation of food based policies and interventions

BACKGROUND

Schools provide opportunities to improve the quality of children's diet, whilst reducing inequalities in childhood diet and health. Evidence supports whole school approaches, including consistency in food quality, eating culture and food education. However, such approaches are often poorly implemented due to the highly complex environments in which schools operate. We aimed to develop a school food systems map using a systems thinking approach to help identify the key factors influencing primary school children's dietary choice.

METHODS

Eight workshops were conducted with 80 children (from schools from varying locations (region of England/UK; urban/rural), deprivation levels and prioritisation of school food policies)) and 11 workshops were held with 82 adult stakeholders across the UK (principals, teachers, caterers, school governors, parents, and local and voluntary sector organisations) to identify factors that influence food choice in children across a school day and their inter-relationships. Initial exploratory workshops started with a 'blank canvas' using a group model building approach. Later workshops consolidated findings and supported a wider discussion of factors, relationships and influences within the systems map. Strengths of the relationship between factors/nodes were agreed by stakeholders and individually depicted on the map. We facilitated an additional eight interactive, in-person workshops with children to map their activities across a whole school day to enable the production of a journey map which was shared with stakeholders in workshops to facilitate discussion.

RESULTS

The final 'CONNECTS-Food' systems map included 202 factors that were grouped into 27 nodes. Thematic analysis identified four key themes: leadership and curriculum; child food preference; home environment; and school food environment. Network analysis highlighted key factors that influence child diet across a school day, which were largely in keeping with the thematic analysis; including: 'available funds/resources', 'awareness of initiatives and resources', 'child food preference and intake', 'eligibility of free school meals', 'family circumstances and eating behaviours', 'peer/social norms', 'priorities of head teachers and senior leaders'.

CONCLUSIONS

Our systems map demonstrates the need to consider factors external to schools and their food environments. The map supports the identification of potential actions, interventions and policies to facilitate a systems-wide positive impact on children's diets.

Challenges in evaluating implementation and effectiveness in real-world settings: evaluation proposal for school-based health-promoting intervention

There are various research designs and approaches to investigate how health-promoting activities are implemented in complex, real-world systems, and to identify potential health effects that might occur following implementation. Although literature describes guidelines to perform and report about implementation research and effect evaluations, no specific guidelines exist on analysing and reporting about the combination of effectiveness data and implementation data collected as part of intervention evaluation in complex and diverse settings. This paper describes the evaluation of primary school-based health-promoting activities in complex systems. Furthermore, an approach for data categorization inspired by Rogers' Diffusion of Innovations theory is presented that can facilitate structuring the study's results and relating the degree of implementation to any impact on effectiveness outcomes that might be observed. Researchers interested in using this approach for data categorization have to ensure that the following three conditions are met: (i) data on an intervention's efficacy in a controlled setting with optimal implementation is available; (ii) key points that define an intervention's optimal implementation are available and (iii) an evaluation study is performed, collecting both effectiveness data and implementation data in a real-world context. This data categorization approach can be useful to generate more insight into an intervention's effectiveness under varying circumstances, and optimal support and advice can be provided to stakeholders to achieve maximum impact of population-based health-promoting interventions in complex, real-world systems. However, the proposed approach is a first suggestion and further testing and adaptation is necessary to increase its usefulness. Knowledge and experience sharing among researchers performing comparable research can increase the knowledge base regarding this subject.

School Garden Prevalence Before and After the Implementation of the Healthy Hunger-Free Kids Act

BACKGROUND

The Healthy Hunger-Free Kids Act (HHFKA) of 2010 supported implementation of school gardens for promoting fruit and vegetable consumption. We examined school garden prevalence over time by school-level factors during the period before and after the implementation of HHFKA.

METHODS

Using data from the New Jersey Child Health Study, conducted in 4 low-income New Jersey cities, prevalence of school gardens among K-12 schools (n = 148) was assessed between school year 2010-2011 and 2017-2018. Multivariable analysis estimated changes in garden prevalence over time adjusting for school-level factors.

RESULTS

Overall, the sample included 97 elementary and 51 middle/high schools. Multivariable logistic regression showed that compared to 2010-2011 (19%) a higher proportion of schools reported having a garden in 2013-2014 (32%, p = 0.025). Over the entire study period, schools with majority Hispanic student enrollment had approximately half the odds of having a garden compared to schools with majority Black students (p = 0.036).

CONCLUSION

School garden prevalence increased in the year immediately following the implementation of the HHFKA but this increase was not sustained over time. Future research should investigate the reasons for this decline and potential disparities by race/ethnicity.

Social, economic, political, and geographical context that counts: meta-review of implementation determinants for policies promoting healthy diet and physical activity

Background

This meta-review investigated the context-related implementation determinants from seven domains (geographical, epidemiological, sociocultural, economic, ethics-related, political, and legal) that were systematically indicated as occurring during the implementation of obesity prevention policies targeting a healthy diet and a physically active lifestyle.

Methods

Data from nine databases and documentation of nine major stakeholders were searched for the purpose of this preregistered meta-review (#CRD42019133341). Context-related determinants were considered strongly supported if they were indicated in ≥60% of the reviews/stakeholder documents. The ROBIS tool and the Methodological Quality Checklist-SP were used to assess the quality-related risk of bias.

Results

Published reviews (k = 25) and stakeholder documents that reviewed the evidence of policy implementation (k = 17) were included. Across documents, the following six determinants from three context domains received strong support: economic resources at the macro (66.7% of analyzed documents) and meso/micro levels (71.4%); sociocultural context determinants at the meso/micro level, references to knowledge/beliefs/abilities of target groups (69.0%) and implementers (73.8%); political context determinants (interrelated policies supported in 71.4% of analyzed reviews/documents; policies within organizations, 69.0%).

Conclusions

These findings indicate that sociocultural, economic, and political contexts need to be accounted for when formulating plans for the implementation of a healthy diet and physical activity/sedentary behavior policies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13340-4.

Home-Grown School Feeding: Implementation Lessons From a Pilot in a Poor Ethnic Minority Community in Vietnam

Background:

Undernutrition threatens the health and future of preschool children in disadvantaged remote communities. Home-grown school feeding (HGSF) in nursery schools could positively impact children’s nutrition while creating multiple benefits for the whole community. However, evidence is lacking on implementation of HGSF within multi-sectoral programs in remote areas.

Objective:

This study assessed an HGSF pilot intervention, part of a nutrition-sensitive agriculture (NSA) program, in a mountain ethnic minority community in Vietnam. It aimed to identify the changes brought about by the intervention, in particular diversity of children’s food, food sources, barriers and facilitators to change, and future challenges and strategies.

Methods:

Mixed-methods assessment covered school meal diversity, cost, and food sources but the key focus was on observed changes resulting from the HGSF intervention and perceived barriers and facilitators to its implementation. Data were collected mainly through semi-structured interviews (n = 30) and seven focus group discussions (n = 76).

Results:

School meals contributed to increasing diversity of food consumed by children. Above 30% of foods used were home-grown. Respondents reported increased school attendance; children’s food preferences and hygiene practices improved as did parents’ caring and feeding practices. Local food systems became less cash-crop-oriented and more self-reliant, contributing to household food security and income generation. Social capital increased. Positive changes were attributed to HGSF and synergy among NSA program components. Poverty and limited resilience to external shocks threatened sustainability.

Conclusions:

Implementing HGSF within an NSA program in a mountainous ethnic minority area with a high prevalence of undernutrition benefitted children and their communities.

Parents’ Communication with Teachers about Food and Nutrition Issues of Primary School Students

Parents and teachers have a major influence in the formation of primary school children’s eating behaviours. Although the cooperation of parents and teachers has frequently been recommended in the promotion of healthy eating habits among primary school children, little is known about the communication between these two groups regarding food- and nutrition-related issues. This paper reports findings from semi-structured interviews with primary school parents (n = 19) and primary teachers (n = 17), as well as findings from a survey of 787 parents in Australia. Audio-recorded interviews were analysed using NVivo and descriptive statistics were calculated for the survey questions. The results indicated that their communications involved various topics, including allergies, lunchbox content, and supervision requests, through diverse communication channels. The risk of offending each other and time scarcity were reported as communication barriers. Parents mainly expected teachers to ensure that their children were given enough time to eat their lunch, teach healthy eating, and be good role models of healthy eating. This study highlights the need to overcome communication barriers between parents and teachers and support teachers in their multifaceted professional roles.

Evaluating an integrated nutrition and mathematics curriculum: primary school teachers' and students' experiences

OBJECTIVE

To present the process evaluation of a curricular Cross-curricular Unit on Portion Size (CUPS) program that integrates nutrition and mathematics, describing teacher and student perspectives on the intervention.

DESIGN

Semi-structured interviews and focus groups were conducted following the implementation of the CUPS program during a pilot randomised controlled trial designed to evaluate efficacy for improved portion size estimation. Lessons involved experiential learning using food models and mathematics cubes and focussed on portion size, food groups, volume and capacity. Data were collected immediately post-intervention and analysed using an inductive thematic approach.

SETTING

Primary schools in Newcastle, Australia.

PARTICIPANTS

Year 3 and/or 4 teachers (n 3) and their students (n 15).

RESULTS

Teachers believed the programme supported the learning of nutrition concepts, with the majority of students enjoying the lessons, cubes and food models. Teachers indicated most students were engaged and became more aware of healthy eating and serve size recommendation. Although teachers enjoyed and valued the lessons, they suggested that the integration of volume and capacity should be further improved in order to address the time barrier for teaching nutrition.

CONCLUSION

The process evaluation reports on challenges and successes of implementing an integrative nutrition programme. This teaching approach could be useful and successful when aligned with teacher' and student' needs. Based on participant feedback, lessons could be refined to enhance integration of mathematics content and to support student learning.

Children’s Participation in Free School Meals: A Qualitative Study among Pupils, Parents, and Teachers

School meals can have a key function in promoting children’s health. However, simply providing a free school meal is not a guarantee that pupils will eat the food. The purpose of this study was to explore factors influencing pupils’ participation in free school meal schemes in Oslo. The study has a qualitative research design, inspired by grounded theory. Data were collected through interviews with pupils, teachers, and parents, and participant observations in two schools participating in a pilot project funded by Oslo Municipality. Line-by-line coding, memo writing, and a constant comparative technique were used to analyze the data. One primary school and one lower-secondary school in different districts in Oslo that were implementing two different free school meal models took part in the study. In total, 39 pupils (5th–10th grade), 15 parents, and 12 school employees were included. Four main factors related to pupils’ participation in free school meals emerged from the analysis: the popularity of the food served, the attraction to the nearby shopping center, social aspects, and predictability. To promote pupils’ participation in free school meal schemes, schools need to solve the challenges of balancing between healthy food and popular but often unhealthy food. To implement school meals further, children and parents’ involvement, regularity of the meals provision, a good flow of information, and the creation of a friendly eating environment are recommended.

Teacher Training and Engagement in Health Promotion Mediates Health Behavior Outcomes

School-based health promotion interventions have been shown to lead to measurable changes in the nutrition and physical activity behaviors. This study examines whether the impact of an intervention program on students’ healthy eating and physical activity was mediated by teacher training and engagement in health promotion. The trial was conducted in three phases: needs assessment of the baseline survey of teachers, mothers’ and children; intervention among seven randomly selected schools that included teacher training in healthy eating and physical activity; and a post-intervention evaluation survey. The SPSS PROCESS for Hayes (Model8) was used to determine moderation and mediation effects. The difference in difference (DID) was calculated for the three main outcomes of the study: eating breakfast daily (DID = 17.5%, p < 0.001); consuming the recommended servings of F&V (DID = 29.4%, p < 0.001); and being physically active for at least 5 days/week (DID = 45.2%, p < 0.001). Schoolchildren’s eating breakfast daily was mediated by their teachers’ training in nutrition (β = 0.424, p = 0.002), teachers’ engagement (β = 0.167, p = 0.036), and mothers preparing breakfast (β = 1.309, p < 0.001). Schoolchildren’s consumption of F&V was mediated by teachers’ engagement (β = 0.427, p = 0.001) and knowing the recommended F&V servings (β = 0.485, p < 0.001). Schoolchildren’s physical activity was mediated by their teachers’ training in physical activity (β = 0.420, p = 0.020) and teachers’ engagement (β = 0.655, p < 0.001). Health behavior changes in the school setting including improvements in eating breakfast, consuming the recommended F&V and physical activity was mediated by teacher training and engagement. Effective teacher training leading to teacher engagement is warranted in the design of health-promotion interventions in the school setting.

Meta-review of implementation determinants for policies promoting healthy diet and physically active lifestyle: application of the Consolidated Framework for Implementation Research

BACKGROUND

Although multiple systematic reviews indicate that various determinants (barriers and facilitators) occur in the implementation processes of policies promoting healthy diet, physical activity (PA), and sedentary behavior (SB) reduction, the overarching synthesis of such reviews is missing. Applying the Consolidated Framework for Implementation Research (CFIR), this meta-review aims to (1) identify determinants that were systematically indicated as occurring during the implementation processes and (2) identify differences in the presence of determinants across reviews versus stakeholder documents on healthy diet/PA/SB policies, reviews/stakeholder documents addressing healthy diet policies versus PA/SB policies targeting any population/setting, and healthy diet/PA/SB policies focusing on school settings.

METHODS

A meta-review of published systematic scoping or realist reviews (k = 25) and stakeholder documents (k = 17) was conducted. Data from nine bibliographic databases and documentation of nine major stakeholders were systematically searched. Included reviews (72%) and stakeholder documents (100%) provided qualitative synthesis of original research on implementation determinants of policies promoting healthy diet or PA or SB reduction, and 28% of reviews provided some quantitative synthesis. Determinants were considered strongly supported if they were indicated by ≥ 60.0% of included reviews/stakeholder documents.

RESULTS

Across the 26 CFIR-based implementation determinants, seven were supported by 66.7-76.2% of reviews/stakeholder documents. These determinants were cost, networking with other organizations/communities, external policies, structural characteristics of the setting, implementation climate, readiness for implementation, and knowledge/beliefs of involved individuals. Most frequently, published reviews provided support for inner setting and individual determinants, whereas stakeholder documents supported outer and inner setting implementation determinants. Comparisons between policies promoting healthy diet with PA/SB policies revealed shared support for only three implementation determinants: cost, implementation climate, and knowledge/beliefs. In the case of healthy diet/PA/SB policies targeting school settings, 14 out of 26 implementation determinants were strongly supported.

CONCLUSIONS

The strongly supported (i.e., systematically indicated) determinants may guide policymakers and researchers who need to prioritize potential implementation determinants when planning and monitoring the implementation of respective policies. Future research should quantitatively assess the importance or role of determinants and test investigate associations between determinants and progress of implementation processes.

TRIAL REGISTRATION

PROSPERO, # CRD42019133341.

Effectiveness of national multicentric school-based health lifestyles intervention among chinese children and adolescents on knowledge, belief, and practice toward obesity at individual, family and schools' levels

BACKGROUND

This study aims to evaluate the effectiveness of the trial of national multicentric school-based health lifestyles intervention toward childhood obesity on the KBP at individual, family and schools' levels.

METHODS

The national trial was a multi-centered, cluster-controlled trial, which was conducted in seven provinces from September 2013 to February 2014, aiming at preventing childhood overweight and obesity. Integrated intervention strategies focused on changing specific practice related to energy intake and expenditure, such as decreasing the consumption of sweetened fizzy drinks, increasing the consumption of vegetables, ensuring proper protein intake, reducing sedentary practice including screen time, and maintaining at least 1 h of moderate to vigorous physical activity. A total of 27,477 children and adolescents in the control group and 30,997 in the intervention group were recruited with a mean follow-up period of 6.7 months. The binomial response mixed-effects model was used for assessing the effects of the national school-based health lifestyles intervention on obesity-related KBP at students individual, parents' and schools' levels.

RESULTS

Children and adolescents in the intervention group mastered better obesity-related knowledge, and they had higher correct response rates to all questions about obesity-related knowledge compared to the control group (P < 0.05). In terms of obesity-related belief, individuals in the intervention group was more motivated than the control group, participants in the intervention group had higher correctness of 71.18, 52.94, and 56.60% than the control group of 68.61, 49.86, and 54.43%, (P < 0.05). In addition, healthier habits of eating breakfast and drinking milk every day were observed in the intervention group. For the beliefs toward obesity, parents of the intervention group had higher correctness than the control group. At the same time except for the fruit consumption, other obesity-related practice in the intervention group were healthier than the control group (P < 0.05). Except for some beliefs and practice, the intervention effect at the parent level was not significant in other aspects.

CONCLUSION

The obesity-related knowledge and beliefs of children and adolescents got improved significantly. However, the effects on the knowledge, beliefs and certain practices of their parents and school administrators failed to reach significance.

Impact of the Cross-Curricular Education Program on Food Intake, Physical Activity, and Body Mass Index of School Children in a Local Community in Northern Serbia

Introduction: The trends in the state of nutrition and physical activity of school-age children in Serbia impose a need to create and evaluate programs to improve their nutrition and physical activity. The purpose of this study was to evaluate the impact of the cross-curricular nutrition and physical activity education program (NPAEP) on food intake, physical activity, and body mass index in first–fourth-grade primary school children. Material and methods: The study used an experimental pre-test (t1) post-test (t2) design. The sample included 167 participants in t1 and 178 in t2. The differences in food intake, physical activity, and body mass index before and after implementation of the cross-curricular nutrition and physical activity education program were analyzed using the Mann–Whitney U test, the Chi-squared test, and the Wilcoxon signed-rank test. Values p < 0.05 were considered statistically significant. Results: Fruit (t1 = 0.70 ± 0.55; t2 = 1.26 ± 0.65; p < 0.001) and dairy intake (t1 = 1.52; t2 = 1.79; p = 0.005) significantly increased in the intervention group. A significant reduction in time spent watching television (t1 = 78.0; t2 = 56.7; p = 0.005) and playing on the computer (t1 = 32.3; t2 = 25.8; p = 0.047) was achieved in the intervention group. Time spent in organized sports activities significantly increased only in the intervention group (t1 = 21.9; t2 = 30.5; p = 0.046). Body mass index did not change significantly in the intervention group after the implementation of the NPAEP. Conclusions: The nutrition and physical activity education program contributed to an increase in fruit and dairy intake and time spent in intense physical activities and a reduction in screen time. The presented results justify the application of the NPAEP in improving the nutrition and physical activity of first–fourth-grade primary school children.

School-based nutrition education improves breakfast-related personal influences and behavior of Indonesian adolescents: a cluster randomized controlled study

BACKGROUND/OBJECTIVES

Many adolescents in developing countries skip breakfast. Innovative nutrition education (NE) strategies are needed to enhance knowledge and skills related to the breakfasts of adolescents in a low socioeconomic setting. The objective was to evaluate short- and long-term effects of a multi-strategy, school-based NE intervention on adolescents' breakfast-related personal influences and behaviors.

SUBJECTS/METHODS

An intervention study with a cluster randomized controlled trial design was conducted in 4 senior high schools in Makassar, Indonesia. The multi-strategy NE intervention was delivered for 3 months. Data were collected using a self-administered questionnaire and a 3-day breakfast recall (face-to-face interview). Wilcoxon, McNemar, and Mann-Whitney tests were used to determine intra- and intergroup differences.

RESULTS

Unlike knowledge, improvement was observed in attitude and self-efficacy scores in the intervention groups (IGs) (P < 0.01); however, no significant changes were observed in the control group (CG). More students showed improved motivation in the IG than in the CG (P > 0.05). Changes in breakfast frequency and macronutrient intake from breakfast were greater in the IG than in the CG (P < 0.05).

CONCLUSIONS

A multi-strategy NE intervention is effective in producing positive changes in breakfast-related attitude, self-efficacy, and motivation of adolescents from a low-middle socioeconomic setting. The intervention improved breakfast frequency and nutrient intake. This intervention has promise for sustaining the observed changes over the long-term.

School Canteens in Selected Areas in Indonesia: A Situation Analysis

BACKGROUND

The school canteen has a massive impact on the dietary intake and nutritional status of school-age children and adolescents. This study aimed at assessing the current situation of school canteens in selected areas in Indonesia and relevant knowledge, attitudes, and behaviors of school-going children and adolescents.

METHODS

A qualitative study was implemented in a purposive sample of 18 schools in Klaten and West Lombok districts with 2 comparison schools in Jakarta and Klaten. Focus group discussions and in-depth interviews were conducted with a wide range of stakeholders to collect information on nutrition knowledge, food preferences, related policies and governance, and opinions toward school canteens. Data were analyzed using thematic synthesis and narrative analysis.

RESULTS

Specific government guidelines on healthy foods and beverages to be sold in canteens are not yet in place. Many canteens had inadequate infrastructure and were managed informally, with limited rules, monitoring, and supervision. Although healthy options including vegetables and fruits were available in most canteens, unhealthy foods and beverages were abundant and cheap. Lack of awareness of the importance of nutrition of school-age children and adolescents was pervasive among all stakeholders. Personal preference and availability were main drivers of the students' food choices.

CONCLUSIONS

Concerted multisectoral and multistakeholders' efforts are warranted to improve the quality of school canteens in Indonesia by developing a comprehensive relevant guideline, improving the capacity of related stakeholders and service providers, enhancing the implementation and monitoring, and generating demand for healthy canteens.

Growing Healthy Minds, Bodies, and Communities: early childhood teachers' perceptions of a nutrition-integrated pilot curriculum

OBJECTIVE

Healthy eating behaviours are often developed early in life, yet nutrition is rarely emphasised in early childhood education. Integration of nutrition into academic content is warranted, still its ability to positively impact teaching and learning has been understudied. Therefore, the current study explored the feasibility of application in the classroom and the perceived usability of a nutrition-integrated pilot curriculum.

DESIGN

Early childhood teachers' perceptions of four nutrition-integrated lessons were explored through a qualitative research approach. Data were collected through pre- and post-focus groups, lesson observations and teacher feedback. Focus group transcripts were analysed using inductive thematic analysis and supplemented with observations and lesson feedback.

SETTING

This pilot study took place in Northwest Mississippi at three pre-schools which are part of the Mississippi Early Learning Collaborative.

PARTICIPANTS

A non-probability convenience sample was utilised to acquire participants. Ten early childhood teachers and 132 Pre-K4 students participated in the study.

RESULTS

Three themes emerged and were categorised accordingly: (a) preconceived concern of the unknown v. experienced reality, (b) promoting buy-in and engagement through hands-on learning experiences and (c) manifestation of perceived prioritisation.

CONCLUSIONS

Nutrition-integrated lessons were reported to be creative, facilitate positive food behaviours and highly engaging for teachers and children. Concerns for new and unfamiliar curriculum were noted but could be alleviated with more detailed instructions. Future nutrition-integrated curriculum efforts should include detailed video instructions and offer a gradual and flexible schedule allowing teacher autonomy in how to prioritise implementation.

Teacher Evaluation of an Experiential Vegetable Education Program for Australian Primary Schools: Does Face-to-Face Training Add Value above Digital Training?

The teacher-led implementation of healthy eating programs in schools is cost-effective and potentially impactful. Teacher acceptability is important for uptake; however, process evaluations are scarce. This study evaluated the effect of two intensities of teacher training on the evaluation of a vegetable education program for Australian primary schools by teachers. The teachers (n = 65) who implemented the program as part of a cluster RCT (25 schools in two states, New South Wales and South Australia) received either low- (provision with materials and online training) or high (additional face-to-face (F2F) training)-intensity training prior to implementing a 5-week vegetable education program. They evaluated the acceptability of a digital training module and program by indicating the level of agreement with 15 and 18 statements, respectively, using 5-point Likert scales. The average item scores ranged from 3.0 to 4.2. All but one item, including student engagement, alignment to the curriculum and intent for reuse of the program, had a rounded average or median score of 4. The level of training intensity did not impact the teacher acceptability ratings. In conclusion, the teacher acceptability was good, and additional F2F training does not add value above the solely digital training of the teachers.

Nutrition across the curriculum: a scoping review exploring the integration of nutrition education within primary schools

Primary schools contribute to promoting healthy eating behaviour and preventing overweight and obesity by providing nutrition education. Research highlights the importance of improving teachers' programme implementation to enhance intervention effectiveness. An integrative approach has been suggested to reduce time barriers that teachers currently experience in teaching nutrition. This scoping review explores use and effectiveness of integrative teaching in primary-school-based nutrition education programmes. Six databases were searched for primary-school-based interventions on nutrition education. Papers reporting on integration of nutrition topics within core curriculum were included. Abstracts and full texts of potentially relevant articles were screened to determine eligibility. Next, data were extracted and tabulated. Findings were collated and summarised to describe intervention characteristics, subject integration and effectiveness of the included programmes. Data describing integration of nutrition into the primary school curriculum were extracted from 39 eligible papers. Nutrition education programmes often involve lessons about food groups and are frequently embedded within the mathematics, science or literacy syllabus. Although articles report on the integration of nutrition, the use of this approach was not commonly described in detail. Only seven papers discussed student outcomes related to the integration of nutrition education within core subjects. The ability to draw strong conclusions about school-based nutrition intervention effectiveness is limited by the current lack of programme description and methodological issues. Hence, more research is warranted to inform evidence on effectiveness of integrative nutrition education for both teacher and student outcomes. Future studies that include greater detail regarding the integrative approach are needed.

Association between Health Practice and Food Stockpiling for Disaster

In this study investigated the association between health practices and food stockpiling for disasters in predicted areas with a high risk of food shortage due to the Nankai Trough earthquake. A survey was conducted during 18-20 December 2019 using a self-administered web-based questionnaire. In total, 1200 individuals registered with an online survey company participated in the study. The association between health practices and food stockpiling status was analyzed (n = 998). 59.1% of participants had a poor Breslow's seven health practice scores (BHPS), 32.9% had a moderate score, and 8.0% had a good score. Multivariable logistic regression analysis revealed that higher BHPS had a significantly higher prevalence of food stockpiling. Additionally, the interrupted group had the highest percentage of participants with low BHPS. Lower BHPS was significantly associated with interrupted stockpiled in the adjusted models. Among the seven health practices, the odds ratio of the "eating breakfast" practice was high. There was a significant positive association between higher health practice scores and food stockpiling for disasters in areas with a high risk of food shortage due to the predicted earthquake. Particularly, it was clarified that individuals who had fewer good health practices were associated with ending up interrupting food stockpiling.

Associations of lifestyle risk factors with overweight or obesity among adolescents: a multicountry analysis

BACKGROUND

About 35% of the global burden of disease has roots in adolescence. Health in adolescence is an important determinant of health in adulthood.

OBJECTIVES

This study aimed to generate risk scores for lifestyle behaviors among adolescents and to estimate the country-specific prevalence of these risk scores. The study also examined the relations of lifestyle risk scores with overweight or obesity among adolescents.

METHODS

We used the most recent data available from 20 nationally representative Global School-based Student Health Surveys. Our analytical sample size was 51,597. The outcome of interest was overweight or obesity. We developed 4 lifestyle risk scores (dietary habits, physical activity, sedentary behavior, and tobacco use), which were used as the exposure variables in this study. Multilevel logistic regression models were used to estimate adjusted ORs with 95% CIs.

RESULTS

In total, 18.2% of the participants were overweight or obese. Across countries, the percentage of adolescents with unhealthy dietary habits ranged from 76.7% (the Cook Islands) to 94.2% (Timor-Leste), physical inactivity ranged from 47.5% (Bangladesh) to 90.1% (the Philippines), and sedentary behavior ranged from 34.5% (Nepal) to 88.2% (Kuwait). Girls engaged in less physical activity than did boys. Increased odds of overweight or obesity were found among participants with high risk scores for physical inactivity (OR: 1.19; 95% CI: 1.11, 1.27) and for unhealthy sedentary behavior (OR: 1.25; 95% CI: 1.16, 1.35) compared with participants with low risk scores. Girls with high tobacco risk scores had higher odds (OR: 1.30; 95% CI: 1.02, 1.65) of overweight or obesity than did girls with low risk scores for tobacco use, whereas there were no significant differences in risk in boys.

CONCLUSIONS

Unhealthy lifestyle behaviors were quite prevalent among adolescents, and higher lifestyle risk scores increased the risk of overweight or obesity.

Health Promoting Schools in Germany. Mapping the Implementation of Holistic Strategies to Tackle NCDs and Promote Health

Noncommunicable diseases (NCDs) and their underlying risk factors are seen as major public health problems that threaten health and welfare systems worldwide. The holistic and resource oriented Health Promoting School (HPS) approach can serve as an appropriate framework for the prevention and control of NCDs. The paper aimed to map the implementation of HPS activities in German schools and to examine associations with potential influencing factors. A series of cross-sectional online studies including five federal states and 5006 school principals (40.2% males, 50.8% females) from primary and secondary public schools was conducted from 2013 to 2018. Principal component analysis (PCA) resulted in two factors of HPS implementation (F1: concrete HPS action, F2: capacity building for HPS). Comparing both factors, a lower implementation level could be identified for HPS capacity building with lowest mean values found for regular teacher training and intersectoral collaboration. Multiple binary regression analyses revealed significant associations between low HPS implementation and male gender (OR: 1.36 to 1.42), younger age (OR: 1.47 to 1.90), secondary school (OR: 1.78 to 3.13) and federal state (Lower Saxony = OR: 1.27 to 1.45; Schleswig-Holstein = OR: 1.95 to 2.46). Moreover, low access to resources, decision-latitude and perceived educational benefits were independently associated with both factors of HPS implementation. Based on the results of this study, there is a need to support schools in their capacity building for health (e.g., regular teacher training, cooperation with local health services). Moreover, considering the core mission of schools, more evidence of the educational impact of health promotion and its translation into the language of education is needed for secondary schools in particular.

Food environment intervention improves food knowledge, wellbeing and dietary habits in primary school children: Project Daire, a randomised-controlled, factorial design cluster trial

Background

Evidence suggests that dietary intake of UK children is suboptimal. As schools provide an ideal natural environment for public health interventions, effective and sustainable methods of improving food knowledge and dietary habits in this population must be identified. Project Daire aimed to improve children’s health-related quality of life, wellbeing, food knowledge and dietary habits via two multi-component interventions.

Methods

Daire was a randomised-controlled, factorial design trial evaluating two interventions across four arms. Primary schools in Northern Ireland were randomised to one of four 6-month intervention arms: i) ‘Nourish’, ii) ‘Engage’, iii) ‘Nourish’ and ‘Engage’ and iv) Control (Delayed). ‘Nourish’ was an intervention aiming to alter the whole-school food environment, provide food-related experiences and exposure to locally produced foods. ‘Engage’ was an age-appropriate, cross-curricular educational intervention on food, agriculture, nutrition science and related careers. Primary outcomes were emotional and behavioural wellbeing and health-related quality of life. A number of secondary outcomes, including dietary intake, cooking competence and food-related knowledge, were also measured.

Results

Fifteen schools from areas of varying socio-economic status participated in the randomised trial. A total of 903 (n = 445 aged 6–7 years and n = 458 aged 10–11 years) primary school pupils took part. Total Difficulties Score improved in all pupils (6–7 and 10–11 year old pupils) who received the ‘Nourish’ intervention compared with those that did not (adjusted difference in mean = − 0.82; 95% CI -1.46, − 0.17; P < 0.02). No statistically significant difference in Health-Related Quality of Life was observed. The ‘Nourish’ intervention also produced some changes in school-based dietary behaviour, which were most apparent in the 10–11 year old pupils. The ‘Nourish’ intervention also produced improvements in understanding of food labels (adjusted difference in mean = 0.15; 95% CI 0.05, 0.25; P < 0.01) and knowledge of vegetables in season (adjusted difference in mean = 0.29; 95% CI 0.01,0.56; P = 0.04) whilst an increased willingness to try new foods and improved perceived cooking competence was also observed.

Conclusions

Improvements in childhood emotional and behavioural wellbeing, dietary intake, knowledge about food, cooking skills and willingness to try new foods were associated with the ‘Nourish’ whole-school food environment intervention. Exploration of the sustainability and long-term effectiveness of such whole-school food interventions should be conducted.

Trial registration

National Institute of Health (NIH) U.S. National Library of Medicine Clinical Trials.gov (ID: NCT04277312).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-021-01086-y.

Nutrition Curriculum Training and Implementation Improves Teachers' Self-Efficacy, Knowledge, and Outcome Expectations

OBJECTIVE

To examine the effects of training and implementation of Forecasting Your Future: Nutrition Matters on teachers' self-efficacy to teach nutrition and teachers' nutrition knowledge and explore outcome expectations for students.

METHODS

A mixed-methods study, with Indiana Family and Consumer Sciences high school teachers randomized to control and intervention, was conducted using baseline surveys, implementation of new or usual curriculum, follow-up survey(s), and semistructured interviews. Self-efficacy and knowledge were analyzed by hierarchical linear modeling. Interviews were thematically analyzed using a 5-phase process to identify outcome expectations.

RESULTS

Intervention teachers (n = 17) had greater increases in nutrition knowledge (P = 0.028) and self-efficacy (P = 0.010) compared with controls (n = 18). Interviews revealed that teachers sought to affect students' long-term health by providing knowledge and skills to make healthy choices.

CONCLUSIONS AND IMPLICATIONS

This training with updated curricula and implementation improved theoretical determinants of effective nutrition instruction. Teachers expected student learning will contribute to future eating behaviors.

A systematic review and meta-analysis of school-based interventions with health education to reduce body mass index in adolescents aged 10 to 19 years

BACKGROUND

Adolescents are increasingly susceptible to obesity, and thus at risk of later non-communicable diseases, due to changes in food choices, physical activity levels and exposure to an obesogenic environment. This review aimed to synthesize the literature investigating the effectiveness of health education interventions delivered in school settings to prevent overweight and obesity and/ or reduce BMI in adolescents, and to explore the key features of effectiveness.

METHODS

A systematic search of electronic databases including MEDLINE, CINAHL, PsychINFO and ERIC for papers published from Jan 2006 was carried out in 2020, following PRISMA guidelines. Studies that evaluated health education interventions in 10-19-year-olds delivered in schools in high-income countries, with a control group and reported BMI/BMI z-score were selected. Three researchers screened titles and abstracts, conducted data extraction and assessed quality of the full text publications. A third of the papers from each set were cross-checked by another reviewer. A meta-analysis of a sub-set of studies was conducted for BMI z-score.

RESULTS

Thirty-three interventions based on 39 publications were included in the review. Most studies evaluated multi-component interventions using health education to improve behaviours related to diet, physical activity and body composition measures. Fourteen interventions were associated with reduced BMI/BMI z-score. Most interventions (n = 22) were delivered by teachers in classroom settings, 19 of which trained teachers before the intervention. The multi-component interventions (n = 26) included strategies such as environment modifications (n = 10), digital interventions (n = 15) and parent involvement (n = 16). Fourteen studies had a low risk of bias, followed by 10 with medium and nine with a high risk of bias. Fourteen studies were included in a random-effects meta-analysis for BMI z-score. The pooled estimate of this meta-analysis showed a small difference between intervention and control in change in BMI z-score (- 0.06 [95% CI -0.10, - 0.03]). A funnel plot indicated that some degree of publication bias was operating, and hence the effect size might be inflated.

CONCLUSIONS

Findings from our review suggest that school-based health education interventions have the public health potential to lower BMI towards a healthier range in adolescents. Multi-component interventions involving key stakeholders such as teachers and parents and digital components are a promising strategy.

Process evaluation of fruit and vegetables distribution interventions in school-based settings: A systematic review

•

Assesses how school fruit & vegetable distribution interventions are implemented.

•

Child fruit & vegetable intake is influenced by how intervention is implemented.

•

Recommendations for implementing fruit & vegetable interventions in schools.

•

Studies should also consider sustainability, cost-effectiveness and implementation.

Despite the importance of process evaluation in program evaluations, research has focused primarily on the effectiveness of fruit and vegetables (FVs) distribution interventions on children’s consumption, with little attention given to how these interventions achieve their outcomes. Five bibliographic databases (Embase, PubMed, ProQuest, Scopus, and Web of Science Core Collection) were searched in June 2019 for studies of interventions where the main focus was the implementation of distributed FVs to school-aged children as a snack. The Critical Appraisal Skills Programme (CASP) tool was used to appraise the risk of bias within included studies. Data were extracted based on study characteristics and findings. Results identified 24 studies reporting on 11 interventions and 1 policy. The findings of this systematic review indicate that the majority of the studies included limited references to implementation research. Recurring limitations include an absence of an evaluation theoretical framework and the data collection methods used. Also, several factors were identified as informing the success of snack-based FVs distribution programs, including participation of the school community, school characteristics, background knowledge, and parental engagement. Lack of timely FVs delivery, limited funding, inadequate awareness about the program, insufficient teachers’ time, and food waste were identified as challenges to successful programming. Findings indicate that distributing FVs to school-aged children as a snack can increase their consumption, but only with proper implementation. Further evaluative research is required to better inform future implementation of snack-based FV distribution interventions in school settings.

Policymakers’ perspectives on designing school-based health initiatives for Victorian adolescents

Initiatives based on the Health Promoting Schools (HPS) framework have previously been successful in improving health and well-being yet there is little evidence of how these findings translate into policy. This study therefore aimed to analyse the political considerations that underpinned policymakers’ decisions for the design and implementation of a programme based on HPS in middle and high schools in Victoria, Australia. Interpretive policy analysis was undertaken using interviews with a purposive sample of government and non-government policy actors. Interviews explored factors influencing programme design and implementation and were analysed using thematic analysis. Ten in-depth interviews, including 11 participants, were conducted. The analysis revealed four themes. The Achievement Program was designed through (i) the establishment of strategic collaborations and good governance, involving people that made valuable and diverse contributions to the design process while acknowledging their (ii) positions of power, (iii) ensuring careful attention was paid to evidence-informed programme design and (iv) incorporation of real-time feedback from other settings. Policymakers believe this approach has the potential to improve policy adoption. There is a need to explore if this approach to policy development influences adherence and improves health outcomes.

Long-term impact of a school-based nutrition intervention on home nutrition environment and family fruit and vegetable intake: A two-year follow-up study

Long-term data on maintenance of intervention effects of health promotion programs targeting fruit and vegetable (F&V) intake in children is lacking. We conducted a two-year follow-up of Brighter Bites, a school-based nutrition education and food co-op intervention found to be effective in increasing child intake of F&V. A one-group, pre-post evaluation design was used to assess the two-year post intervention impact of the program on child and parent dietary intake and home nutrition environment. In 2016-2017 school year, we conducted a follow up of 262 parent-child dyads who had previously participated in Brighter Bites in a 2013-2015 evaluation study in six low-income Texas elementary schools. Child dietary intake was measured using a parent-reported food frequency questionnaire, and surveys measured parent F&V intake, and home nutrition environment. Results of a multi-level regression analysis showed that, two years post-intervention, as compared to baseline, there was a significant increase in child intake of fruit, vegetable, and fiber, and significant decreases in total fat intake and percent daily calories from sugary beverages (p < 0.05). Parent dietary data showed significant increases in fruit intake, and intake of F&V combined (p < 0.05). Changes in home nutrition environment included: increased frequency of cooking behaviors, increased usage of nutrition facts labels in making grocery purchasing decisions, and increased food availability of F&V (p < 0.05). This study demonstrates potential long-term sustained impact of a comprehensive school-based intervention among low-income children and their families.

Opportunities for intervention and innovation in school food within UK schools

We have recently been funded by the UK Prevention Research Partnership (UKPRP) to develop a UK school food network. The overarching aim is to build a community working towards a more health-promoting food and nutrition system in UK schools (primary and secondary). Here we describe the current status of school food research, including a review of the literature supporting the health-promoting schools approach and outline the opportunities for intervention and innovation establishment of the network present. Key potential school food research themes are described, and their prioritisation within the network, as well as network activities that have been planned, with the ultimate ambition of reducing socio-economic diet-related inequalities, and, consequently, non-communicable disease risk.

Exploring the association between mental wellbeing, health-related quality of life, family affluence and food choice in adolescents

Young people choose energy-dense, nutrient-poor diets, yet understanding of potential determinants is limited. Associations between food choices, mental wellbeing, health-related quality of life (HRQoL) and family affluence were explored to identify targets for intervention to promote dietary health and wellbeing in young people. Adolescents were recruited via post-primary schools in the UK and surveyed at two time-points when aged 13-14 years and 15-16 years. The questionnaire enquired about mental wellbeing using the Short Warwick-Edinburgh Mental Wellbeing Scale, HRQoL using the KIDSCREEN-10, socio-economic status using the Family Affluence Scale and food choice by Food Frequency Questionnaire (FFQ). With missing and anomalous cases excluded, the sample comprised 1208 cases. Factor analysis on the FFQ indicated five food choice factors: 'Junk Food'; 'Meat'; 'Healthy Protein'; 'Fruit/Vegetables'; 'Bread/Dairy'. Multivariate regression analysis indicated that frequent consumption of Junk Food was associated with being male and lower mental wellbeing. Frequent Meat intake was associated with being male and with lower HRQoL. Frequent choice of Bread/Dairy foods was more common among males and associated with higher wellbeing and greater affluence. Those who consumed Fruit/Vegetables frequently were more likely to be female, have higher HRQoL, higher mental wellbeing, and greater family affluence. These direct associations endured between time points. The dietary factors were not mutually exclusive. Those who frequently chose Junk Food were less likely to choose Fruit/Vegetables. Frequent choice of Meat was associated with more frequent choice of Junk Food and Healthy Protein. Intervention to improve dietary and psychological health in young people should target males, those in less affluent households, seek to reduce consumption of 'junk' food, and increase fruit and vegetable intake.

School-based obesity prevention interventions in Latin America: A systematic review

OBJECTIVE

To evaluate the implementation and effectiveness of school-based interventions to prevent obesity conducted in Latin America and provide suggestions for future prevention efforts in countries of the region.

METHODS

Articles published in English, Spanish, and Portuguese between 2000 and 2017 were searched in four online databases (Google Scholar, PubMed, LILACS, and REDALYC). Inclusion criteria were: studies targeting school-aged children and adolescents (6-18 years old), focusing on preventing obesity in a Latin American country using at least one school-based component, reporting at least one obesity-related outcome, comprising controlled or before-and-after design, and including information on intervention components and/or process.

RESULTS

Sixteen studies met the inclusion criteria. Most effective interventions (n = 3) had moderate quality and included multi-component school-based programs to promote health education and parental involvement focused on healthy eating and physical activity behaviors. These studies also presented a better study designs, few limitations for execution, and a minimum duration of six months.

CONCLUSIONS

Evidence-based prevention experiences are important guides for future strategies implemented in the region. Alongside gender differences, an adequate duration, and the combined use of quantitative and qualitative evaluation methods, evidence-based prevention should be considered to provide a clearer and deeper understanding of the true effects of school-based interventions.

Effects of the KEIGAAF intervention on the BMI z-score and energy balance-related behaviors of primary school-aged children

The aim of the current study was to evaluate the one- and two-year effectiveness of the KEIGAAF intervention, a school-based mutual adaptation intervention, on the BMI z-score (primary outcome), and energy balance-related behaviors (secondary outcomes) of children aged 7-10 years.A quasi-experimental study was conducted including eight intervention schools and three control schools located in low socioeconomic neighborhoods in the Netherlands. Baseline measurements were conducted in March and April 2017 and repeated after one and 2 years. Data were collected on children's BMI z-score, sedentary behavior (SB), physical activity (PA) behavior, and nutrition behavior through the use of anthropometric measurements, accelerometers, and questionnaires, respectively. All data were supplemented with demographics, and weather conditions data was added to the PA data. Based on the comprehensiveness of implemented physical activities, intervention schools were divided into schools having a comprehensive PA approach and schools having a less comprehensive approach. Intervention effects on continuous outcomes were analyzed using multiple linear mixed models and on binary outcome measures using generalized estimating equations. Intervention and control schools were compared, as well as comprehensive PA schools, less comprehensive PA schools, and control schools. Effect sizes (Cohen's d) were calculated.In total, 523 children participated. Children were on average 8.5 years old and 54% were girls. After 2 years, intervention children's BMI z-score decreased (B = -0.05, 95% CI -0.11;0.01) significantly compared to the control group (B = 0.20, 95% CI 0.09;0.31). Additionally, the intervention prevented an age-related decline in moderate-to-vigorous PA (MVPA) (%MVPA: B = 0.95, 95% CI 0.13;1.76). Negative intervention effects were seen on sugar-sweetened beverages and water consumption at school, due to larger favorable changes in the control group compared to the intervention group. After 2 years, the comprehensive PA schools showed more favorable effects on BMI z-score, SB, and MVPA compared to the other two conditions.This study shows that the KEIGAAF intervention is effective in improving children's MVPA during school days and BMI z-score, especially in vulnerable children. Additionally, we advocate the implementation of a comprehensive approach to promote a healthy weight status, to stimulate children's PA levels, and to prevent children from spending excessive time on sedentary behaviors.Trial registrationNetherlands Trial Register, NTR6716 ( NL6528 ), Registered 27 June 2017 - retrospectively registered.

Effects of food policy actions on Indigenous Peoples' nutrition-related outcomes: a systematic review

INTRODUCTION

Indigenous Peoples worldwide endure unacceptable health disparities with undernutrition and food insecurity often coexisting with obesity and chronic diseases. Policy-level actions are required to eliminate malnutrition in all its forms. However, there has been no systematic synthesis of the evidence of effectiveness of food and nutrition policies for Indigenous Peoples around the world. This review fills that gap.

METHODS

Eight databases were searched for peer-reviewed literature, published between 2000 and 2019. Relevant websites were searched for grey literature. Articles were included if they were original studies, published in English and included data from Indigenous Peoples from Western colonised countries, evaluated a food or nutrition policy (or intervention), and provided quantitative impact/outcome data. Study screening, data extraction and quality assessment were undertaken independently by two authors, at least one of whom was Indigenous. A narrative synthesis was undertaken with studies grouped according to the NOURISHING food policy framework.

RESULTS

We identified 78 studies from Canada, Australia, Aotearoa/New Zealand and the USA. Most studies evaluated targeted interventions, focused on rural or remote Indigenous communities. The most effective interventions combined educational strategies with policies targeting food price, composition and/or availability, particularly in retail and school environments. Interventions to reduce exposure to unhealthy food advertising was the only area of the NOURISHING framework not represented in the literature. Few studies examined the impact of universal food policies on Indigenous Peoples' diets, health or well-being.

CONCLUSION

Both targeted and universal policy action can be effective for Indigenous Peoples. Actions that modify the structures and systems governing food supply through improved availability, access and affordability of healthy foods should be prioritised. More high-quality evidence on the impact of universal food and nutrition policy actions for Indigenous Peoples is required, particularly in urban areas and in the area of food marketing.

Importance of Self-Efficacy in Eating Behavior and Physical Activity Change of Overweight and Non-Overweight Adolescent Girls Participating in Healthy Me: A Lifestyle Intervention with Mobile Technology

Very little is known about how multicomponent interventions directed to entire populations work in selected groups of adolescents. The aim was to evaluate the effectiveness of the Healthy Me one-year program on changes in healthy eating and physical activity among overweight and non-overweight female students. Randomization involved the allocation of full, partial or null intervention. The randomized field trial was implemented in 48 secondary schools (clusters) all over Poland among 1198 15-year-old girls. In this study, a sample of N = 1111 girls who participated in each evaluation study was analyzed. Using multimedia technologies, efforts were made to improve health behaviors and increase self-efficacy. The main outcome was a health behavior index (HBI), built on the basis of six nutritional indicators and one related to physical activity. HBI was analyzed before and immediately after intervention and at three months' follow-up, and the HBI change was modeled. Statistical analysis included nonparametric tests and generalized linear models with two-way interactions. Comparing the first and third surveys, in the overweight girls, the HBI index improved by 0.348 (SD = 3.17), while in the non-overweight girls it had worsened. After adjusting for other factors, a significant interaction between body weight status and level of self-efficacy as predictors of HBI changes was confirmed. The program turned out to be more beneficial for overweight girls.

Effectiveness of school-based nutrition interventions in sub-Saharan Africa: a systematic review

OBJECTIVE

To evaluate the effect of school-based nutrition interventions (SBNI) involving schoolchildren and adolescents in sub-Saharan Africa (SSA) on child nutrition status and nutrition-related knowledge, attitudes and behaviour.

DESIGN

A systematic review on published school nutrition intervention studies of randomised controlled trials, controlled clinical trials, controlled before-and-after studies or quasi-experimental designs with control. Nine electronic bibliographic databases were searched. To be included, interventions had to involve changes to the school's physical and social environments, to the school's nutrition policies, to teaching curriculum to incorporate nutrition education and/or to partnership with parents/community.

SETTING

Schools in SSA.

PARTICIPANTS

School-aged children and adolescents, aged 5-19 years.

RESULTS

Fourteen studies met our inclusion criteria. While there are few existing studies of SBNI in SSA, the evidence shows that food supplementation/fortification is very effective in reducing micronutrient deficiencies and can improve nutrition status. Secondly, school nutrition education can improve nutrition knowledge, but this may not necessarily translate into healthy nutrition behaviour, indicating that nutrition knowledge may have little impact without a facilitating environment. Results regarding anthropometry were inconclusive; however, there is evidence for the effectiveness of SBNI in improving cognitive abilities.

CONCLUSIONS

There is enough evidence to warrant further trials of SBNI in SSA. Future research should consider investigating the impact of SBNI on anthropometry and nutrition behaviour, focusing on the role of programme intensity and/or duration. To address the high incidence of micronutrient deficiencies in low- and middle-income countries, food supplementation strategies currently available to schoolchildren should be expanded.

Prevalence of current school-level nutrition policies and practices of secondary schools in NSW, Australia

ISSUE ADDRESSED

Lowering the rates of adolescent overweight and obesity is a public health priority. The implementation of nutrition policies and practices in schools is recommended by various health organisations, but there is little information on the extent of their implementation. The aim of this study is to describe the prevalence of the implementation of recommended school-level nutrition policies and practices in secondary schools in New South Wales (NSW), Australia, and reported barriers and facilitators to the adoption of such policies and practices in school plans.

METHODS

A cross-sectional study was undertaken with school principals and canteen managers. All eligible secondary schools in NSW were approached to participate in a telephone survey (n = 440). Descriptive statistics were used to describe prevalence, and associations between school characteristics and implementation were examined using univariate statistics.

RESULTS

A total of 137 school principals and 80 canteen managers completed the survey. The implementation of practices on drinking water during class, healthy food and beverage marketing and learning opportunities regarding healthy eating was high (>90% of participating schools). The implementation of practices regarding the restriction of unhealthy drinks in school canteens, healthy school fundraisers and staff training related to healthy eating was reported in under 25% of participating schools. There were no significant differences in implementation by school sector, socio-economic status and geographic location. The main barrier to inclusion of nutrition policies and practices in the school plan was having other priorities and commitments (28.5%), and the main facilitator was support from stakeholders, the staff, students and their parents (37.2%).

CONCLUSIONS

There is opportunity to improve the implementation of nutrition policies and practices in NSW secondary schools. SO WHAT?: Strategies are needed for targeting barriers. These include: gaining support from school staff, students and parents, provision of resources and funding and staff training.

The Role of School Leaders' Health Literacy for the Implementation of Health Promoting Schools

Background: The promotion of health literacy is seen as an urgent goal in public health and education and, hence, should be integrated in the school context as a component of the holistic health promoting school (HPS) approach. However, only limited empirical studies have addressed health literacy of school staff so far. Hence, this study aimed to examine the level of health literacy among school leaders and its association with the extent of HPS implementation. Methods: A cross-sectional study with n = 680 school principals and members of the school management board from Germany was carried out at the end of 2018. Individual health literacy, attitudes, and competencies towards HPS and occupational self-efficacy served as independent variables and the level of HPS implementation was the dependent variable. Data were analyzed using univariate and bivariate analysis as well as multiple binary logistic regression. Results: 29.3% of school leaders show a limited health literacy with significantly higher values found for male respondents. Regression analyses revealed that male gender (OR: 1.91, 95% CI: 1.22–2.99), HPS attitudes (OR: 3.17, 95% CI: 2.13–4.72), and HPS competencies (OR: 3.66, 95% CI: 2.43–5.50) were associated with a lower level of HPS implementation. Furthermore, regression analyses differentiated by gender showed that limited health literacy is associated with a low level of HPS implementation for male school leaders only (OR: 2.81, 95% CI: 1.22–6.45). Conclusions: The promotion of health literacy especially for male leaders would not only result in positive effects on an individual level but also could contribute to a stronger implementation of activities on school health promotion. We suggest integrating health literacy, HPS attitudes, and competencies more strongly into the qualification and in further training of school leaders.