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Yoong SL, Lum M, Wolfenden L, Jackson J, Barnes C, Hall AE, McCrabb S, Pearson N, Lane C, Jones JZ, Nolan E, Dinour L, McDonnell T, Booth D, Grady A. Healthy eating interventions delivered in early childhood education and care settings for improving the diet of children aged six months to six years. Cochrane Database Syst Rev 2023; 8:CD013862. [PMID: 37606067 PMCID: PMC10443896 DOI: 10.1002/14651858.cd013862.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
Abstract
BACKGROUND Dietary intake during early childhood can have implications on child health and developmental trajectories. Early childhood education and care (ECEC) services are recommended settings to deliver healthy eating interventions as they provide access to many children during this important period. Healthy eating interventions delivered in ECEC settings can include strategies targeting the curriculum (e.g. nutrition education), ethos and environment (e.g. menu modification) and partnerships (e.g. workshops for families). Despite guidelines supporting the delivery of healthy eating interventions in this setting, little is known about their impact on child health. OBJECTIVES To assess the effectiveness of healthy eating interventions delivered in ECEC settings for improving dietary intake in children aged six months to six years, relative to usual care, no intervention or an alternative, non-dietary intervention. Secondary objectives were to assess the impact of ECEC-based healthy eating interventions on physical outcomes (e.g. child body mass index (BMI), weight, waist circumference), language and cognitive outcomes, social/emotional and quality-of-life outcomes. We also report on cost and adverse consequences of ECEC-based healthy eating interventions. SEARCH METHODS We searched eight electronic databases including CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, ERIC, Scopus and SportDiscus on 24 February 2022. We searched reference lists of included studies, reference lists of relevant systematic reviews, the World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov and Google Scholar, and contacted authors of relevant papers. SELECTION CRITERIA We included randomised controlled trials (RCTs), including cluster-RCTs, stepped-wedge RCTs, factorial RCTs, multiple baseline RCTs and randomised cross-over trials, of healthy eating interventions targeting children aged six months to six years that were conducted within the ECEC setting. ECEC settings included preschools, nurseries, kindergartens, long day care and family day care. To be included, studies had to include at least one intervention component targeting child diet within the ECEC setting and measure child dietary or physical outcomes, or both. DATA COLLECTION AND ANALYSIS Pairs of review authors independently screened titles and abstracts and extracted study data. We assessed risk of bias for all studies against 12 criteria within RoB 1, which allows for consideration of how selection, performance, attrition, publication and reporting biases impact outcomes. We resolved discrepancies via consensus or by consulting a third review author. Where we identified studies with suitable data and homogeneity, we performed meta-analyses using a random-effects model; otherwise, we described findings using vote-counting approaches and via harvest plots. For measures with similar metrics, we calculated mean differences (MDs) for continuous outcomes and risk ratios (RRs) for dichotomous outcomes. We calculated standardised mean differences (SMDs) for primary and secondary outcomes where studies used different measures. We applied GRADE to assess certainty of evidence for dietary, cost and adverse outcomes. MAIN RESULTS We included 52 studies that investigated 58 interventions (described across 96 articles). All studies were cluster-RCTs. Twenty-nine studies were large (≥ 400 participants) and 23 were small (< 400 participants). Of the 58 interventions, 43 targeted curriculum, 56 targeted ethos and environment, and 50 targeted partnerships. Thirty-eight interventions incorporated all three components. For the primary outcomes (dietary outcomes), we assessed 19 studies as overall high risk of bias, with performance and detection bias being most commonly judged as high risk of bias. ECEC-based healthy eating interventions versus usual practice or no intervention may have a positive effect on child diet quality (SMD 0.34, 95% confidence interval (CI) 0.04 to 0.65; P = 0.03, I2 = 91%; 6 studies, 1973 children) but the evidence is very uncertain. There is moderate-certainty evidence that ECEC-based healthy eating interventions likely increase children's consumption of fruit (SMD 0.11, 95% CI 0.04 to 0.18; P < 0.01, I2 = 0%; 11 studies, 2901 children). The evidence is very uncertain about the effect of ECEC-based healthy eating interventions on children's consumption of vegetables (SMD 0.12, 95% CI -0.01 to 0.25; P =0.08, I2 = 70%; 13 studies, 3335 children). There is moderate-certainty evidence that ECEC-based healthy eating interventions likely result in little to no difference in children's consumption of non-core (i.e. less healthy/discretionary) foods (SMD -0.05, 95% CI -0.17 to 0.08; P = 0.48, I2 = 16%; 7 studies, 1369 children) or consumption of sugar-sweetened beverages (SMD -0.10, 95% CI -0.34 to 0.14; P = 0.41, I2 = 45%; 3 studies, 522 children). Thirty-six studies measured BMI, BMI z-score, weight, overweight and obesity, or waist circumference, or a combination of some or all of these. ECEC-based healthy eating interventions may result in little to no difference in child BMI (MD -0.08, 95% CI -0.23 to 0.07; P = 0.30, I2 = 65%; 15 studies, 3932 children) or in child BMI z-score (MD -0.03, 95% CI -0.09 to 0.03; P = 0.36, I2 = 0%; 17 studies; 4766 children). ECEC-based healthy eating interventions may decrease child weight (MD -0.23, 95% CI -0.49 to 0.03; P = 0.09, I2 = 0%; 9 studies, 2071 children) and risk of overweight and obesity (RR 0.81, 95% CI 0.65 to 1.01; P = 0.07, I2 = 0%; 5 studies, 1070 children). ECEC-based healthy eating interventions may be cost-effective but the evidence is very uncertain (6 studies). ECEC-based healthy eating interventions may have little to no effect on adverse consequences but the evidence is very uncertain (3 studies). Few studies measured language and cognitive skills (n = 2), social/emotional outcomes (n = 2) and quality of life (n = 3). AUTHORS' CONCLUSIONS ECEC-based healthy eating interventions may improve child diet quality slightly, but the evidence is very uncertain, and likely increase child fruit consumption slightly. There is uncertainty about the effect of ECEC-based healthy eating interventions on vegetable consumption. ECEC-based healthy eating interventions may result in little to no difference in child consumption of non-core foods and sugar-sweetened beverages. Healthy eating interventions could have favourable effects on child weight and risk of overweight and obesity, although there was little to no difference in BMI and BMI z-scores. Future studies exploring the impact of specific intervention components, and describing cost-effectiveness and adverse outcomes are needed to better understand how to maximise the impact of ECEC-based healthy eating interventions.
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Affiliation(s)
- Sze Lin Yoong
- Global Centre for Preventive Health and Nutrition, Institute for Health Transformation, School of Health and Social Development, Faculty of Health, Deakin University, Victoria, Australia
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Melanie Lum
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Luke Wolfenden
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Jacklyn Jackson
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Courtney Barnes
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Alix E Hall
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Sam McCrabb
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Nicole Pearson
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Cassandra Lane
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Jannah Z Jones
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Erin Nolan
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Lauren Dinour
- College of Education and Human Services, Montclair State University, Montclair, New Jersey, USA
| | - Therese McDonnell
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland
| | - Debbie Booth
- Auchmuty Library, University of Newcastle, Callaghan, Australia
| | - Alice Grady
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
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Yoong SL, Lum M, Wolfenden L, Jackson J, Barnes C, Hall AE, McCrabb S, Pearson N, Lane C, Jones JZ, Dinour L, McDonnell T, Booth D, Grady A. Healthy eating interventions delivered in early childhood education and care settings for improving the diet of children aged six months to six years. Cochrane Database Syst Rev 2023; 6:CD013862. [PMID: 37306513 PMCID: PMC10259732 DOI: 10.1002/14651858.cd013862.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND Dietary intake during early childhood can have implications on child health and developmental trajectories. Early childhood education and care (ECEC) services are recommended settings to deliver healthy eating interventions as they provide access to many children during this important period. Healthy eating interventions delivered in ECEC settings can include strategies targeting the curriculum (e.g. nutrition education), ethos and environment (e.g. menu modification) and partnerships (e.g. workshops for families). Despite guidelines supporting the delivery of healthy eating interventions in this setting, little is known about their impact on child health. OBJECTIVES To assess the effectiveness of healthy eating interventions delivered in ECEC settings for improving dietary intake in children aged six months to six years, relative to usual care, no intervention or an alternative, non-dietary intervention. Secondary objectives were to assess the impact of ECEC-based healthy eating interventions on physical outcomes (e.g. child body mass index (BMI), weight, waist circumference), language and cognitive outcomes, social/emotional and quality-of-life outcomes. We also report on cost and adverse consequences of ECEC-based healthy eating interventions. SEARCH METHODS We searched eight electronic databases including CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, ERIC, Scopus and SportDiscus on 24 February 2022. We searched reference lists of included studies, reference lists of relevant systematic reviews, the World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov and Google Scholar, and contacted authors of relevant papers. SELECTION CRITERIA We included randomised controlled trials (RCTs), including cluster-RCTs, stepped-wedge RCTs, factorial RCTs, multiple baseline RCTs and randomised cross-over trials, of healthy eating interventions targeting children aged six months to six years that were conducted within the ECEC setting. ECEC settings included preschools, nurseries, kindergartens, long day care and family day care. To be included, studies had to include at least one intervention component targeting child diet within the ECEC setting and measure child dietary or physical outcomes, or both. DATA COLLECTION AND ANALYSIS Pairs of review authors independently screened titles and abstracts and extracted study data. We assessed risk of bias for all studies against 12 criteria within RoB 1, which allows for consideration of how selection, performance, attrition, publication and reporting biases impact outcomes. We resolved discrepancies via consensus or by consulting a third review author. Where we identified studies with suitable data and homogeneity, we performed meta-analyses using a random-effects model; otherwise, we described findings using vote-counting approaches and via harvest plots. For measures with similar metrics, we calculated mean differences (MDs) for continuous outcomes and risk ratios (RRs) for dichotomous outcomes. We calculated standardised mean differences (SMDs) for primary and secondary outcomes where studies used different measures. We applied GRADE to assess certainty of evidence for dietary, cost and adverse outcomes. MAIN RESULTS: We included 52 studies that investigated 58 interventions (described across 96 articles). All studies were cluster-RCTs. Twenty-nine studies were large (≥ 400 participants) and 23 were small (< 400 participants). Of the 58 interventions, 43 targeted curriculum, 56 targeted ethos and environment, and 50 targeted partnerships. Thirty-eight interventions incorporated all three components. For the primary outcomes (dietary outcomes), we assessed 19 studies as overall high risk of bias, with performance and detection bias being most commonly judged as high risk of bias. ECEC-based healthy eating interventions versus usual practice or no intervention may have a positive effect on child diet quality (SMD 0.34, 95% confidence interval (CI) 0.04 to 0.65; P = 0.03, I2 = 91%; 6 studies, 1973 children) but the evidence is very uncertain. There is moderate-certainty evidence that ECEC-based healthy eating interventions likely increase children's consumption of fruit (SMD 0.11, 95% CI 0.04 to 0.18; P < 0.01, I2 = 0%; 11 studies, 2901 children). The evidence is very uncertain about the effect of ECEC-based healthy eating interventions on children's consumption of vegetables (SMD 0.12, 95% CI -0.01 to 0.25; P =0.08, I2 = 70%; 13 studies, 3335 children). There is moderate-certainty evidence that ECEC-based healthy eating interventions likely result in little to no difference in children's consumption of non-core (i.e. less healthy/discretionary) foods (SMD -0.05, 95% CI -0.17 to 0.08; P = 0.48, I2 = 16%; 7 studies, 1369 children) or consumption of sugar-sweetened beverages (SMD -0.10, 95% CI -0.34 to 0.14; P = 0.41, I2 = 45%; 3 studies, 522 children). Thirty-six studies measured BMI, BMI z-score, weight, overweight and obesity, or waist circumference, or a combination of some or all of these. ECEC-based healthy eating interventions may result in little to no difference in child BMI (MD -0.08, 95% CI -0.23 to 0.07; P = 0.30, I2 = 65%; 15 studies, 3932 children) or in child BMI z-score (MD -0.03, 95% CI -0.09 to 0.03; P = 0.36, I2 = 0%; 17 studies; 4766 children). ECEC-based healthy eating interventions may decrease child weight (MD -0.23, 95% CI -0.49 to 0.03; P = 0.09, I2 = 0%; 9 studies, 2071 children) and risk of overweight and obesity (RR 0.81, 95% CI 0.65 to 1.01; P = 0.07, I2 = 0%; 5 studies, 1070 children). ECEC-based healthy eating interventions may be cost-effective but the evidence is very uncertain (6 studies). ECEC-based healthy eating interventions may have little to no effect on adverse consequences but the evidence is very uncertain (3 studies). Few studies measured language and cognitive skills (n = 2), social/emotional outcomes (n = 2) and quality of life (n = 3). AUTHORS' CONCLUSIONS ECEC-based healthy eating interventions may improve child diet quality slightly, but the evidence is very uncertain, and likely increase child fruit consumption slightly. There is uncertainty about the effect of ECEC-based healthy eating interventions on vegetable consumption. ECEC-based healthy eating interventions may result in little to no difference in child consumption of non-core foods and sugar-sweetened beverages. Healthy eating interventions could have favourable effects on child weight and risk of overweight and obesity, although there was little to no difference in BMI and BMI z-scores. Future studies exploring the impact of specific intervention components, and describing cost-effectiveness and adverse outcomes are needed to better understand how to maximise the impact of ECEC-based healthy eating interventions.
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Affiliation(s)
- Sze Lin Yoong
- Global Centre for Preventive Health and Nutrition, Institute for Health Transformation, School of Health and Social Development, Faculty of Health, Deakin University, Victoria, Australia
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Melanie Lum
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Luke Wolfenden
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Jacklyn Jackson
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Courtney Barnes
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Alix E Hall
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Sam McCrabb
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Nicole Pearson
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Cassandra Lane
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Jannah Z Jones
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Lauren Dinour
- College of Education and Human Services, Montclair State University, Montclair, New Jersey, USA
| | - Therese McDonnell
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland
| | - Debbie Booth
- Auchmuty Library, University of Newcastle, Callaghan, Australia
| | - Alice Grady
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
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Kristiansen AL, Himberg-Sundet A, Bjelland M, Lien N, Holst R, Andersen LF. Exploring intervention components in association with changes in preschool children's vegetable intake: the BRA-study. BMC Res Notes 2021; 14:214. [PMID: 34059115 PMCID: PMC8165990 DOI: 10.1186/s13104-021-05629-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 05/22/2021] [Indexed: 11/10/2022] Open
Abstract
Objective The present study aimed to explore kindergarten staffs’ perceived usefulness of intervention components in association with changes in children’s vegetable intake and vegetables served in the kindergarten. Assessment of the perceived usefulness of intervention components consisted of a paper-based questionnaire for the kindergarten staff assessing usefulness of posters, supplementary material and 1-day inspirational course. Children’s vegetable intake in the kindergarten was assessed by direct observation, while vegetables served was assessed by a 5-day weighted vegetable diary. Results Seventy-three kindergartens in two counties in Norway participated (response rate 15%) and parental consent was obtained for 633 children 3–5 years of age at baseline (response rate 39%). Mixed effect models indicated a tendency that posters were associated with increased child vegetable intake (P = 0.062). Surprisingly, a low degree of perceived usefulness of supplementary material was associated with the largest increase in child vegetable intake (P = 0.020). No significant associations between perceived usefulness of intervention components and vegetables served in the kindergarten were found. This study indicated a tendency that posters were associated with increased child vegetable intake; however, this may also be due to synergies between multiple intervention components. Trial registration International Standard Randomized Controlled Trials ISRCTN51962956 (http://www.isrctn.com/ISRCTN51962956). Registered 21 June 2016 (retrospectively registered). Supplementary Information The online version contains supplementary material available at 10.1186/s13104-021-05629-1.
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Affiliation(s)
- Anne Lene Kristiansen
- Faculty of Humanities, Sports and Educational Science, Department of Sports, Physical Education and Outdoor Studies, University of South-Eastern Norway, PO Box 235, 3603, Kongsberg, Norway. .,Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Blindern, PO Box 1046, 0317, Oslo, Norway.
| | - Anne Himberg-Sundet
- Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Blindern, PO Box 1046, 0317, Oslo, Norway
| | - Mona Bjelland
- Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Blindern, PO Box 1046, 0317, Oslo, Norway
| | - Nanna Lien
- Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Blindern, PO Box 1046, 0317, Oslo, Norway
| | - René Holst
- Department of Biostatistics, Institute of Basic Medical Sciences, University of Oslo, Blindern, PO Box 1122, 0317, Oslo, Norway
| | - Lene Frost Andersen
- Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Blindern, PO Box 1046, 0317, Oslo, Norway
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