Efficacy of school-based interventions aimed at decreasing sugar-sweetened beverage consumption among adolescents: a systematic review

Exploring the association between adolescent-perceived parental monitoring on dietary intake

Parenting practices such as parental monitoring are known to positively impact dietary behaviours in offspring. However, links between adolescent-perceived parental monitoring and dietary outcomes have rarely been examined and never in an Australian context. This study investigated whether adolescent-perceived parental monitoring is associated with more fruit and vegetable, and less sugar-sweetened beverages (SSB) and junk food consumption in Australian adolescents. Cross-sectional data was collected as part of baseline measurement for a randomised controlled trial in 71 Australian schools in 2019. Self-reported fruit, vegetable, SSB and junk food intake, perceived parental monitoring and sociodemographic factors were assessed. Each dietary variable was converted to "not at risk/at risk" based on dietary guidelines, binary logistic regressions examined associations between dietary intake variables and perceived parental monitoring while controlling for gender and socio-economic status. The study was registered in ANZCTR clinical trials. The sample comprised 6053 adolescents (Mage = 12.7, SD = 0.5; 50.6% male-identifying). The mean parental monitoring score was 20.1/24 (SD = 4.76) for males and 21.9/24 (SD = 3.37) for females. Compared to adolescents who perceived lower levels of parental monitoring, adolescents reporting higher parental monitoring had higher odds of insufficient fruit (OR = 1.03; 95% CI = 1.02-1.05) and excessive SSB (OR = 1.07; 95% CI = 1.06-1.09) intake, but lower odds of excessive junk food (OR = 0.96; 95% CI = 0.95-0.98) and insufficient vegetable (OR = 0.97, 95% CI = 0.96-0.99) intake. Adolescent dietary intake is associated with higher perceived parental monitoring; however, these associations for fruit and SSB differ to junk food and vegetable intake. This study may have implications for prevention interventions for parents, identifying how this modifiable parenting factor is related to adolescent diet has highlighted how complex the psychological and environmental factors contributing to dietary intake are.

Association between watching eating shows and unhealthy food consumption in Korean adolescents

BACKGROUND

Eating habits formed during adolescence greatly influence the maintenance of health in adulthood. With the recent development of social media and easy access to the Internet, adolescents watch plenty of food videos, particularly Mukbang and Cookbnag(eating show)content. This media genre's impact on food choices has been covered in several studies; however, studies on unhealthy eating habits directly related to adolescents' exposure to eating shows are insufficient.

METHODS

For this study, we used data from the 18th Korea Youth Risk Behavior Survey conducted in 2022 and finalized 50,451 participants. The extent of exposure to eating show media over the course of a week, as well as the consumption of fast food, sugar-sweetened beverages (SSBs), and high caffeinated beverages within that week were measured through self-reporting questionnaires. We classified the participants into two groups based on their frequency of watching eating shows. A multiple logistic regression analysis was performed to investigate the association between eating show and unhealthy food consumption.

RESULTS

For both males and females, eating show exposure was strongly associated with the consumption of fast food (male: OR:1.37, 95% CI:1.26-1.49; female: OR:1.46, 95% CI:1.36-1.57), SSB (male: OR:1.42, 95% CI:1.26-1.60; female: OR:1.51, 95% CI:1.35-1.70), and high caffeinated beverage (male: OR:1.30, 95% CI:1.23-1.37; female: OR:1.24, 95% CI:1.18-1.31). It was observed that both sexes were more likely to frequently eat unhealthy food than students who did not watch eating shows.

CONCLUSION

Among Korean adolescents, students exposed to eating shows, which primarily aim to entertain, were more likely to consume fast food, SSBs, and high caffeinated beverages. Therefore, this study's findings suggest that eating show could influence adolescents' food choices, highlighting the need for interest in emerging cultures and corresponding health policies.

Kids SIPsmartER reduces sugar-sweetened beverages among Appalachian middle-school students and their caregivers: a cluster randomized controlled trial

BACKGROUND

High consumption of sugar-sweetened beverages (SSB) is a global health concern. Additionally, sugar-sweetened beverage (SSB) consumption is disproportionately high among adolescents and adults in rural Appalachia. The primary study objective is to determine the intervention effects of Kids SIPsmartER on students' SSB consumption. Secondary objectives focus on caregivers' SSB consumption and secondary student and caregiver outcomes [e.g, body mass index (BMI), quality of life (QOL)].

METHODS

This Type 1 hybrid, cluster randomized controlled trial includes 12 Appalachian middle schools (6 randomized to Kids SIPsmartER and 6 to control). Kids SIPsmartER is a 6-month, 12 lesson, multi-level, school-based, behavior and health literacy program aimed at reducing SSB among 7th grade middle school students. The program also incorporates a two-way text message strategy for caregivers. In this primary prevention intervention, all 7th grade students and their caregivers from participating schools were eligible to participate, regardless of baseline SSB consumption. Validated instruments were used to assess SSB behaviors and QOL. Height and weight were objectively measured in students and self-reported by caregivers. Analyses included modified two-part models with time fixed effects that controlled for relevant demographics and included school cluster robust standard errors.

RESULTS

Of the 526 students and 220 caregivers, mean (SD) ages were 12.7 (0.5) and 40.6 (6.7) years, respectively. Students were 55% female. Caregivers were mostly female (95%) and White (93%); 25% had a high school education or less and 33% had an annual household income less than $50,000. Regardless of SSB intake at baseline and relative to control participants, SSB significantly decreased among students [-7.2 ounces/day (95% CI = -10.7, -3.7); p < 0.001, effect size (ES) = 0.35] and caregivers [-6.3 ounces/day (95% CI = -11.3, -1.3); p = 0.014, ES = 0.33]. Among students (42%) and caregivers (28%) who consumed > 24 SSB ounces/day at baseline (i.e., high consumers), the ES increased to 0.45 and 0.95, respectively. There were no significant effects for student or caregiver QOL indicators or objectively measured student BMI; however, caregiver self-reported BMI significantly decreased in the intervention versus control schools (p = 0.001).

CONCLUSIONS

Kids SIPsmartER was effective at reducing SSB consumption among students and their caregivers in the rural, medically underserved Appalachian region. Importantly, SSB effects were even stronger among students and caregivers who were high consumers at baseline.

TRIAL REGISTRATION

Clincialtrials.gov: NCT03740113. Registered 14 November 2018- Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03740113 .

Student and caregiver acceptability of a school-based intervention to improve sugar-sweetened beverage behaviors: a mixed methods study

Kids SIPsmartER is a 6-month behavioral and health literacy intervention effective at reducing sugar-sweetened beverage (SSB) intake among middle school students and their caregivers in the rural Appalachian region. This exploratory mixed methods study utilized a convergent parallel design to assess participant acceptability of a school-based curriculum for students and a text messaging program for caregivers. Acceptability was assessed using surveys (873 students and 453 caregivers), five focus groups (34 students) and telephone interviews (22 caregivers). Quantitative data were analyzed descriptively, and qualitative data were content coded. On a 5-point scale, average quantitative survey acceptability ratings ranged from 2.7 to 3.3 among three student-rated questions and 4.1 to 4.2 among four caregiver-rated questions. Qualitative focus group findings suggested that students preferred curricular activities that were hands-on and involved social interaction, while caregiver interview results showed high acceptability of the text messaging program's design, including usability, content messages and personalization. Students and caregivers reported similar program benefits: increased knowledge of SSBs and health risks, increased awareness of SSB behaviors and support to make beverage behavior changes. Results from this study can be used to understand Kids SIPsmartER's effectiveness data, communicate the intervention's acceptability with stakeholders and plan for future implementation studies.

Towards a conceptual framework for the prevention of gambling-related harms: Findings from a scoping review

The global gambling sector has grown significantly over recent years due to liberal deregulation and digital transformation. Likewise, concerns around gambling-related harms-experienced by individuals, their families, their local communities or societies-have also developed, with growing calls that they should be addressed by a public health approach. A public health approach towards gambling-related harms requires a multifaceted strategy, comprising initiatives promoting health protection, harm minimization and health surveillance across different strata of society. However, there is little research exploring how a public health approach to gambling-related harms can learn from similar approaches to other potentially harmful but legal sectors such as the alcohol sector, the tobacco sector, and the high in fat, salt and sugar product sector. Therefore, this paper presents a conceptual framework that was developed following a scoping review of public health approaches towards the above sectors. Specifically, we synthesize strategies from each sector to develop an overarching set of public health goals and strategies which-when interlinked and incorporated with a socio-ecological model-can be deployed by a range of stakeholders, including academics and treatment providers, to minimise gambling-related harms. We demonstrate the significance of the conceptual framework by highlighting its use in mapping initiatives as well as unifying stakeholders towards the minimization of gambling-related harms, and the protection of communities and societies alike.

Using Non-Violent Discipline Tools: Evidence Suggesting the Importance of Attunement

Training in non-violent discipline is important to prevent violence against children and ensure that their caregivers remain a safe base for them. This paper aims to deepen understanding of non-violent discipline by exploring attunement as a mechanism in the effectiveness of non-violent discipline tools. Attunement describes the sensitive responsiveness of caregivers towards their children and has been found to be central to the formation of secure attachment bonds and development of self-regulation. It includes understanding or being "in tune with" the child's needs and signals, matching these with appropriate responses. The objective of this paper is to explore attunement in relation to non-violent discipline. Peer-reviewed systematic reviews previously included in a systematic overview of evidence on non-violent discipline options were screened for information relevant to attunement. All reviews were published in English between 1999 and 2018 and offered evidence on at least one non-violent discipline tool. Although no reviews explicitly addressed attunement, evidence was found suggesting its importance in the use and effectiveness of discipline methods. Research directly investigating attunement in discipline is needed.

Thirsty? Choose Water! A regional perspective to promoting water consumption in secondary school students

OBJECTIVE

Adolescents are high consumers of sugar-sweetened beverages (SSB), which contribute to overweight and obesity - a significant public health issue. Evidence suggests that replacing SSB with water and school-based interventions can reduce consumption. This study examines the acceptability of a previously trialled intervention (Thirsty? Choose Water!) in regional and remote secondary schools.

DESIGN

An open-label randomised controlled trial using a two-by-two factorial design tested the outcomes of a behavioural and/or environmental intervention on SSB and water consumption.

SETTING

Regional and remote secondary schools (public, catholic and independent) within the boundaries of two regional Local Health Districts within New South Wales.

PARTICIPANTS

Twenty-four schools participated in the study. The target group was year 7 students (n 1640) - 72 % of eligible students completed baseline data. The study followed students into year 8 (n 1188) - 52 % of eligible students completed post-intervention data. Forty teachers undertook training to deliver the intervention.

RESULTS

Interventions showed high levels of acceptability. Students demonstrated changes in knowledge, attitudes and consumption behaviours. Multivariable ordinal logression analysis demonstrated that all interventions increased the odds of students increasing their water consumption (though not statistically significant). Conversely, the combined (OR: 0·75; 95 % CI: 0·59, 0·97) or environmental intervention (OR: 0·68; 95 % CI: 0·51, 0·90) had greater odds of reducing SSB consumption and was statistically significant.

CONCLUSIONS

This study builds on recent Australian evidence regarding the impact of school-based interventions on water and SSB consumption. In this study, despite a minor intervention change, and the impacts of fires, floods and COVID-19 on study implementation, the interventions were highly regarded by the school communities with positive outcomes.

Effectiveness of a School Drinking Water Promotion and Access Program for Overweight Prevention

BACKGROUND AND OBJECTIVE

Drinking water promotion and access shows promise for preventing weight gain. This study evaluated the impact of Water First, a school-based water promotion and access intervention on changes in overweight.

METHODS

Low-income, ethnically diverse elementary schools in California's Bay Area were cluster-randomized to intervention and control groups. Water First includes classroom lessons, water stations, and schoolwide water promotion over 1 school year. The primary outcome was overweight prevalence (BMI-for-age-and-sex ≥85th percentile). Students (n = 1249) in 56 fourth-grade classes in 18 schools (9 intervention, 9 control) from 2016 to 2019 participated in evaluation at baseline, 7, and 15 months. Data collection was interrupted in 8 additional recruited schools because of coronavirus disease 2019.

RESULTS

Of 1262 students from 18 schools, 1249 (47.4% girls; mean [SD] age, 9.6 [0.4] years; 63.4% Hispanic) were recruited. From baseline to 7 months, there was no significant difference in changes in overweight prevalence in intervention schools (-0.2%) compared to control schools (-0.4%) (adjusted ratio of odds ratios [ORs]: 0.7 [confidence interval (CI): 0.2-2.9] P = 0.68). From baseline to 15-months, increases in overweight prevalence were significantly greater in control schools (3.7%) compared to intervention schools (0.5%). At 15 months, intervention students had a significantly lower change in overweight prevalence (adjusted ratio of ORs: 0.1 [CI: 0.03-0.7] P = .017) compared to control students. There were no intervention effects for obesity prevalence.

CONCLUSIONS

Water First prevented increases in the prevalence of overweight, but not obesity, in elementary school students.

Validation d’un questionnaire mesurant la consommation de boissons sucrées, jus et eau auprès d’adolescents francophones

Purpose: To examine the temporal stability and relative validity of the adapted French version of an English self-reported questionnaire measuring the beverage intake (BEVQ) of adolescents.Methods: The French adaptation of the BEVQ (AF-BEVQ) included conversion from the imperial to the metric system and the adjustment of some formats to those available in Canada. Next, 60 adolescents from two regions in Quebec completed the AF-BEVQ and two web-based 24-hour dietary recalls (R24W) (one for a weekday and one for a weekend day) on two occasions, two weeks apart.Results: The AF-BEVQ had moderate intraclass correlation coefficients (ICC) for amounts of sugar-sweetened beverages (ICC: 0.68; 95% confidence interval [CI]: 0.46-0.81), fruit juice (ICC: 0.54; 95% CI: 0.23-0.72) and water (ICC: 0.66; 95% CI: 0.38-0.81) consumed. The amounts of sugar-sweetened beverages (rs = 0.49; p < 0.0001), fruit juice (rs = 0.38; p = 0.0024) and water (rs = 0.65; p < 0.0001) reported in the AF-BEVQ were significantly correlated with those of both R24Ws.Conclusions: For the most part, the AF-BEVQ had adequate metrological properties. It is an interesting tool to quickly measure the sugar-sweetened beverage, fruit juice and water intake of French-speaking adolescents.

Exploratory Analysis of Social Networks Linked to the Provision of Beverages in Costa Rican Schools

Sugar-sweetened beverages (SSBs) are implicated in weight gain and adverse cardiometabolic heath. Social networks of stakeholders involved in providing potable water and sugar-sweetened beverages (SSBs) in high schools in Costa Rica were studied using social analysis network. In public and private schools, the interactions between the stakeholders in charge of providing beverages are fragmented and their role in preventing the availability of SSBs is weak. School canteen owners ultimately decide what beverages are available at school, which may cause students to choose beverages that increase the risk of overweight/obesity. It is therefore urgently necessary to improve the capacity for two-way interactions between the stakeholders to enhance their roles in the provision of beverages. Hence, it is essential to reinforce the stakeholders' leadership, and set up innovative ways to exert it in order to develop a shared vision of the types of drinks that should be available in the school environment.

Outcomes of a Caregiver-Focused Short Message Service (SMS) Intervention to Reduce Intake of Sugar-Sweetened Beverages in Rural Caregivers and Adolescents

This study examined enrollment, retention, engagement, and behavior changes from a caregiver short message service (SMS) component of a larger school-based sugar-sweetened beverage (SSB) reduction intervention. Over 22 weeks, caregivers of seventh graders in 10 Appalachian middle schools received a two-way SMS Baseline Assessment and four monthly follow-up assessments to report their and their child's SSB intake and select a personalized strategy topic. Between assessments, caregivers received two weekly one-way messages: one information or infographic message and one strategy message. Of 1873 caregivers, 542 (29%) enrolled by completing the SMS Baseline Assessment. Three-quarters completed Assessments 2-5, with 84% retained at Assessment 5. Reminders, used to encourage adherence, improved completion by 19-40%, with 18-33% completing after the first two reminders. Most caregivers (72-93%) selected a personalized strategy and an average of 28% viewed infographic messages. Between Baseline and Assessment 5, daily SSB intake frequency significantly (p < 0.01) declined for caregivers (-0.32 (0.03), effect size (ES) = 0.51) and children (-0.26 (0.01), ES = 0.53). Effect sizes increased when limited to participants who consumed SSB twice or more per week (caregivers ES = 0.65, children ES = 0.67). Findings indicate that an SMS-delivered intervention is promising for engaging rural caregivers of middle school students and improving SSB behaviors.

Primordial prevention: Reducing consumption of sugar-sweetened beverages in racial/ethnic populations

Beyond pharmacotherapy in adulthood, primordial prevention in United States (U.S.) children and adolescents is needed to avoid the upcoming tsunami of cardiometabolic and cardiovascular disease (CVD). Healthcare disparities were unmasked by the disparate morbidity and mortality of COVID-19 in racial/ethnic populations, especially in persons with obesity, diabetes, and CVD. One potential successful strategic improvement of childhood cardiovascular health is to reduce sugar consumption in early life as CVD is the number one cause of death in patients with Type 2 diabetes (T2D). Furthermore, cardiologists treat more patients with T2D than endocrinologists. This commentary challenges cardiovascular specialists and other clinicians to address the increasing burden of cardiometabolic and CVD in adults, especially in racial/ethnic populations, by supporting primordial prevention in childhood.

Improving adolescents' dietary behaviours in the school-setting: challenges and opportunities

Adolescence is a critical time of physical, psychological and social development, and thus, optimal nutritional intakes are required during this life stage. Despite this, adolescence is recognised as a period of nutritional vulnerability, with many reportedly failing to meet current dietary guidelines. The school-setting presents a favourable environment to intervene and promote positive dietary behaviours and is also inclusive regardless of socio-economic status. However, a lack of consensus exists on how best to utilise schools to facilitate improvements in dietary behaviours among this age group. Whilst previous research has focused on identifying the factors motivating dietary choices within the school-setting, less is known on the optimum strategies to enhance these dietary choices which could positively contribute to the design of future interventions. It is reported that adolescents have good nutritional knowledge, although this does not appear to be a central consideration when making their dietary choices. Alternative factors at the individual (taste, visual appeal, familiarity, food quality, price, portion size, value for money, time/ convenience), social (peer influence), physical (product placement) and macro environment (food availability) levels have been frequently cited as important influences on adolescents' dietary choices in school. Although school-based interventions have shown potential in achieving positive dietary change among adolescents, more research is needed to determine the most effective methods in improving dietary behaviours in schools. This review summarises the key factors which influence adolescents' school-based dietary choices and the effectiveness of previously conducted interventions, identifying promising components for consideration when developing future dietary interventions within the school-setting.

Parent-based interventions to improve multiple lifestyle risk behaviors among adolescents: A systematic review and meta-analysis

Lifestyle risk behaviors often co-occur and are prevalent among adolescents. Parent-based interventions addressing risk behaviors concurrently have the potential to improve youth and parent outcomes. This systematic review evaluated the efficacy of parent-based interventions targeting multiple lifestyle risk behaviors among adolescents and parents. MEDLINE (Ovid), Embase (Ovid), PsycInfo (Ovid), Scopus, CINAHL, the Cochrane Database of Systematic Reviews (CDSR) and Cochrane Central Register of Controlled Trials (CENTRAL) were searched from 2010-May 2021. Eligible studies were randomised controlled trials (RCTs) of parent-based interventions addressing 2+ risk behaviors: alcohol use, smoking, poor diet, physical inactivity, sedentary behaviors, and poor sleep. Studies directly targeting parents, and that assessed adolescent outcomes (11-18 years) were eligible. Where possible, random-effects meta-analysis was conducted. From 11,975 identified records, 46 publications of 36 RCTs (n = 28,322 youth, n = 7385 parents) were eligible. Parent-based interventions were associated with improved adolescent moderate-to-vigorous physical activity (MVPA) [Odds Ratio (OR) = 1.82, 95% CI = 1.18, 2.81; p = 0.007], and reduced screen time (SMD = -0.39, 95% CI = -0.62, -0.16, p = 0.0009) and discretionary food intake (SMD = -0.18; 95% CI = -0.30, -0.06; p = 0.002) compared to controls. However, there was some evidence that interventions increased the odds of ever using tobacco in the medium-term (OR = 1.47, 95% CI = 0.99, 2.18, p = 0.06) and of past month tobacco use in the long-term (OR = 1.46, 95% CI = 1.12, 1.90; p = 0.005). Overall, the quality of evidence was moderate. Parent-based interventions targeting multiple risk behaviors improved adolescent MVPA, and reduced screen time discretionary food intake. Further research is needed to address sleep problems and increase intervention efficacy, particularly for alcohol and tobacco use.

Identifying modifiable obesogenic behaviors among Latino adolescents in primary pediatric care

Latino adolescents engage in more obesogenic behaviors, including sedentary behaviors and sugary drink consumption, than White adolescents. However, it is unclear whether engagement in obesogenic behaviors differs within the Latino population. Cross-sectional data were examined from Latino adolescents ages 13–17 with a well-child visit (2016–2019) in an integrated healthcare system. Adolescents self-reported on four daily obesogenic behaviors: 1) consuming < 5 servings of fruits/vegetables; 2) drinking > 1 juice/soda; 3) exercising/playing sports < 60 min; and 4) > 2 h screen time. A composite variable of ≥ 3 self-reported behaviors was constructed. Multivariable logistic regression was used to examine associations between obesogenic behaviors with age category (13–15 or 16–17 years), sex, household language preference (English/Spanish), neighborhood deprivation index (NDI quartiles), and body mass index (BMI). Among 77,514 Latino adolescents (mean age 14.7 ± 1.4; 50 % female), 23 % lived in Spanish-speaking households, 43 % resided in census tracts with the highest (most deprived) NDI quartile, and 45 % had an overweight or obese BMI. Older (vs younger) adolescents had higher odds of insufficient fruit/vegetable intake (OR 1.20; CI 1.17–1.24), greater sedentary behavior (OR 1.51; 1.46–1.56), and reporting > 2 h screen time (OR 1.07; 1.03–1.11). Adolescents in the 4th (vs 1st) NDI quartile (OR 1.34; 1.26–1.42) and those with obesity (vs healthy weight) (OR 1.55; 1.42–1.70 for class 3 obesity) had higher odds of ≥ 3 obesogenic behaviors. In conclusion, among Latino adolescents, older age, obesity, and living in more deprived neighborhoods were associated with greater obesogenic behaviors. Identifying adolescents more likely to engage in obesogenic behaviors can inform targeted lifestyle interventions.

System dynamics modelling to engage community stakeholders in addressing water and sugar sweetened beverage consumption

Background

Participatory approaches to develop community-based system dynamics models to tackle complexity are promising, but research is needed in how simulation models can be developed with community stakeholders to yield significant system insights. This study presents the results of a community-based system dynamics modelling process to increase water consumption and decrease sugar sweetened beverage consumption in Portland, Victoria, a regional town in Australia.

Methods

A series of group model building workshops with 11 community stakeholders addressing the topic of water and sugar sweetened beverage consumption was conducted in Portland. A simulating system dynamics model was built with stakeholders to inform action planning.

Results

A system dynamics model was created to provide insight into water and sugar sweetened beverage consumption in Portland. The model included six feedback loops describing the causal effects of sugar sweetened beverage consumption habits and norms, water taste, water consumption norms, public water availability, and public health benefits. For example, the sugar sweetened beverage consumption norm loop modelled how people overestimating others’ consumption may motivate an increase in their own consumption, feeding back and further amplifying an increase in sugar sweetened beverage consumption. The model contributed to the foundation of a strong partnership to improve the taste of water and educate the public on water consumption.

Conclusions

Engaging stakeholders in system dynamics modelling about water and sugar sweetened beverage consumption increased engagement and collaboration to address the problem among community stakeholders.

'I Knew I Should Stop, but I Couldn't Control Myself': a qualitative study to explore the factors influencing adolescents' consumption of sugar-sweetened beverages and sugary snacks from a socio-ecological perspective

OBJECTIVE

To explore the factors influencing Taiwanese adolescents' consumption of sugar-sweetened beverages (SSB) and sugary snacks from a socio-ecological perspective.

DESIGN

This study adopted a qualitative design by using face-to-face, in-depth interviews guided by a semistructured questionnaire.

SETTING

Eight junior high schools in New Taipei City and Changhua County, Taiwan, September to November 2018.

PARTICIPANTS

Fifty-nine participants aged 12-14 years participated in this study.

RESULTS

Reflexive thematic analysis was used to analyse the data. This study identified four themes to address the multifaceted factors that influence adolescents' consumption of SSB and sugary snacks. At the intrapersonal level, physiological factors, psychological factors, individual economic factors and taste preferences were mentioned in connection with people's consumption of SSB and sugary snacks. Positive or negative influences of parents, siblings, peers and teachers on SSB and sugary snack intake were identified at the interpersonal level. The availability of SSB and sugary snacks at home, their availability in vending machines or in school stores in the school environment and participants' access to convenience stores and hand-shaken drink shops in the broader community influenced SSB and sugary snack consumption. Additionally, food culture and food advertising were identified as influencing societal factors.

CONCLUSIONS

Overall, this qualitative study determined not only that the consumption of SSB and sugary snacks is influenced by intrapersonal factors but also that interpersonal, environmental and societal factors affect adolescents' increased sugar intake. The findings are helpful to broaden the options for designing and developing interventions to decrease SSB and sugary snack consumption by adolescents.

What makes interventions aimed at improving dietary behaviours successful in the secondary school environment? A systematic review of systematic reviews

OBJECTIVE

To systematically review evidence from systematic reviews of interventions to improve dietary behaviours and reduce food wastage in secondary school pupils.

DESIGN

CINAHL, Cochrane Reviews, EMBASE, MEDLINE, PsychINFO and Web of Science were searched for systematic reviews of school-based dietary interventions from 2000 to 2020 published in a peer-reviewed journal in English. Articles were reviewed independently by two authors. AMSTAR-2 was used for quality assessment.

SETTING

Secondary school dietary interventions.

PARTICIPANTS

Adolescents (aged 11-18).

RESULTS

In total, thirteen systematic reviews of dietary interventions in secondary schools met the inclusion criteria. A number of key characteristics of interventions that contributed to improvements in food choices in secondary school pupils were identified. These included the combination of education and environmental restructuring, incorporation of computer-based feedback, media or messaging, peer and/or parent involvement, an increase in the availability of healthy foods and the use of behavioural theory as a basis to the intervention. Intervention components that contributed specifically to a reduction in sugar-sweetened beverage intake or an increase in fruit and vegetable consumption, which are particularly relevant to adolescents, could not be determined. Similarly, evidence for interventions that improve nutritional knowledge and attitudes was limited.

CONCLUSIONS

This systematic review of systematic reviews has identified a number of components of dietary interventions that can be explored to improve dietary behaviours in secondary school environments and, if demonstrated to be effective, be considered for inclusion in policies and strategies to improve the school food environment and promote dietary change.

The outcomes of [project name removed for blinding - subsequently documented as XX] Determining the effects of a behavioural and an environmental intervention on water and sugar sweetened beverage consumption in adolescents: A randomised controlled trial

ISSUE

Childhood obesity is a serious public health challenge. Consumption of sugar-sweetened beverages (SSBs) is one contributing factor, with adolescents being the highest consumers.

METHODS

This study used a randomised controlled trial and two-by-two factorial design to determine the effectiveness of a school-based behavioural intervention (including education/promotional messages) and/or environmental intervention (chilled water station), on encouraging adolescents to choose water instead of SSBs. Sixty-one secondary schools (n=8,992 eligible students) were recruited and randomly allocated to one of four study groups, the behavioural intervention, the environmental intervention, both interventions or neither.

RESULTS

The primary outcome was increased water consumption; secondary outcomes included changes in students' knowledge and attitudes about water and SSBs and changes in SSBs consumption. For students who received at least one intervention there was an increased odds (though not statistically significant) of higher water consumption compared to those that received no intervention. There was a decrease in SSBs consumption for students who received both interventions combined (OR = .67; 95% confidence interval, 0.55-.082; P<0.01).

CONCLUSIONS

The combined intervention had a greater effect on decreasing SSBs consumption. This is noteworthy given SSBs are a key contributor to overweight and obesity. SO WHAT?: To our knowledge this is the first Australian study examining combined school-based interventions to specifically promote the consumption of water and decrease the consumption of SSBs in adolescents. The study findings add to the evidence regarding the benefits of delivering multi-component school-based interventions which add value to existing interventions that address the complex public health issue of overweight and obesity.

Water Wins, Communication Matters: School-Based Intervention to Reduce Intake of Sugar-Sweetened Beverages and Increase Intake of Water

We compared three interventions designed for reducing the consumption of sugar-sweetened beverages (SSBs) aimed at decreasing the risk of overweight and obesity among children. We included three experimental (n = 508) and one control school (n = 164) in Slovenia (672 children; 10–16 years) to evaluate interventions that influence behaviour change via environmental (E), communication (C), or combined (i.e., double) environmental and communication approaches (EC) compared to no intervention (NOI). Data of children from the ‘intervention’ and ‘non-intervention’ schools were compared before and after the interventions. The quantity of water consumed (average, mL/day) by children increased in the C and EC schools, while it decreased in the E and NOI schools. Children in the C and EC schools consumed less beverages with sugar (SSBs + fruit juices), and sweet beverages (beverages with: sugar, low-calorie and/or noncaloric sweeteners) but consumed more juices. The awareness about the health risks of SSB consumption improved among children of the ‘combined intervention’ EC school and was significantly different from the awareness among children of other schools (p = 0.03). A communication intervention in the school environment has more potential to reduce the intake of SSBs than a sole environmental intervention, but optimum results can be obtained when combined with environmental changes.

Individual, Social, and Environmental Correlates of Energy Drink Use Among Adolescents

OBJECTIVE

To investigate the correlates of adolescent energy drink (ED) use using a socioecological approach to inform future interventions.

METHODS

In 2017-2018, 3,688 students attending 25 randomly selected Western Australian secondary schools completed a self-report survey. A backward stepwise logistic regression analysis was used to construct a model of the most significant individual (n = 12), social (n = 3), and environmental (n = 4) factors associated with being an ED user (ie, past month ED use).

RESULTS

Overall, 18% of participants were ED users. The factors significantly associated with being an ED user included being male (P < 0.001), having a higher disposable income (P < 0.001), perceiving EDs as good for health (P = 0.009), perceiving EDs as safe for someone their age to drink (P < 0.001), having a sensation-seeking personality (P = 0.011), having friends who drink EDs (P < 0.001), having parents who would give them an ED if asked (P < 0.001), and having EDs available at home (P < 0.001).

CONCLUSIONS AND IMPLICATIONS

Initiatives to reduce ED intake among adolescents need to be multifaceted, addressing individual, social, and environmental factors. It is also important that educational interventions target both parents and adolescents.

Effectiveness of education intervention to reduce sugar-sweetened beverages and 100% fruit juice in children and adolescents: a scoping review

OBJECTIVE

To determine the impact of educational intervention in reducing the consumption of sugar-sweetened beverages (SSBs) and 100% fruit juice in children and adolescents.

DESIGN

We conducted a comprehensive Ovid Medline and Scopus search. Articles had to be peer-reviewed, full-text and published in English. Studies had to be controlled intervention, published between 1 January 2010 to 7 February 2021, and in children and adolescents. Study quality was measured using the Quality Assessment Tool for Controlled Intervention Studies.

RESULTS

Forty intervention articles were included in this review involving 25,069 children and adolescents. All studies employed a quantitative research method using the Randomized Controlled Trial designs. Twenty-eight out of forty interventions used psychosocial theories. Study quality ranged from 'fair' to 'good.' Results showed that education intervention effectively reduced SSBs, and reduced 100% fruit juice in children.

EXPERT OPINION

Reducing the SSBs consumption in children should be initiated by conducting school-based programs consisting of interactive learning process, psychosocial theories and the involvement of parents or caregivers. Theories that focus on personal, behavior and environment factors improve the effectiveness of the intervention. More research is warranted to investigate the impacts of 100% fruit juice on obesity, dental caries and risk of co-morbidities in children.

Dietary Intake and Sources of Added Sugars in Various Food Environments in Costa Rican Adolescents

Consumption of added sugars, especially from sugar-sweetened beverages (SSBs), has been associated with several negative health outcomes during adolescence. This study aimed to identify dietary intake and food sources of added sugars in the home, school, and neighborhood environments of Costa Rican adolescents. Dietary intake of added sugars was determined using 3-day food records in a cross-sectional study of 818 adolescents aged 12 to 19 and enrolled in rural and urban schools in the province of San José. On average, 90% of adolescents consumed more than 10% of their total energy intake from added sugars. Furthermore, 74.0% of added sugars were provided at home, 17.4% at school, and 8.6% in the neighborhood. Added sugars were primarily provided by frescos (29.4%), fruit-flavored still drinks (22.9%), and sugar-sweetened carbonated beverages (12.3%), for a total contribution of 64.6%. Our findings suggest that Costa Rican adolescents have a plethora of added sugar sources in all food environments where they socialize. However, it is relevant for public health to consider the home and school environments as fundamental units of interventions aimed at reducing added sugars in the adolescent diet. Frescos prepared at home and school and fruit-flavored still drinks must be the focus of these interventions.

Impact of Measures Aiming to Reduce Sugars Intake in the General Population and Their Implementation in Europe: A Scoping Review

Objectives: Implementing public health measures is necessary to decrease sugars intake, which is associated with increased risk of noncommunicable diseases. Our scoping review aimed to identify the types of measures implemented and evaluated to decrease sugars intake in the population and to assess their impact.

Methods: Following a review of systematic reviews (SRs) published in 2018, we systematically searched new SR (May 2017–October 2020) in electronic databases. We also searched the measures implemented in Europe in the NOURISHING database. Two researchers selected the reviews, extracted and analysed the data.

Results: We included 15 SRs assessing economic tools (n = 5), product reformulation and labels/claims (n = 5), and educational/environmental interventions (n = 7). Economic tools, product reformulation and environmental measures were effective to reduce sugar intake or weight outcomes, while labels, education and interventions combining educational and environmental measures found mixed effects. The most frequently implemented measures in Europe were public awareness, nutritional education, and labels.

Conclusion: Among measures to reduce sugar intake in the population, economic tools, product reformulation, and environmental interventions were the most effective, but not the more frequently implemented in Europe.

Students' perceptions of school sugar-free, food and exercise environments enhance healthy eating and physical activity

OBJECTIVE

The objective of this study was to examine the relationships between students' perceptions of their school policies and environments (i.e. sugar-sweetened beverages (SSB) free policy, plain water drinking, vegetables and fruit eating campaign, outdoor physical activity initiative, and the SH150 programme (exercise 150 min/week at school)) and their dietary behaviours and physical activity.

DESIGN

Cross-sectional study.

SETTING

Primary, middle and high schools in Taiwan.

PARTICIPANTS

A nationally representative sample of 2433 primary school (5th-6th grade) students, 3212 middle school students and 2829 high school students completed the online survey in 2018.

RESULTS

Multivariate analysis results showed that after controlling for school level, gender and age, the students' perceptions of school sugar-free policies were negatively associated with the consumption of SSB and positively associated with consumption of plain water. Schools' campaigns promoting the eating of vegetables and fruit were positively associated with students' consumption of vegetables. In addition, schools' initiatives promoting outdoor physical activity and the SH150 programme were positively associated with students' engagement in outdoor physical activities and daily moderate-to-vigorous physical activity.

CONCLUSIONS

Students' perceptions of healthy school policies and environments promote healthy eating and an increase in physical activity for students.

Sugar-sweetened beverages consumption among New Zealand children aged 8-12 years: a cross sectional study of sources and associates/correlates of consumption

Background

The benefit of reducing sugar-sweetened beverage (SSB) consumption is widely accepted, but updated and in-depth data on New Zealand (NZ) children’s SSB consumption is lacking. The aims of this study were to describe beverage consumption, focusing on SSBs in primary school age children living in Auckland; to examine the association of selected socio-demographic, home, community and school factors and children’s beverage knowledge/attitudes with regards to beverage consumption; to explore the relationship between SSBs consumption and adiposity in children.

Methods

A cross-sectional, Auckland-wide survey of 578 school age children (8-12 years) was conducted using questionnaires to collect data on beverage consumption, beverage knowledge/attitudes, and selected socio-demographic and home, community, school factors. Body fat percentage (BF%) was assessed using bioelectrical impedance (BIA).

Results

Ninety-six percent of children consumed ≥1 serving of SSBs a week; with ≥5 servings reported by 62% of children. Of all SSBs assessed, consumption of ≥1 serving of sugar sweetened milk-based beverages (85%, mainly milk drinks made from powder) was most prevalent, followed by fruit juice (46%) and sugar-containing carbonated drinks (39%, mainly soft/fizzy drinks). Among unsweetened beverages, plain water was reported to be consumed < 2 times a day by 22% of children, and plain milk < 1 serving a day by 53%. Higher consumption of SSBs was associated with socio-economic disadvantage, non-NZ European ethnicities (Māori, Pacific, Asian, others), availability of SSBs in the home, frequent takeaway/convenience shop visits, children’s incorrect perception of adequate SSBs consumption frequency, and higher BF% (females only). School health policy and encouragement of children to consume un-sweetened beverages was not associated with SSBs consumption.

Conclusions

The consumption of SSBs is prevalent in NZ school age children, with higher consumption rates observed among those from socially disadvantaged areas. This high consumption is associated with higher BF% in females. Multi-contextual interventions to decrease SSBs should target children, and their families/environment, particularly those from socially disadvantaged areas.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12345-9.

A trial of a six-month sugar-sweetened beverage intervention in secondary schools from a socio-economically disadvantaged region in Australia

OBJECTIVE

This study assessed the effectiveness of a school-based intervention in reducing adolescents' sugar-sweetened beverage (SSB) consumption and percentage of energy from SSBs. Secondary outcomes were SSB consumption within school, average daily energy intake, and body mass index z-scores.

METHODS

Six secondary schools located in New South Wales, Australia were recruited to participate in a six-month pilot randomised controlled trial (1:1). The intervention included components targeting the school nutrition environment, curricula and community. Outcomes were collected via online surveys, observations, anthropometric measurements and project records. Between-group differences were assessed via linear mixed models.

RESULTS

At the six-month intervention endpoint (n=862) there were no statistically significant differences between students in intervention or control schools for mean daily intake of SSBs (8.55mL; CI -26.77, 43.87; p=0.63), percentage daily energy from SSBs (0.12% kJ; CI -0.55, 0.80; p=0.72), or for secondary outcomes. Acceptability of the school-based strategies were high, however intervention fidelity varied across schools.

CONCLUSION

While acceptable, improving fidelity of implementation and increasing the duration or intensity of the intervention may be required to reduce SSB intake. Implications for public health: Engaging parents and education stakeholders in the development phase to co-design interventions may prove beneficial in improving intervention fidelity and enhance behavioural outcomes.

Characteristics of the School Food Environment Affect the Consumption of Sugar-Sweetened Beverages Among Adolescents

Sugar-sweetened beverages are widely available and accessible in school environment, and their presence and characteristics of this environment can influence their consumption. This study examines the association of drinking fountains per 100 students, soft drink sales, soft drink advertising, and the presence of street vendors and sugar-sweetened beverages consumption among adolescents in Brazil. This cross-sectional study was carried out using data from the Study of Cardiovascular Risk in Adolescents that was conducted between March 2013 and December 2014. The sample comprised 71,475 adolescents aged 12–17 years from 1,247 public and private schools in Brazilian cities. Sugar-sweetened beverages consumption was the dependent variable. The main effect was the school food environment, which was evaluated based on drinking fountains per 100 students, soft drink sales, soft drink advertising, and the presence of street vendors. Public and private schools that sold soft drinks were associated with higher average sugar-sweetened beverages consumption among adolescents. Our study highlights the importance of creating healthy school food environments by banning sugar-sweetened beverages in schools accordingly.

Effects of School-Based Interventions on Reducing Sugar-Sweetened Beverage Consumption among Chinese Children and Adolescents

We set up a series of school-based interventions on the basis of an ecological model targeting sugar-sweetened beverage (SSB) reduction in Chinese elementary and middle schools and evaluated the effects. A total of 1046 students from Chinese elementary and middle schools were randomly recruited in an intervention group, as were 1156 counterparts in a control group. The interventions were conducted in the intervention schools for one year. The participants were orally instructed to answer all the questionnaires by themselves at baseline and after intervention. The difference in difference statistical approach was used to identify the effects exclusively attributable to the interventions. There were differences in grade composition and no difference in sex distribution between the intervention and control groups. After adjusting for age, sex, and group differences at baseline, a significant reduction in SSB intake was found in the intervention group post intervention, with a decrease of 35.0 mL/day (p = 0.034). Additionally, the frequency of SSB consumption decreased by 0.2 times/day (p = 0.071). The students in the elementary schools with interventions significantly reduced their SSB intake by 61.6 mL/day (p = 0.002) and their frequency of SSB consumption by 0.3 times/day (p = 0.017) after the intervention. The boys in the intervention group had an intervention effect of a 50.2 mL/day reduction in their SSB intake (p = 0.036). School-based interventions were effective in reducing SSB consumption, especially among younger ones. The boys were more responsive to the interventions than the girls. (ChiCTR, ChiCTR1900020781.)

A Systematic Review of the Recent Consumption Levels of Sugar-Sweetened Beverages in Children and Adolescents From the World Health Organization Regions With High Dietary-Related Burden of Disease

This review aimed to investigate national estimates of sugar-sweetened beverage (SSB) consumption in children and adolescents aged 2 to 18 years, from countries in regions particularly burdened by dietary-related chronic illnesses. The most recent studies or reports from included countries (n = 73) with national-level consumption data of SSBs in children and adolescents, collected between January 2010 and October 2019, were considered for inclusion. A random effects meta-analysis was used to calculate pooled estimates of the mean consumption of SSB in millimeters per day. Heterogeneity between national estimates was assessed using the I² statistic and explored via subgroup analyses by the World Health Organization region, age groups, and country-level income. Forty-eight studies were included in the review reporting national estimates of consumption for 51 countries. The highest estimate of daily consumption was in China at 710.0 mL (95% confidence interval [CI] = 698.8-721.2), while the lowest was in Australia at 115.1 mL (95% CI = 111.2-119.1). Pooled synthesis of daily SSB consumption of the 51 countries was 326.0 mL (95% CI = 288.3-363.8), although heterogeneity was high, and was not explained by subgroup analyses. While there is considerable variability between countries, intake of SSB remains high among children and adolescents internationally underscoring the need for public health efforts to reduce SSBs consumption.

A Brief Motivational Intervention Differentially Reduces Sugar-sweetened Beverage (SSB) Consumption

Background

Environmental and behavioral interventions hold promise to reduce sugar-sweetened beverage (SSBs) consumption.

Purpose

To test, among frequent SSB consumers, whether motivations to consume SSBs moderated the effects of (a) a workplace SSB sales ban (environmental intervention) alone, and (b) a “brief motivational intervention” (BI) in addition to the sales ban, on changes in SSB consumption.

Methods

We assessed whether (1) baseline motivations to consume SSBs (craving, psychological stress, or taste enjoyment) impacted changes in daily SSB consumption at 6-month follow-up among frequent (>12oz of SSBs/day) SSB consumers (N = 214); (2) participants randomized to the BI (n = 109) versus to the sales ban only (n = 105) reported greater reductions in SSB consumption at follow-up; and (3) motivations to consume SSBs moderated any changes in SSB consumption.

Results

In response to the sales ban alone, individuals with stronger SSB cravings (+1 SD) at baseline showed significantly smaller reductions in daily SSB consumption at 6-month follow-up relative to individuals with weaker (−1 SD) SSB cravings (2.5 oz vs. 22.5 oz), p < .01. Receiving the BI significantly increased reductions for those with stronger SSB cravings: Among individuals with stronger cravings, those who received the BI evidenced significantly greater reductions in daily SSB consumption [M(SE) = −19.2 (2.74) oz] than those who did not [M(SE) = −2.5 (2.3) oz, p < .001], a difference of 16.72 oz.

Conclusions

Frequent SSB consumers with stronger SSB cravings report minimal reductions in daily SSB consumption with a sales ban only, but report greater reductions if they also receive a motivational intervention. Future multilevel interventions for institutions should consider both environmental and individualized multi-level interventions.

Clinical Trial information

NCT02585336.

Thirsty? Choose Water! Encouraging Secondary School Students to choose water over sugary drinks. A descriptive analysis of intervention components

BACKGROUND

Childhood obesity is a significant public health issue. Sugar-sweetened beverage (SSB) consumption contributes to this and adolescents are high consumers. This paper provides a descriptive overview of a school-based intervention to address this.

METHODS

61 secondary schools in New South Wales were randomised to receive a behavioural intervention (BI), a chilled water station (CWS), both interventions or neither (control). The BI was delivered through classroom lessons, school-based promotion and vaccination clinic. The CWS intervention included the installation of one CWS per school. Intervention effectiveness over time was assessed via student surveys at baseline, post-intervention and follow-up (individual-level outcomes), feedback from teachers and vaccination nurses, a school information survey, and remotely monitored CWS water usage (school-level outcomes).

RESULTS

Teachers reported the BI was useful in teaching students about drinking water and negative consequences of SSBs. Nurses considered the post-vaccination waiting period a good opportunity to deliver health promotion messages. Students in this group showed statistically significant changes in knowledge about SSBs, dehydration effects and changes in daily SSB consumption (T1 23.18%; T3 18.20%). Positive feedback regarding CWSs was received with an increase in water consumption reported for students in this group (T1 86.15% to T3 89.66%) and a statistically significant increase in students carrying a water bottle to school and filling it observed.

CONCLUSIONS

Both interventions were readily implemented with high levels of acceptability and impact on students' knowledge and SSB consumption. The study demonstrates how to promote water consumption in schools utilising two different interventions. SO WHAT?: Evidence regarding how to decrease SSB consumption amongst secondary school students has been strengthened.

A cluster randomised controlled trial of a secondary school intervention to reduce intake of sugar-sweetened beverages: Mid-intervention impact of switchURsip environmental strategies

ISSUE ADDRESSED

Secondary schools provide an opportune setting for interventions addressing excessive sugar-sweetened beverage (SSB) intake in adolescence. This trial aimed to assess the impact of school environmental strategies, delivered as part of a broader intervention, among Year 7-9 students' SSB consumption.

METHODS

Between March and July 2018, we conducted a cluster randomised controlled trial with 862 students attending six secondary schools (3 intervention and 3 control) in New South Wales. The intervention targeted SSB availability, placement, promotion and pricing, and increased availability and promotion of water. Control schools followed their usual programmes. Primary outcomes included mean daily SSB consumption (millilitres) and mean daily percentage energy from SSB (kilojoules). Sub-group analysis explored primary outcomes for gender, school year level and frequency of canteen use.

RESULTS

Of the 2265 eligible students, 1092 (50.2%) provided active parental consent and 940 (86.0%) participated in baseline data collection. No significant differences were observed between groups at follow-up for mean daily SSBs consumed (-10.17 mL, CI: -24.78; 45.12, P = 0.57) or mean daily percentage energy from SSBs (-0.20%, CI: -0.87; 0.47, P = .56). Significant effects were observed among girls in intervention compared to girls in control schools for mean daily SSB consumption (-52.02 mL, CI 99.8; 94.14, P = .03) and mean daily percentage of energy from SSBs (-0.90%, CI: -1.82; 0.02, P = .05).

CONCLUSIONS

At 3-month mid-intervention evaluation, the intervention failed to impact on mean daily consumption and mean percentage energy from SSBs, overall. However, an intervention effect was observed in girls. The limited overall effect is likely due to inadequate intervention dose related to the short duration, limiting opportunities for schools to fully implement the environmental strategies. SO WHAT?: A longer intervention duration with additional implementation support to allow adequate time to embed the strategies within the school is recommended. Implementation support strategies would ensure staff are supported throughout the process.

Effectiveness of lifestyle interventions in preventing harmful weight gain among adolescents: A systematic review of systematic reviews

Obesity in adolescence is associated with stigma during school years, early emergence of co-morbidities in adulthood and premature mortality. Adolescence presents a key window of opportunity to intervene for building healthy eating and physical activity routines and prevent weight gain. This review of reviews assesses the evidence on the effectiveness of prevention interventions conducted with adolescents. Nine reviews assessing the effects of lifestyle interventions in adolescents (defined as age 10 to 19 years old) on weight gain were identified from the 10 health databases searched. Only four reviews conducted meta-analyses, of which, three (two exercise-focused) demonstrated positive changes in primary outcomes of body mass index (BMI) and/or BMI z-score (range of decrease in BMI from 0.06 to 0.47 kg/m²⁾ ). Most were conducted in school settings, and all but two reviews were of low quality. Few reviews reported external validity components that would enable clearer directions for policy makers to implement in real-world settings. More than 140 distinct interventions were included in the reviews, but there remains a serious gap in evidence for effective interventions in adolescents.

Current Systems-Level Evidence on Nutrition Interventions to Prevent and Treat Cardiometabolic Risk in the Pediatric Population: An Evidence Analysis Center Scoping Review

Improving and maintaining cardiometabolic health remains a major focus of health efforts for the pediatric population. Recent research contributes understanding of the systems-level nutrition factors influencing cardiometabolic health in pediatric individuals. This scoping review examines current evidence on interventions and exposures influencing pediatric cardiometabolic health to inform registered dietitian nutritionists working at each systems level, ranging from individual counseling to public policy. A literature search of MEDLINE, CINAHL, Cochrane Databases of Systematic Reviews, and other databases was conducted to identify evidence-based practice guidelines, systematic reviews, and position statements published in English from January 2017 until April 2020. Included studies addressed nutrition interventions or longitudinal exposures for participants 2 to 17 years of age who were healthy or had cardiometabolic risk factors. Studies were categorized according level of the social-ecological framework addressed. The databases and hand searches identified 2614 individual articles, and 169 articles were included in this scoping review, including 6 evidence-based practice guidelines, 141 systematic reviews, and 22 organization position statements. The highest density of systematic reviews focused on the effects of dietary intake (n = 58) and interventions with an individual child or family through counseling or education (n = 54). The least frequently examined levels of interventions or exposures were at the policy level (n = 12). Registered dietitian nutritionists can leverage this considerable body of recent systematic reviews to inform a systems-level, collaborative approach to prevention and treatment of pediatric cardiometabolic risk factors.

Health behavior patterns of sugar-sweetened beverage consumption among Brazilian adolescents in a nationally representative school-based study

Studies on sugar-sweetened beverage consumption patterns can help in the individual and population level management of chronic non-communicable diseases and other conditions. This study aimed to identify the association between health behavior patterns and the consumption of sugar-sweetened beverages among Brazilian adolescents from a nationally representative school-based study. A cross-sectional study analyzed data from 71,553 adolescents aged 12–17 years who attended public and private schools in Brazilian cities, from the Study of Cardiovascular Risk in Adolescents. Principal component analysis was performed to identify health behavior patterns, and ordered logistic regression was performed to identify the association between health behavior patterns and sugar-sweetened beverage consumption. Sugar-sweetened beverage consumption (mL/day) was used as the dependent variable. The analyses were performed using Stata software version 14.0 with a significance level of 0.05. Patterns 2 (alcoholic beverage and smoking habit) and 3 (ultra-processed food and screen time) of health behaviors and regularly purchasing snacks in the school cafeteria increased the odds of sugar-sweetened beverage consumption, while pattern 1 (water, unprocessed and minimally processed food and physical activity) decreased these odds. The adoption of healthy habits can indirectly stimulate the adoption of other habits beneficial to health. These results indicate the importance of adopting a set of regulatory measures to reduce sugar-sweetened beverage consumption.

Effectiveness of behavioral interventions and behavior change techniques for reducing soft drink intake in disadvantaged adolescents: A systematic review and meta-analysis

Reducing sugar-sweetened beverage (SSB) intake is an important dietary target, especially among socioeconomically disadvantaged ethnic minority adolescents. This review and meta-analysis evaluated the effectiveness of behavioural interventions aiming to reduce SSB intake in socioeconomically disadvantaged ethnic minority adolescents and examined which behaviour change techniques (BCTs) were most effective. A systematic search was conducted using the PRISMA criteria. Quality assessments were done using the Cochrane criteria. In a narrative synthesis, studies were divided into effective and non-effective, and relative effectiveness ratios of individual BCTs were calculated. Pooled standardized mean differences (SMDs) and their 95% confidence intervals were estimated with random-effects models using cluster robust methods. Twenty-two studies were included in the qualitative synthesis. A meta-analysis (n = 19) revealed no significant between-group differences in reduction of SSB intake. Five self-regulatory BCTs had an effectiveness ratio >50%: feedback, goal-setting, action planning, self-monitoring and problem-solving/barrier identification. The risk of bias assessments were judged to be moderate to high risk for randomized controlled trials (RCTs) studies and low to moderate for pre-post studies. There was no indication of publication bias. In conclusion, self-regulatory BCTs may be effective components to change SSB behaviour. However, high-quality research is needed to evaluate the effectiveness of behavioural interventions and identify BCTs effective for reducing SSB intake among disadvantaged adolescents with ethnic minority backgrounds.

The drivers, trends and dietary impacts of non-nutritive sweeteners in the food supply: a narrative review

Poor diets, including excess added sugar consumption, contribute to the global burden of disease. Subsequently, many nutrition policies have been implemented to reduce added sugar intake and improve population health, including taxes, education, labelling and environmental interventions. A potential consequence of these policy actions is the substitution of added sugars with non-nutritive sweeteners (NNS) in a variety of foods and beverages. NNS are used to reduce the energy and sugar content of foods and beverages while maintaining their palatability. Evidence of the toxicological risks of NNS is inconsistent, though concerns have been raised over the potential substitution effects of ultra-processed foods containing NNS for whole foods. This review aimed to provide an overview of current NNS food supply and consumption patterns, assess added sugar-reduction policies and their impact on NNS, and determine the impact of NNS on food choice, energy intake and diet quality. NNS are widely available in a variety of products, though most commonly in carbonated beverages, dairy products, confectionery, table-top sweeteners and fruit drinks. However, the longitudinal trends of different product categories, and differences between geographies and economy-income levels, require further study. Few studies have examined NNS consumption trends globally, though an increase in NNS consumption in beverages has been observed in some regions. Research examining how the increased availability of low-sugar, NNS-containing products affects global dietary patterns is limited, particularly in terms of their potential substitution effects.

Primary prevention of overweight and obesity in adolescents: An overview of systematic reviews

The aim of this overview of systematic reviews was to summarize evidence from up-to-date reviews of the effectiveness of interventions aimed at preventing overweight and obesity in adolescents aged 10 to 19 years. We searched nine databases for systematic reviews published between January 2008 and November 2019. We used A Measurement Tool to Assess Systematic Reviews (AMSTAR) 2 to assess the quality of reviews, excluding those of critically low quality, and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool to grade the certainty of included evidence. We included 13 reviews. Three reviews focused on dietary behaviour, six on physical activity, and four on both types of behaviours. Individual-oriented and school-based interventions dominated. Results across reviews showed little or no effect on body mass index, or physical activity levels of adolescents, whereas results from a couple of reviews suggest possibly beneficial effects of public health interventions on dietary behaviours (i.e., consumption of sugar-sweetened beverages). The certainty of evidence was low to very low for all outcomes. Overall, the evidence base for the effect of primary interventions to prevent overweight and obesity in adolescents is weak. In particular, there is a lack of reviews assessing the impact of environmental interventions targeting adolescents, and reviews addressing social inequality are virtually absent from this body of literature.

Environmental Interventions to Reduce the Consumption of Sugar-Sweetened Beverages: Abridged Cochrane Systematic Review

BACKGROUND

Regular consumption of sugar-sweetened beverages (SSB) can increase the risk for obesity, type 2 diabetes, cardiovascular disease, and dental caries. Interventions that alter the physical or social environment in which individuals make beverage choices have been proposed to reduce the consumption of SSB.

METHODS

We included randomised controlled, non-randomised controlled, and interrupted time series studies on environmental interventions, with or without behavioural co-interventions, implemented in real-world settings, lasting at least 12 weeks, and including at least 40 individuals. Studies on the taxation of SSB were not included, as these are subject of a separate Cochrane review. We used standard Cochrane methods for data extraction, risk of bias assessment, and evidence grading and synthesis. Searches were updated to January 24, 2018.

RESULTS

We identified 14,488 unique records and assessed 1,030 full texts for eligibility. We included 58 studies comprising a total of 1,180,096 participants and a median length of follow-up of 10 months. We found moderate-certainty evidence for consistent associations with decreases in SSB consumption or sales for the following interventions: traffic light labelling, price increases on SSB, in-store promotion of healthier beverages in supermarkets, government food benefit programs with incentives for purchasing fruits and vegetables and restrictions on SSB purchases, multi-component community campaigns focused on SSB, and interventions improving the availability of low-calorie beverages in the home environment. For the remaining interventions we found low- to very-low-certainty evidence for associations showing varying degrees of consistency.

CONCLUSIONS

With observed benefits outweighing observed harms, we suggest that environmental interventions to reduce the consumption of SSB be considered as part of a wider set of measures to improve population-level nutrition. Implementation should be accompanied by evaluations using appropriate methods. Future studies should examine population-level effects of interventions suitable for large-scale implementation, and interventions and settings not yet studied thoroughly.

Study protocol of the Health4Life initiative: a cluster randomised controlled trial of an eHealth school-based program targeting multiple lifestyle risk behaviours among young Australians

INTRODUCTION

Lifestyle risk behaviours, including alcohol use, smoking, poor diet, physical inactivity, poor sleep (duration and/or quality) and sedentary recreational screen time ('the Big 6'), are strong determinants of chronic disease. These behaviours often emerge during adolescence and co-occur. School-based interventions have the potential to address risk factors prior to the onset of disease, yet few eHealth school-based interventions target multiple behaviours concurrently. This paper describes the protocol of the Health4Life Initiative, an eHealth school-based intervention that concurrently addresses the Big 6 risk behaviours among secondary school students.

METHODS AND ANALYSIS

A multisite cluster randomised controlled trial will be conducted among year 7 students (11-13 years old) from 72 Australian schools. Stratified block randomisation will be used to assign schools to either the Health4Life intervention or an active control (health education as usual). Health4Life consists of (1) six web-based cartoon modules and accompanying activities delivered during health education (once per week for 6 weeks), and a smartphone application (universal prevention), and (2) additional app content, for students engaging in two or more risk behaviours when they are in years 8 and 9 (selective prevention). Students will complete online self-report questionnaires at baseline, post intervention, and 12, 24 and 36 months after baseline. Primary outcomes are consumption of sugar-sweetened beverages, moderate-to-vigorous physical activity, sleep duration, sedentary recreational screen time and uptake of alcohol and tobacco use.

ETHICS AND DISSEMINATION

This study has been approved by the University of Sydney (2018/882), NSW Department of Education (SERAP no. 2019006), University of Queensland (2019000037), Curtin University (HRE2019-0083) and relevant Catholic school committees. Results will be presented to schools and findings disseminated via peer-reviewed journals and scientific conferences. This will be the first evaluation of an eHealth intervention, spanning both universal and selective prevention, to simultaneously target six key lifestyle risk factors among adolescents.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12619000431123), 18 March 2019.

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.

Correlates of sugar-sweetened beverages consumption among adolescents

Objective:

To identify correlates and underlying beliefs regarding the adolescents’ intention to abstain from consuming sugar-sweetened beverages (SSB) and the consumption of ≤1 daily portion of SSB.

Design:

Correlational study.

Setting:

Region of Chaudière-Appalaches in the province of Quebec, Canada.

Participants:

311 adolescents aged 13–18 years completed a self-administrated online questionnaire based on the Reasoned Action Approach. Frequency and quantity of different types of SSB within the past month were measured.

Results:

Total mean SSB intake was 882·6 ml/d (654·0 kJ/d ). Only 11·3 % abstained from SSB within the last month. Intention to abstain from SSB was explained by identification as SSB abstainers (β = 0·47), perceived norm (β = 0·32), attitude (β = 0·30), age 13–14 years (β = –0·27) and perception of the school environment (β = 0·14), which explained 66 % of the variance. Consumption of ≤1 daily portion of SSB was explained by the intention to abstain (OR = 1·55; 95 % CI 1·14, 2·11), perceived behavioural control to abstain (OR = 1·80; 95 % CI 1·29, 2·52), sex (girls v. boys: OR = 2·34; 95 % CI 1·37, 3·98) and socio-economic status (advantaged v. disadvantaged school: OR = 2·08; 95 % CI 1·21, 3·56). Underlying beliefs (i.e. more energy, decreased risk of addiction and friends’ approval) associated with intention as well as perceived barriers (e.g. access to SSB, after an activity that makes you thirsty), and facilitating factors (e.g. access to water) linked to SSB consumption were identified.

Conclusions:

The results can inform public health interventions to decrease SSB consumption and their associated health problems among adolescents.

Nutritional profile of sugar-sweetened beverages destined to the youngsters marketed in Brazil and Portugal

ABSTRACT Objective To analyze and compare the sugar content in sugar sweetened beverages in Brazil and Portugal, according to the Pan American Health Organization nutritional profile model. Methods One hundred six equivalent sugary beverages were selected in the markets of São Paulo, Brazil and Porto, Portugal. Nutritional information reported on the labels was reviewed, according to the Pan American Health Organization nutritional profile model, regarding the critical content of free sugars, salt, total saturated fats and trans fatty acids. Results The Brazilian nectars presented higher amounts of sugar and vitamin C compared to Portuguese nectars that contained more protein. The juices in Portugal contained a higher content of vitamin C and Portuguese dairy beverages had higher levels of protein and sodium, while the Brazilian ones had more total fats. According to the critical nutrients proposed by the Pan American Health Organization, Brazil had excess sodium in dairy beverages and soft drinks, while in Portugal excess sodium was found in nectars and dairy beverages. In both countries, excess free sugars were present in all beverages. Conclusion The amount of sugar in the beverages represents an important contribution of added sugar, especially in the Brazilian nectars. The identification of this component in sugary beverages is fundamental for the adoption of strategies of food education to control obesity.

RE-AIM analysis of a community-partnered policy, systems, and environment approach to increasing consumption of healthy foods in schools serving low-income populations

While working in partnership with a school district on their wellness policy builds a culture of health, additional strategies are needed to reinforce students eating healthy.

Effectiveness of behavioral interventions to reduce the intake of sugar-sweetened beverages in children and adolescents: a systematic review and meta-analysis

Context

Consumption of sugar-sweetened beverages (SSBs) among children has been associated with adverse health outcomes. Numerous behavioral interventions aimed at reducing the intake of SSBs among children have been reported, yet evidence of their effectiveness is lacking.

Objective

This systematic review explored the effectiveness of educational and behavioral interventions to reduce SSB intake and to influence health outcomes among children aged 4 to 16 years.

Data Sources

Seven databases were searched for randomized controlled trials published prior to September 2016. Studies identified were screened for eligibility.

Study Selection

Trials were included in the review if they met the PICOS (Population, Intervention, Comparison, Outcome, and Study design) criteria for inclusion of studies.

Data Extraction

Data were extracted by 2 reviewers following Cochrane guidelines and using Review Manager software.

Results

Of the 16 trials included, 12 were school based and 4 were community or home based. Only 3 trials provided data that could be pooled into a meta-analysis for evaluating change in SSB intake. Subgroup analyses showed a trend toward a significant reduction in SSB intake in participants in school-based interventions compared with control groups. Change in body mass index z scores was not statistically significant between groups.

Conclusions

The quality of evidence from included trials was considered moderate, and the effectiveness of educational and behavioral interventions in reducing SSB intake was modest.

Systematic Review Registration

PROSPERO registration number CRD42014004432.

Short-Term Effects of the Serious Game "Fit, Food, Fun" on Nutritional Knowledge: A Pilot Study among Children and Adolescents

“Serious games” are a novel and entertaining approach for nutritional education. The aim of this pilot study was to evaluate the short-term effectiveness of “Fit, Food, Fun” (FFF), a serious game to impart nutritional knowledge among children and adolescents. Data collection was conducted at two secondary schools in Bavaria, Germany. The gameplay intervention (gameplay group; GG) consisted of a 15-minute FFF gameplay session during each of three consecutive days. The teaching intervention (teaching group; TG) was performed in a classic lecture format. Nutritional knowledge was evaluated via questionnaires at baseline and post-intervention. Statistical analyses were performed using R (R Core Team, 2018). In total, baseline data were available for 39 participants in the GG and 44 participants in the TG. The mean age was 13.5 ± 0.7 years in the GG and 12.8 ± 0.9 years in the TG. There was a significant (p-value < 0.001) improvement in nutritional knowledge in both intervention groups. Moreover, a between-group difference with a significantly (p-value = 0.01) higher increase in nutritional knowledge was detected for the TG. This pilot study provides evidence for the short-term effectiveness of both educational interventions on the improvement in nutritional knowledge. Finally, the FFF game might be an adequate educational tool for the transfer of nutritional knowledge among children and adolescents.

Food literacy programmes in secondary schools: a systematic literature review and narrative synthesis of quantitative and qualitative evidence

OBJECTIVE

The current review aimed to synthesise the literature on food literacy interventions among adolescents in secondary schools, the attitudes and perceptions of food literacy interventions in secondary schools, and their effects on dietary outcomes.

DESIGN

The systematic review searched five electronic databases from the earliest record to present.

SETTING

The studies selected for the review were from sixteen countries: Australia (n 10), Canada (n 1), China (n 1), France (n 1), Greece (n 2), Iran (n 1), South Africa (n 1), South India (n 1), Kenya (n 1), Norway (n 2), Portugal (n 1), Denmark (n 1), Northern Ireland (n 1), USA (n 17), UK (n 1) and Sweden (n 2).

PARTICIPANTS

Adolescents aged 10-19 years.

RESULTS

Forty-four studies were eligible for inclusion. Adolescents with greater nutritional knowledge and food skills showed healthier dietary practices. Studies found a mixed association between food literacy and long-term healthy dietary behaviour. Two studies showed an improvement in adolescents' cooking skills and food safety knowledge; six studies showed an improvement in overall food safety knowledge; six studies showed an improvement in overall food and nutritional knowledge; and two studies showed an improvement in short-term healthy dietary behaviour.

CONCLUSIONS

Food literacy interventions conducted in a secondary-school setting have demonstrated a positive impact on healthy food and nutritional knowledge. However, there appears to be limited evidence supporting food literacy interventions and long-term dietary behaviours in adolescents. More evidence-based research is required to adequately measure all domains of food literacy and more age-specific food literacy interventions.