Impact of a Smarter Lunchroom intervention on food selection and consumption among adolescents and young adults with intellectual and developmental disabilities in a residential school setting

Interventions based on sensory-hedonic strategies and on nudging to facilitate vegetable and pulses consumption in the school environment

Childhood and adolescence shape lifelong taste preferences and dietary habits, making them crucial periods for promoting healthy and sustainable eating. As students consume up to half of their daily energy intake at school, school interventions can have a significant impact on promoting plant-based diets. Although the benefits of promoting plant-based diets on children's and adolescents' health and environmental sustainability are well established and various studies report promising effects of interventions based on sensory-hedonic strategies and on nudging in promoting vegetables and pulses in schools, a comprehensive collection of those reports is lacking. Therefore, this systematic review aims to collect published literature on the above interventions in schools that focus on promoting the consumption of vegetables and pulses to children and adolescents. Three databases-PubMed, Scopus, and Web of Science-were searched over all years until March 2022 using pre-specified terms. From the 10.488 studies identified, a total of 57 studies reporting sensory-hedonic (e.g., manipulating food sensory properties or their hedonic value) or nudging (e.g., changing the presentation) interventions targeting children and/or adolescents in schools and aiming at promoting vegetables and/or pulses were included. Overall, interventions based on sensory-hedonic strategies (either enhancing the perception of well-accepted flavor and texture or manipulating their hedonic value) and on nudging (through incentives and prompts) are effective in promoting vegetables and pulses. A gap in the literature was identified for interventions targeting adolescents and promoting pulses. Finally, multicomponent interventions, rather than using one strategy alone, could be more successful.

A Systematic Review of Health Promotion Programs to Improve Nutrition for People with Intellectual Disability

PURPOSE OF REVIEW

To investigate the type and effectiveness of health promotion programs designed to improve nutrition for people with intellectual disability. This review also sought to highlight gaps in the evidence by mapping interventions to the socio-ecological model.

RECENT FINDINGS

To date, reviews on health promotion programs for people with intellectual disability have focused on individualised weight management interventions and behaviour change techniques. No reviews have focused solely on nutrition or considered a broader range of interventions and policies targeted beyond the individual. This review found that health promotion interventions to date were predominantly at the individual level of the socio-ecological model and of varying effectiveness. Of the non-individually focused interventions, those targeting the physical environment or considering multiple socio-ecological levels achieved the greatest improvements in nutrition outcomes. Nutrition and obesity prevention research and policy need to include intellectual disability as part of equity considerations, while intellectual disability policy needs to consider the broader food environment.

A pilot study of a school lunchroom intervention in a predominately Latinx sample

OBJECTIVE

The purpose of the study was to assess the feasibility of an environmental school lunchroom intervention ('Smarter Lunchrooms') and test initial efficacy within a predominately Latinx population.

DESIGN

We collected baseline and intervention lunchroom food consumption and waste data in a pre-post, single group design. Meal consumption data was analyzed using Nutrition Data System for Research software to obtain estimates of nutritional content.

MAIN OUTCOME MEASURES

Feasibility.

SECONDARY MEASURES

Plate Waste, Nutrient Intake.

RESULTS

Participants were 88 1st-4th graders (51% female; 77% Latinx). Our recruitment rate was 45%, we were able to implement 8 Smarter Lunchroom strategies, and we were able to collect 82 baseline plate photos (93%) and 80 intervention photos (90%) of school lunches. On average, students threw away more than half of their meals on both days. Fruit consumption and fiber per 1000 kcal were significantly poorer at intervention compared to baseline.

CONCLUSIONS

Our findings highlight challenges in collecting consumption data in a real-world setting. We describe directions for future research taking into consideration our "lessons learned" from this formative work.

Brief Report: Feasibility and Acceptability of a Remote-Based Nutrition Education Program for Adolescents with Autism Spectrum Disorder: A COVID-19 Pilot Study

To examine the feasibility and acceptability of a remote-based nutrition education program during COVID-19 for adolescents with autism spectrum disorder (ASD). Ten adolescents with ASD participated in a 4-week nutrition education program utilizing Zoom software during COVID-19. Topics included shopping for healthy food, and food preparation safety measures. Attendance was collected for each session. Participants, parents, and the classroom teacher completed post-program surveys and interviews. The course attendance rate was 97%. Every adolescent reported they would participate in similar future programs, and the teacher/parents felt the program was a positive experience for the participants. The remote-based nutrition education program appeared to be feasible and acceptable to participants. Future research should focus on program efficacy.

Food Waste in Schools: A Pre-/Post-test Study Design Examining the Impact of a Food Service Training Intervention to Reduce Food Waste

This study aimed to assess change in school-based food waste after training and implementing the Smarter Lunchrooms Movement (SLM) strategies with school food service workers. This non-controlled trial was implemented in a random sample of 15 elementary and middle schools in a Community Eligibility Program school district in the Northeast, the United States. Baseline and post-intervention food waste measurements were collected at two different time points in each school (n = 9258 total trays measured). Descriptive statistics, independent t-tests, and regression analyses were used to assess SLM strategies’ impact on changes in percent food waste. The mean number of strategies schools implemented consistently was 7.40 ± 6.97 SD, with a range of 0 to 28 consistent strategies. Independent t-tests revealed that at post-test, there was a significant (p < 0.001) percent reduction (7.0%) in total student food waste and for each food component: fruit (13.6%), vegetable (7.1%), and milk (4.3%). Overall, a training session on food waste and the SLM strategies with school-based food service workers reduced school food waste. However, the extent of the training and SLM strategies to reduce food waste varied on the basis of the consistency and type of strategies implemented.

Identifying characteristics and outcomes in youth with obesity and developmental disabilities

BACKGROUND

Youth with developmental disability are at increased risk of obesity; literature focusing on the two is rare.

OBJECTIVE

To identify characteristics and outcomes of youth presenting for obesity care having a disability as compared to without.

METHODS

A medical record review of youth aged 2-18 years initiating obesity care 2013-2015 at a tertiary care obesity management program. Youth were grouped by disability status to identify differences in presenting characteristics and factors associated with a reduction in body mass index (BMI) percent of the 95th BMI percentile (BMIp95) over 12 months. Logistic regression (LR) models examined associations with BMIp95 drop (<5-points versus ≥5-points) for each disability group.

RESULTS

Of 887 subjects, 253 (28.5%) had a disability. At presentation, youth with disability were more often (p < 0.01) male (58.5% versus 47.9%), had birth weight <2500 g (14.1% versus 8.4%), had a father who was not obese (61.6% versus 47.4%), and were on weight influencing medications. Overall, 182 subjects (20.5%) completed 12-month follow-up. At follow-up, the with disability group (n = 63) had mean -2.3 (SD 10.7) BMIp95 change (p = 0.679); youth having a motor disability less often had ≥5-point BMIp95 drop (odds ratio 0.15, 95% confidence interval 0.04-0.59). At follow-up, the no disability group (n = 119) had mean -2.9 (SD 8.5) BMIp95 change; youth identified as having initial severe obesity status and not having a parent with diabetes more often had ≥5-point BMIp95 drop.

CONCLUSION

Youth with developmental disabilities were as successful in obesity care as those without disabilities. Predictors of success differed between the groups.

Main Factors Influencing Whole Grain Consumption in Children and Adults-A Narrative Review

Despite their recognized health benefits, intakes of whole grains (WG) are below recommended levels in almost all countries worldwide. This observation highlights the need to increase WG consumption by understanding factors influencing this consumption and how they could be favorably impacted. This review focused on facilitators of and barriers to WG consumption and how to improve the effectiveness of programs aiming at increasing WG consumption. The main methods to facilitate WG intakes in both adults and children seem to be to (i) increase the availability and the variety of foods containing WG, (ii) improve their sensory appeal, (iii) reduce their purchase cost, (iv) use a familiarization period to introduce them to consumers (with a gradual increase in consumed amounts and repeated exposure), and (v) improve communication and labeling to enhance consumers’ ability to identify products with WG. These strategies may be used to improve the effectiveness of programs aiming at promoting WG consumption, with a further emphasis on the need to apply them over a long period of time, and potentially to include tasting sessions of new foods containing WG. Finally, these strategies should involve broad partnerships between multiple stakeholders at the regulatory, institutional and industrial levels.

Recruitment settings, delivery contexts, intervention techniques and outcomes of health promotion programmes for young adults with intellectual and developmental disabilities: A systematic review

BACKGROUND

People with intellectual and developmental disabilities (IDD) are at risk of developing long term health conditions, and a preventative health agenda research is emerging. However, little is known about the recruitment settings, delivery contexts, intervention techniques and outcomes of health promotion programmes for this population. Therefore, the aim of this review was to synthesize and evaluate these characteristics.

METHOD

A systematic review of studies identified from multiple databases on healthy lifestyle interventions for adolescents and young people with IDD was conducted. Data were synthesized and evaluated using a logic model. Quality of rigour was also assessed.

RESULTS

Sixteen geographically diverse studies were selected and evaluated. Participants were most commonly recruited from schools, with interventions typically taking place in a gym setting and involving physical activity training.

CONCLUSIONS

This review indicates that physical activity and dietary interventions in people with IDD may lead to lifestyle changes, however more robust evidence is required. Educational settings are conducive, with settings beyond schools requiring further consideration.

Improving Cardiovascular Health through Nudging Healthier Food Choices: A Systematic Review

Obesity and metabolic syndrome are considered major public health problems, and their negative impact on cardiovascular disease (CVD) and diabetes mellitus type 2 (DM2) is profound. Targeting modifiable risk factors such as dietary habits is therefore of great importance. Many of today’s health challenges with overweight and obesity may have behavioral roots, and traditional methods such as regulations and campaigns are often insufficient to improve dietary choices. Nudging or choice architecture might be a viable tool to influence people’s everyday choices and behaviors to better outcomes. This paper reviews the current state of the rapidly expanding number of experimental field studies that investigate the effects/associations of nudging on healthy food choices. A systematic literature search was conducted in PubMed, where 142 citations were identified. Based on selection criteria, six randomized controlled trials and 15 non-randomized controlled trials were ultimately included. The results of this systematic review show that many of the studies included traffic-light labeling, which may be a promising strategy. The reviewed findings, however, also highlight the challenges that confront experimental studies examining the impact of nudging on diet.

Measuring Food Waste and Consumption by Children Using Photography

A photography method was used to measure waste on food trays in school lunch in France, using the 5-point quarter-waste scale. While food waste has been studied extensively in US school lunches, the structure of the French lunch meal is quite different, with multiple courses, and vegetables (raw and cooked) in more than one course. Vegetables were the most wasted food category as usually seen in school lunch research, especially cooked vegetables, which were wasted at rates of 66%-83%. Raw vegetables were still wasted more than main dishes, starchy products, dairy, fruit, and desserts. Vegetables were also the most disliked food category, with the classes of vegetables falling in the same order as for waste. Waste and liking were highly correlated. Sensory characteristics of the food were cited as a main reason for liking/disliking. There is a strong connection between food liking and food consumption, and this connection should be the basis for future attempts to modify school lunch to improve consumption. The photographic method of measuring food waste at an individual level performed well.

The effect of nudges aligned with the renewed Flemish Food Triangle on the purchase of fresh fruits: An on-campus restaurant experiment

OBJECTIVE

This study examined the effect of nudges, inspired by the recently renewed Flemish Food Triangle, on fruit sales in a Belgian on-campus university restaurant.

METHODS

In this mixed-method real-life experiment, nudges were added weekly over a period of four consecutive weeks: placement of (1) Food Triangle posters in the restaurant, (2) 'green heart' icons above the fruit stands, and (3) substitution and (4) social norm messages at the fruit stands. During baseline (no intervention) and all intervention weeks, dessert sales were registered. Short interviews were used to ask customers about their perceptions regarding the intervention. Follow-up measurements (7 and 30 weeks later) evaluated the longer-term effectiveness, while all nudges remained in place. Dessert sales were analyzed separately for both sexes, students and staff categories (based on academic degree).

RESULTS

Compared to baseline, the combination of the Food Triangle and the green heart intervention materials in week 2 resulted in significant increases in fruit consumption across almost all subgroups. The other intervention materials used in the current study had rather limited effects in the short term. After 7 weeks of follow-up, significant fruit sale increases were established for all subgroups compared to baseline. At 30 weeks follow-up, the effect for staff B (Bachelor's degree) disappeared. The majority of the respondents (66.4%) had noticed at least one of the nudges, while only 3.4% indicated to have adjusted their dessert choice as a result of the nudges.

CONCLUSIONS

The combination of nudges was effective in the long term and increased fruit purchase in nearly all subgroups. Short interviews show that a more active approach may be needed to increase effect sizes.

Interventions for Increasing Acceptance of New Foods Among Children and Adults with Developmental Disorders: A Systematic Review

People with developmental disorders (DD) often display high levels of selective eating, which can result in micronutrient deficiencies. It is therefore essential to explore ways to increase dietary variety in this population. To identify different types of interventions promoting increased acceptance of new foods or dietary variety for DD populations and to determine their effectiveness. Thirty-six studies met criteria for inclusion in the review. Twenty-two types of intervention were identified with 34 studies being reported as effective and 33 of these incorporating components drawn from learning theory. Multi-component interventions centred on operant conditioning, systematic desensitisation and changes to environment and familial practices were reported as effective for individuals.

A systematic review and meta-analysis of the effectiveness of nudging to increase fruit and vegetable choice

Background

Nudging refers to interventions that organize the choice architecture in order to alter people's behaviour in a predictable way without forbidding any options or significantly changing their economic incentives. As a strategy to encourage healthy behaviour, nudging can serve as a complement to health education. However, the empirical evidence regarding the effectiveness of nudging as a way to influence food choice remains contradictory. To address this issue, a systematic review and meta-analysis was conducted to test the effects of nudging to encourage people to select more fruit and vegetables.

Methods

A systematic literature search was performed on PubMed, Medline, PsycInfo, Cochrane library, Scopus and Google Scholar. After quality assessment, 20 articles (23 studies) were retained for narrative synthesis. Twelve articles (14 studies) contained enough information to calculate effect-sizes for meta-analysis using Comprehensive Meta-analysis software.

Results

The meta-analysis shows that nudging interventions that aim to increase fruit and/or vegetable choice/sales/servings have a moderately significant effect (d = 0.30), with the largest effect for altering placement (d = 0.39) and combined nudges (d = 0.28).

Conclusion

The results of this review provide an indication of the effectiveness of nudging on fruit and vegetable choice in terms of actual effect-sizes, while also highlighting the problems that must be addressed before more definitive conclusions can be drawn.

The effect of a portion size intervention on French fries consumption, plate waste, satiety and compensatory caloric intake: an on-campus restaurant experiment

Background

One of the driving factors of dietary overconsumption throughout the last decennia is the increase of food portion sizes. Larger portions induce higher daily energy intake, so reducing portion size may reduce intake of excess calories. However, real-life studies about the effects of portion size reduction are lacking. Therefore, this study examined the effect of a French fries portion size reduction on French fries consumption, French fries plate waste, satiety and caloric intake during the subsequent afternoon among university students and employees in a Belgian on-campus restaurant setting. Moreover, this study evaluated consumers’ perception about the portion size reduction.

Methods

The study took place over a two-time (i.e. baseline and intervention week) 4-day period (Tuesday–Friday) in the on-campus restaurant where ±1200 meals are served every day. French fries’ portions were reduced by 20% by replacing the usual porcelain bowl served during the baseline week (±200 g) with smaller volume paper bags during the intervention week (±159 g) in a pre-post real-life experiment. French fries consumption and plate waste were measured in 2056 consumers at baseline and 2175 consumers at intervention. Additionally, interviews were conducted directly after lunch and again between 4 and 6 p.m. on the same day to assess satiety and caloric intake at pre and post in a small subsample of both French fries consumers (n = 19) and non-French fries consumers (n = 14). Post-intervention, the same subsample was interviewed about their perception of the portion size reduction (n = 28).

Results

Total French fries intake decreased by 9.1%, and total plate waste decreased by 66.4%. No differences were found in satiety or caloric intake between baseline and intervention week among the French fries’ consumers. The majority (n = 24, 86%) of French fries consumers noticed the reduction in portion size during the intervention. Although most participants (n = 19, 68%) perceived the reduced portion size as sufficient, only a minority of participants (n = 9, 32%) indicated post-intervention that they would agree with a permanent implementation.

Conclusions

Reducing portion size may lead to reduced caloric intake, without changing perceived levels of satiety.

Use and effectiveness of behavioural economics in interventions for lifestyle risk factors of non-communicable diseases: a systematic review with policy implications

AIM

There is limited evidence on what behavioural economics strategies are effective and can be used to inform non-communicable diseases (NCDs) public health policies designed to reduce overeating, excessive drinking, smoking, and physical inactivity. The aim of the review is to examine the evidence on the use and effectiveness of behavioural economics insights on reducing NCDs lifestyle risk factors.

METHODS

Medline, Embase, PsycINFO, and EconLit were searched for studies published between January 2002 and July 2016 and reporting empirical, non-pharmacological, interventional research focusing on reducing at least one NCDs lifestyle risk factor by employing a behavioural economics perspective.

RESULTS

We included 117 studies in the review; 67 studies had a low risk of bias and were classified as strong or very strong, 37 were moderate, and 13 were weak. We grouped studies by NCDs risk factors and conducted a narrative synthesis. The most frequent behavioural economics precepts used were incentives, framing, and choice architecture. We found inconclusive evidence regarding the success of behavioural economics strategies to reduce alcohol consumption, but we identified several strategies with policy-level implications which could be used to reduce smoking, improve nutrition, and increase physical activity.

CONCLUSION

Most studies targeting tobacco consumption, physical activity levels, and eating behaviours from a behavioural economics perspective had promising results with potential impact on NCDs health policies. We recommend future studies to be implemented in real-life settings and on large samples from diverse populations.

Comparing the behavioural impact of a nudge-based handwashing intervention to high-intensity hygiene education: a cluster-randomised trial in rural Bangladesh

OBJECTIVE

To determine the impact of environmental nudges on handwashing behaviours among primary school children as compared to a high-intensity hygiene education intervention.

METHODS

In a cluster-randomised trial (CRT), we compared the rates of handwashing with soap (HWWS) after a toileting event among primary school students in rural Bangladesh. Eligible schools (government run, on-site sanitation and water, no hygiene interventions in last year, fewer than 450 students) were identified, and 20 schools were randomly selected and allocated without blinding to one of four interventions, five schools per group: simultaneous handwashing infrastructure and nudge construction, sequential infrastructure then nudge construction, simultaneous infrastructure and high-intensity hygiene education (HE) and sequential handwashing infrastructure and HE. The primary outcome, incidence of HWWS after a toileting event, was compared between the intervention groups at different data collection points with robust-Poisson regression analysis with generalised estimating equations, adjusting for school-level clustering of outcomes.

RESULTS

The nudge intervention and the HE intervention were found to be equally effective at sustained impact over 5 months post-intervention (adjusted IRR 0.81, 95% CI 0.61-1.09). When comparing intervention delivery timing, the simultaneous delivery of the HE intervention significantly outperformed the sequential HE delivery (adjusted IRR 1.58 CI 1.20-2.08), whereas no significant difference was observed between sequential and simultaneous nudge intervention delivery (adjusted IRR 0.75, 95% CI 0.48-1.17).

CONCLUSION

Our trial demonstrates sustained improved handwashing behaviour 5 months after the nudge intervention. The nudge intervention's comparable performance to a high-intensity hygiene education intervention is encouraging.

Food Waste in the National School Lunch Program 1978-2015: A Systematic Review

BACKGROUND

Food waste studies have been used for more than 40 years to assess nutrient intake, dietary quality, menu performance, food acceptability, cost, and effectiveness of nutrition education in the National School Lunch Program (NSLP).

OBJECTIVE

Describe methods used to measure food waste and respective results in the NSLP across time.

METHODS

A systematic review using PubMed, Science Direct, Informaworld, and Institute of Scientific Information Web of Knowledge was conducted using the following search terms: waste, school lunch, plate waste, food waste, kitchen, half method, quarter method, weight, and photography. Studies published through June 2015 were included. The systematic review followed preferred reporting items for systematic reviews and meta-analyses recommendations.

RESULTS

The final review included 53 articles. Food waste methodologies included in-person visual estimation (n=11), digital photography (n=11), direct weighing (n=23), and a combination of in-person visual estimation, digital photography, and/or direct weighing (n=8). A majority of studies used a pre-post intervention or cross-sectional design. Fruits and vegetables were the most researched dietary component on the lunch tray and yielded the greatest amount of waste across studies.

CONCLUSIONS

Food waste is commonly assessed in the NSLP, but the methods are diverse and reporting metrics are variable. Future research should focus on establishing more uniform metrics to measure and report on food waste in the NSLP. Consistent food waste measurement methods will allow for better comparisons between studies. Such measures may facilitate better decision making about NSLP practices, programs, and policies that influence student consumption patterns across settings and interventions.

Treatment of Obesity Among Youth With Intellectual and Developmental Disabilities: An Emerging Role for Telenursing

Childhood obesity is a serious health issue, associated with medical comorbidity and psychosocial impairment that can persist into adulthood. In the United States, youth with intellectual and developmental disabilities are more likely to be obese than youth without disabilities. A large body of evidence supports the efficacy of family-based treatment of childhood obesity, including diet, physical activity, and behavior modification, but few interventions have been developed and evaluated specifically for this population. We highlight studies on treatment of obesity among youth with intellectual and developmental disabilities, including both residential/educational settings as well as outpatient/hospital settings. All interventions were delivered in-person, and further development of promising approaches and delivery via telenursing may increase access by youth and families. Nursing scientists can assume an important role in overcoming barriers to care for this vulnerable and underserved population.

The Michigan Healthy School Action Tools process generates improvements in school nutrition policies and practices, and student dietary intake

The Michigan Healthy School Action Tools (HSAT) is an online self-assessment and action planning process for schools seeking to improve their health policies and practices. The School Nutrition Advances Kids study, a 2-year quasi-experimental intervention with low-income middle schools, evaluated whether completing the HSAT with a facilitator assistance and small grant funding resulted in (1) improvements in school nutrition practices and policies and (2) improvements in student dietary intake. A total of 65 low-income Michigan middle schools participated in the study. The Block Youth Food Frequency Questionnaire was completed by 1,176 seventh-grade students at baseline and in eighth grade (during intervention). Schools reported nutrition-related policies and practices/education using the School Environment and Policy Survey. Schools completing the HSAT were compared to schools that did not complete the HSAT with regard to number of policy and practice changes and student dietary intake. Schools that completed the HSAT made significantly more nutrition practice/education changes than schools that did not complete the HSAT, and students in those schools made dietary improvements in fruit, fiber, and cholesterol intake. The Michigan HSAT process is an effective strategy to initiate improvements in nutrition policies and practices within schools, and to improve student dietary intake.

Obesity Prevention for Children with Developmental Disabilities

The prevention of obesity in children with DD is a pressing public health issue, with implications for health status, independent living, and quality of life. Substantial evidence suggests that children with developmental disabilities (DD), including those with intellectual disabilities (ID) and autism spectrum disorder (ASD), have a prevalence of obesity at least as high if not higher than their typically developing peers. The paper reviews what is known about the classic and unique risk factors for childhood obesity in these groups of children, including dietary, physical activity, sedentary behavior, and family factors, as well as medication use. We use evidence from the literature to make the case that primary prevention at the individual/family, school and community levels will require tailoring of strategies and adapting existing intervention approaches.