The importance of school lunches to the overall dietary intake of children in Sweden: a nationally representative study

Effects of Universal School-Based Parental Support for Children's Healthy Diet and Physical Activity-the Healthy School Start Plus Cluster-Randomised Controlled Trial

Health promotion from an early age is key to preventing unhealthy weight development in childhood, and parental involvement is essential. The school-based Healthy School Start intervention aims to promote healthy dietary and activity habits in the home environment and prevent child obesity through parental support. This study evaluated the effectiveness of the third iteration of the programme on children's dietary and activity behaviours, and body composition through a cluster-randomised controlled trial. The trial included 17 schools (8 intervention) in disadvantaged areas in mid-Sweden with 353 families with 5- to 7-year-old children. The primary outcomes were intake of selected healthy and unhealthy foods and beverages measured using photography. Secondary outcomes were physical activity and sedentary time measured by accelerometry, and measured weight and height. All outcomes were assessed at baseline and post-intervention (8 months). Linear multi-level regression showed significant favourable effects of the intervention for intake of sweet beverages (b =  - 0.17, p = 0.04), intake of healthy foods (b = 0.11, p = 0.04), and more time in moderate to vigorous physical activity during weekdays (b = 5.68, p = 0.02). An unfavourable sub-group effect of the intervention was found for children from families with low education regarding sedentary time on weekends (b = 23.04, p = 0.05). The results align with the previous two trials of the programme, indicating that school-based parental support is a useful approach for health promotion in young children in disadvantaged areas. Trial registration: ClinicalTrials.gov: No. NCT03390725, retrospectively registered on January 4, 2018, https://clinicaltrials.gov/ct2/show/NCT03390725 .

Design, Methods, and Participation in Riksmaten Young Children-A Swedish National Dietary Survey

Background

National dietary surveys provide essential data for risk benefit assessments of foods and nutrients, for management and policy development. Physical activity measurement and biomonitoring can provide important complementary data but are less commonly included.

Objectives

This study aimed to describe the study design and methods of the cross-sectional Swedish national dietary survey Riksmaten Young Children (Riksmaten småbarn), of children aged 9 mo, 18 mo, and 4 y. Participation/dropout rates for the 2 older age groups are also presented. The impact of different recruitment strategies is discussed.

Methods

Children (N = 16,655) were randomly selected from the population register; invitations to guardians were sent by post and where possible, followed up by telephone. Food intake was assessed by a 2-d food diary and/or questionnaire. Height and weight were reported after measurement. Physical activity (accelerometery, 7 d) and stool, blood, and urine samples were assessed in subgroups.

Results

Food consumption data were collected in 1828 children (11% of the invited; 18 mo: n = 1078, and 4 y: n = 750). Of participants also in subgroups, 71% provided physical activity data (n = 1307), 60% stool samples (n = 630), and 51% blood and/or urine samples (n = 593). The study population represented all geographic regions and types of municipalities in Sweden, but participating households had both higher education level and higher income than the target population. Only minor differences were seen in participation rates between recruitment via post and telephone compared with those through post only (12% compared with 10%). Repeated contact attempts were needed for the majority of participants (65%). Despite the low-participation rate, 99% of the participants completed the study once started.

Conclusions

Although it was a challenge to recruit participants, Riksmaten Young Children provides a substantial amount of information at national level, representative in terms of sex, geography, and family structure. The underrepresentation of households with lower socioeconomic position must be considered when generalizing results.

Unpacking the cost of the lunchbox for Australian families: a secondary analysis

Ninety per cent of Australian school children bring a home-packed lunch to school, with 44% of the food consumed during school hours being unhealthy. Among other factors, cost is a key consideration for food provision; however, the costs to Australian families are not well understood. Therefore, we aimed to determine what families are currently paying for school lunchboxes in Australian primary schools and to examine associations between food costs and socio-demographic factors with dietary quality. An audit of local retail outlets was used to determine the food costs of lunchbox contents. Costs (AUD) were adjusted for inflation as of early 2023. The lunchboxes of 1026 children aged 4-12 years at 12 Catholic primary schools in New South Wales, Australia, were assessed at the start of the day, using photography assessment methods and a validated School Food Checklist. The mean cost of lunchbox contents was $4.48 AUD (SD 1.53), containing a mean energy of 2699 kJ (SD 859), with 37.3% (SD 23.9) of energy sourced from unhealthy foods. Multiple linear regression analyses found that the strongest predictors of higher lunchbox cost (P < 0.05) were a higher proportion of energy from unhealthy foods (B = 0.016) and lower Socio-Economic Indexes for Areas (B = -0.178), when controlling for child socio-demographics. The results indicated that lunchbox food costs to Australian families are comparable to alternative school food service models in Australia and internationally. Results demonstrate the cost of food is not the only barrier to providing a healthy school lunchbox. Demonstrating a need for cost-considerate systematic interventions addressing food provision challenges and socio-economic disparities faced by families.

Implementation and effectiveness of a school-based intervention to increase adherence to national school meal guidelines: a non-randomised controlled trial

OBJECTIVE

Implementation of school meal guidelines is often inadequate, and evidence for effective implementation strategies for school-based nutrition interventions is limited. The aim of the present study was to examine the implementation and effectiveness of a multi-strategy implementation intervention to increase adherence to the Norwegian national school meal guideline.

DESIGN

The study was a school-based hybrid implementation effectiveness trial with a pre-post non-equivalent control group design, testing three implementation strategies: internal facilitation, training and an educational meeting.

SETTING

Primary schools and after-school services in two counties in south-east Norway.

PARTICIPANTS

School principals, after-school leaders and class teachers from thirty-three schools in the intervention county and principals and after-school leaders from thirty-four schools in a comparison county.

RESULTS

There was a significant difference of 4 percentage points in change scores between the intervention and the comparison groups at follow-up, after adjusting for baseline adherence (B = 0·04, seB = 0·01, t = 3·10, P = 0·003). The intervention effect was not associated with the school's socio-economic profile. School-level fidelity was the implementation dimension that was most strongly correlated (r s = 0·48) with the change scores in the intervention group, indicating that principals' support is important for gaining the largest intervention effects.

CONCLUSIONS

A school-based intervention with low intensity, based on trained teachers as internal facilitators, can increase adherence to the national school meal guideline among Norwegian primary schools, irrespective of local socio-economic conditions. Implementation fidelity, at an organisational level, may be a useful predictor for intervention outcomes in schools.

Sixteen-year trends in fruit consumption and related socioeconomic inequalities among adolescents in Western European countries

PURPOSE

To investigate time trends in daily fruit consumption among Western European adolescents and in related socioeconomic inequalities.

METHODS

We used nationally representative data from 18 countries participating in five rounds (2002 to 2018) of the cross-sectional "Health Behaviour in School-aged Children" (HBSC) survey (n = 458,973). The questionnaire, standardised across countries and rounds, was self-administered at school by 11-, 13- and 15-year-old adolescents. Daily fruit consumption was assessed using a short food frequency questionnaire (sFFQ). Socioeconomic inequalities were measured using the Family Affluence Scale (FAS). Multilevel logistic regressions were applied to study linear time trends in daily fruit consumption, overall, by country and by FAS.

RESULTS

Between 2002 and 2018, daily fruit consumption increased in 10 countries (OR range, 1.04 to 1.13, p < 0.05) and decreased in 3 (OR range 0.96 to 0.98, p < 0.05). In all survey years combined, prevalence of daily fruit consumption was significantly higher among high FAS groups (42.6%) compared to medium (36.1%) and low FAS groups (31.7%; all countries: p < 0.001). Between 2002 and 2018, socioeconomic inequalities in fruit consumption increased in Austria, Germany, Italy, Netherlands, Scotland, Sweden, and Switzerland. Only in Norway FAS inequalities decreased while the prevalence increased.

CONCLUSION

The prevalence of daily fruit consumption generally increased among adolescents between 2002 and 2018 in Western European countries, yet socioeconomic inequalities increased in some countries. Public health interventions should continue to promote fruit consumption with special attention to lower socioeconomic groups.

High availability of vegetables and fruit through government-funded school lunch is not reflected in 4th grade pupils' intake

Background

An increased intake of vegetable and fruit (VF) through school meals can contribute to the prevention of non-communicable diseases.

Objective

The purpose of this study was to investigate what types of VF 4th grade pupils (10-11 years old) choose, how much they eat when they are given the opportunity to serve themselves from the daily vegetable buffet available at lunch, and whether this varies with socioeconomic background and gender.

Design

A cross-sectional study design was used where pupils' VF intake was measured during 5 days with a photographic method. In total, 196 pupils from nine public schools participated.

Results

The results show that pupils on average ate less than one type of VF per day from the vegetable buffet. Girls, pupils with a higher socio-economic status (SES) and those with a more frequent VF intake at home, ate more types of VF per day from the vegetable buffet than their counterparts. The median intake of VF from the vegetable buffet was generally low, 20.4 g/day. The intake was two thirds higher for pupils with higher SES in comparison with pupils with lower SES; 25 g/day versus14 g/day (P = 0.001). No gender differences in grams per day of VF were identified (P = 0.123).

Discussion

This study indicates that a well-stocked vegetable buffet as part of government-funded school lunch does not automatically contribute substantially to the recommended daily intake of VF among a sample of 4th grade pupils in a high-income country like Sweden.

Conclusions

The results of the study can be interpreted as a missed opportunity to increase the intentional consumption of VF among pupils in a way that would have implications for public health as well as attenuating differences between socioeconomic groups.

Evaluation of food intake through residual analysis in 90 Basque school canteens

OBJECTIVE

To measure the consumption of 25 food items (Comstock scale), to test whether school management type (public schools vs. private with subsidy schools) and food origin (on-site preparation vs. catering) affected food consumption and to quantify variability associated with territory, school and individual.

METHOD

This cross-sectional study involved 14,717 schoolchildren of ages 2-16, recruited in 90 schools of the Basque Autonomous Community (Spain). Waste (non-consumed food) of 25 analysed food items was visually estimated by trained school monitors, via the Comstock categorical scale thus adapted: 1=0%; 2=25%; 3=50%, 4=75% and 5=100%. To analyse the data, mixed modelling was applied.

RESULTS

Vegetables, fish and fruits were the less-accepted food types. While school management did not affect food intake, on-site food preparation had better acceptance for legumes with vegetables, oily and lean fish, meat and pre-cooked meals. The largest source of variability in food intake not accounted for by school management and food preparation was the individual subject, while school and territory had moderate and almost no effects, respectively.

CONCLUSIONS

Acceptance of the 25 evaluated foods is adequate, albeit can be improved. We believe that promoting on-site food preparation should improve the acceptance of legumes with vegetables, oily/lean fish, meat and pre-cooked meals. We recommend that future interventions oriented to improve intake should focus on individual subjects.

Content of lunchboxes of Dutch primary school children and their perceptions of alternative healthy school lunch concepts

OBJECTIVE

To investigate the content of lunchboxes of primary school children and to examine children's support and preferences for alternative healthy school lunch concepts.

DESIGN

A cross-sectional study among Dutch children from seven primary schools. The content of the lunchboxes was assessed by photographs. Support and preferences for alternative lunch concepts were examined via a self-reported questionnaire. Linear regression analyses were used to investigate the associations between children's support and preferences and sex, educational group and migration background.

SETTING

The Netherlands.

PARTICIPANTS

Primary school children.

RESULTS

A total of 660 children were included (average 9·9 years old). Most lunchboxes contained sandwiches and a drink. Few lunchboxes contained fruit or vegetables. The alternative school lunch concepts elicited mixed support among children. The lunch concepts 'Sandwiches prepared by the children themselves' and a 'hot lunch buffet' had the highest mean support, while the concept 'a healthy lunch brought from home' was the most preferred concept. Small significant differences were observed depending on sex, educational group and migration background.

CONCLUSION

Lunchboxes of Dutch children contained sandwiches and a drink but rarely fruit and vegetables. Among different alternatives, children reported the highest support for the preparation of their own sandwiches in class or a hot lunch buffet. Future studies should investigate if these alternative lunch concepts improve the dietary intake of children.

Which factors promote and prohibit successful implementation and normalization of a healthy school lunch program at primary schools in the Netherlands?

BACKGROUND

A school provided healthy lunch might help to improve the nutritional quality of children's lunches. However, in the Netherlands, school lunch programs are not common. The aim of this study was to identify factors that promote or inhibit the implementation of a school lunch program at primary schools, from the viewpoint of school professionals.

METHODS

A cross-sectional online survey was conducted among 204 primary school professionals. The normalization process theory and its four constructs (i.e. coherence, cognitive participation, collective action, reflective monitoring) were used to develop questions and interpret findings. Descriptive statistics were used for 14 multiple choice questions (yes, no, don't know) and thematic content analysis for qualitative responses.

RESULTS

Participants had a shared understanding about how a lunch program differed from current practices. Most participants had the same view on the rationale for implementation (coherence), such as equality among children. Sixty percent expected that a healthy school lunch will contribute to healthier eating by the children. Participants showed different degrees of cognitive participation (46% indicated that healthy school lunch is good idea). Commitment depended on their belief whether providing a healthy lunch was part of their responsibility as school and 30% expected a large effect on their daily work (collective action). When appraising school lunch implementation (reflective monitoring), participants' concerns focused on feasibility and adaptability of a program in their own school.

CONCLUSIONS

The introduction of a school lunch program will require substantial effort, although there is considerable support and understanding about potential benefits. The findings point to a number of preconditions for large-scale introduction, including the need for support-both financially and organizationally-bottom-up involvement of teachers, children and parents and freedom to adapt the program.

Analysis of Association between Adolescents' Food Habits and Body Mass Change in a Population-Based Sample: Diet and Activity of Youth during COVID-19 (DAY-19) Study

The COVID-19 pandemic may have contributed to food habit changes, including some negative ones that may increase the risk of overweight and obesity. The aim of the study was to analyze the association between adolescents' food habits, body mass change, as well as physical activity level in a population-based sample within the Diet and Activity of Youth during COVID-19 (DAY-19) Study. The DAY-19 Study was conducted in a cohort of 1333 students (aged 10-16 years) recruited in schools after stratified random quota sampling of primary schools (sampling counties within voivodeships and schools within counties) in June 2020. The food habits were assessed for the period of the COVID-19 pandemic and the period before the COVID-19 pandemic while using Adolescent Food Habits Checklist (AFHC). The body mass changes were assessed based on body weight and height for the period of the COVID-19 pandemic and the period before the COVID-19 pandemic while using Polish growth reference values. The physical activity changes were assessed based on the subjective assessment of adolescents. It was stated that for female adolescents declaring body mass gain during the COVID-19 pandemic the highest AFHC purchase scores (healthy purchase habits) (p < 0.0001) were accompanied by the lowest AFHC consumption score (unhealthy consumption habits) (p < 0.0001), as well as for female adolescents declaring physical activity decrease during the COVID-19 pandemic the highest AFHC purchase scores (healthy purchase habits) were observed (p = 0.0333). It was stated that for male adolescents declaring physical activity increased during the COVID-19 pandemic, the highest AFHC consumption scores (healthy consumption habits) were observed (p = 0.0003). In the case of a majority of participants, the general food habits were unchanged, which was observed mainly for food habits associated with food preparation. More food habits changes associated with the COVID-19 pandemic resulting in body mass changes were observed in females than in male adolescents. Body mass gain during the COVID-19 pandemic in adolescents may have resulted from unhealthy consumption habits, accompanied by decreased physical activity, in spite of the fact that this sub-group presented healthy purchase habits, which was observed especially for female adolescents.

Investigation of the Associations between Diet Quality and Health-Related Quality of Life in a Sample of Swedish Adolescents

Most adolescents do not consume a high-quality diet, while self-reported mental health problems within this group are increasing. This study aimed to investigate the association between diet quality and health-related quality of life, and to explore the differences in diet quality and health-related quality of life between gender and parental education status. In this cross-sectional study, a detailed web-based recall method was implemented to determine dietary intake, which was analysed using the newly developed Swedish Healthy Eating Index for Adolescents 2015 (SHEIA15) and the Riksmaten Adolescents Diet Diversity Score (RADDS), to determine diet quality. The KIDSCREEN-10 questionnaire was used to measure health-related quality of life, and parental education was self-reported through questionnaires. Parental education was divided into two groups: ≤12 years or >12 years. The study included 1139 adolescents from grade 7 (13−14 years old), 51% were girls. The results showed that girls had higher scores for healthy eating and diet diversity but lower scores for health-related quality of life. A positive association was found between diet diversity and health-related quality of life (Adj R2 = 0.072, p = 0.001), between vegetable/fruit consumption and health-related quality of life (Adj R2 = 0.071, p = 0.002), and between healthy eating and diet diversity (Adj R2 = 0.214, p < 0.001). No association was found between healthy eating and health-related quality of life for all participants. The mean scores for healthy eating and diet diversity were significantly higher in the higher education parental group. In conclusion, higher diet diversity and increased fruit and vegetable consumption could be a strategy to improve health-related quality of life among adolescents. There is a need to promote better diet quality, especially in households of low parental education. In addition, there is a further need to investigate the potential benefits of improved diet quality on mental health and overall well-being.

Health and Sustainable Nutritional Choices from Childhood: Dietary Pattern and Social Models

BACKGROUND

The role of diet in the pediatric age for optimal development, achievement, and maintenance of a healthy status is well recognized. Increasing attention is nowadays also paid to reducing the burden of human nutrition on the planet's health for present and future generations.

SUMMARY

Beyond environmental sustainability, the transition to diets rich in animal and processed foods contributes to an overall unhealthy nutritional status leading to an increased prevalence of obesity- and diet-related noncommunicable diseases. Childhood overweight and obesity are a growing public health crisis worldwide. The aim of this narrative review was to summarize evidence of the nutritional status and dietary habits in children and the link with environmental sustainability.

KEY MESSAGE

Optimizing nutrition in infancy and establishing healthy lifestyles from the preschool years might help to reduce the risk of overweight, and all the disorders related, respecting the sustainability dimension.

Demographic, life-style and physiological determinants of serum per- and polyfluoroalkyl substance (PFAS) concentrations in a national cross-sectional survey of Swedish adolescents

PER: and polyfluoroalkyl substances (PFAS) may affect adolescent health, yet factors related to PFAS concentrations in serum are poorly understood. We studied demographic, life-style and physiological determinants of serum PFAS concentrations in Swedish adolescents from a nation-wide survey, Riksmaten Adolescents 2016-17 (RMA, age 10-21 years, n = 1098). Serum samples were analyzed for 42 PFAS, using liquid chromatography-tandem mass spectrometry. The cumulative probability model was used to estimate associations between serum PFAS and determinants, using ordinal logistic regression. Legacy linear (lin-) perfluorooctanoic acid (PFOA), perfluorononaoic acid (PFNA), perfluorodecanoic acid (PFDA), perfluoroundecanoic acid (PFUnDA), lin-perfluorohexanesulfonic acid (PFHxS) and lin-/branched (br-) perfluorooctanesulfonic acid (PFOS) were quantifiable in ≥70% of the samples. The emerging PFAS 9-chlorohexanedecafluoro-3-oxanone-1-sulfonic acid (9Cl-PF3ONS) was quantified in 5.4% of the samples, suggesting initiation of long-range transport far from production sites. Median concentrations of all legacy PFAS were <2 ng/g serum, with a few participants having very high (>100 ng/g serum) lin-PFHxS and lin-/br-PFOS concentrations due to previous high exposure from PFAS-contaminated drinking water. Legacy PFAS exposure was strongly associated with birth country of the participants and their mothers. 2-fold higher estimated adjusted mean (EAM) concentrations were seen among high income country participants with mothers from high income countries than among low/lower-middle income country participants with mothers from the same category. Menstruating females had lower br-PFOS EAM concentrations than those who were not. Iron status (plasma ferritin) among females may be a marker of intensity of menstrual bleeding, but it was not significantly associated with legacy PFAS concentrations among females. Further studies are needed to determine how physiological changes occurring around menstruation affect the toxicokinetics of PFAS in females. In conclusion, PFAS are pollutants of the industrialized world and some of the identified determinants may be overlooked confounders/effect modifiers that should be included in future PFAS/health studies among adolescents.

What works to improve school lunch nutritional quality - legislation or self-audit?

OBJECTIVE

Sweden updated its legislation on universal free school meals in 2011 and nutrition was explicitly mentioned. This study i) describes cross-sectional changes in school lunch nutritional quality during the following eight years, and ii) examines if repeated self-auditing, using a fully automated, online tool (School Food Sweden), based on the implementation strategy of audit and feedback, was associated with improvements.

DESIGN

Both repeated cross-sectional and longitudinal design. Factors associated with meeting nutritional criteria were examined using variance weighted least squares regression and logistic regression.

SETTING

Sweden.

PARTICIPANTS

Primary schools who self-selected to audit meal quality between March 2012 and July 2019.

RESULTS

Almost half of all (ca 4800) primary schools signed up to use the tool, and 1500 audited nutritional quality at least once. Repeated cross-sectional analyses showed the proportion meeting the nutritional criteria increased significantly between 2012/13 (11%) and 2018/19 (34%). Longitudinally, each additional audit completed increased the odds of meeting the nutritional criteria by 1.30 (CI 1.20-1.41), controlling for region and time elapsed since the legislative change. In 774 schools with repeat audits, both number of audits and frequency of accessing feedback predicted meeting the nutritional criteria (OR 2.02, CI 1.23-3.31), even after adjusting for time since the legislative change and days elapsed since previous audit.

CONCLUSIONS

Both legislation and self-audit with automatic feedback appear effective in helping schools to improve school meal quality. Self-audit with feedback may be an effective complement to legislation, or a promising alternative in settings where regulation is not an option.

The food and nutrient intake of 5- to 12-year-old Australian children during school hours: a secondary analysis of the 2011-2012 National Nutrition and Physical Activity Survey

OBJECTIVE

School food intake of Australian children is not comprehensively described in literature, with limited temporal, nationally representative data. Greater understanding of intake at school can inform school-based nutrition promotion. This study aimed to describe the dietary intake of primary-aged children during school hours and its contribution to daily intake.

DESIGN

This secondary analysis used nationally representative, cross-sectional data from the 2011 to 2012 National Nutrition and Physical Activity Survey. Dietary intake was assessed using validated 24-h dietary recalls on school days. Descriptive statistics were undertaken to determine energy, nutrients, food groups and food products consumed during school hours, as well as their contributions to total daily intake. Associations between school food intake and socio-demographic characteristics were explored.

SETTING

Australia.

PARTICIPANTS

Seven hundred and ninety-five children aged 5-12 years.

RESULTS

Children consumed 37 % of their daily energy and 31-43 % of select nutrient intake during school hours, with discretionary choices contributing 44 % of school energy intake. Most children consumed less than one serve of vegetables, meat and alternatives or milk and alternatives during school hours. Commonly consumed products were discretionary choices (34 %, including biscuits, processed meat), bread (17 %) and fruit (12 %). There were limited associations with socio-economic position variables, apart from child age.

CONCLUSIONS

Children's diets were not aligned with national recommendations, with school food characterised by high intake of discretionary choices. These findings are consistent with previous Australian evidence and support transformation of the Australian school food system to better align school food consumption with recommendations.

IMplementation and evaluation of the school-based family support PRogram a Healthy School Start to promote child health and prevent OVErweight and obesity (IMPROVE) - study protocol for a cluster-randomized trial

Background

IMPROVE aims to conduct a hybrid type 3 evaluation design to test the effectiveness of bundled implementation strategies on intervention fidelity of the Healthy School Start (HSS) program, while simultaneously monitoring effects on health outcomes of children and parents. The HSS is a 4-component family support program for children starting school (5–7 years of age) promoting healthy dietary habits and physical activity in the home environment to prevent childhood obesity and parents’ risk of developing type 2 diabetes.

Methods

IMPROVE is a cluster-randomized controlled trial with two arms to evaluate and compare the effects of two different bundles of implementation strategies on intervention fidelity expressed as adherence and responsiveness at 12 and 24 months (primary outcomes). Thirty schools in two municipalities will participate in the study reaching about 1400 families per school year. In stakeholder workshops, key implementation determinants were identified according to the domains of the Consolidated Framework for Implementation Research. Through a consensus process with stakeholders, two bundles of implementation strategies were tailored to address context-specific determinants. Schools randomly assigned to group 1 will receive bundle 1 (Basic) and group 2 will receive bundle 1 + 2 (Enhanced). Bundle 2 consists of external facilitation, fidelity monitoring and feedback strategies. Secondary outcomes will include change in acceptability, appropriateness, feasibility, and organisational readiness as perceived by school staff. In addition, child weight status and diet, and parents’ feeding practices and risk of type 2 diabetes will be monitored. Linear and ordinal regression analysis will be used to test the effect on the primary and secondary outcomes, taking clustering and covariates into consideration where needed. Process evaluation will be conducted through key stakeholder interviews to investigate experiences of the program and perceptions on sustainability.

Discussion

This systematic approach to investigating the effectiveness of two different bundles of implementation strategies tailored to context-specific determinants on the fidelity of the HSS intervention will provide new insight into feasible implementation strategies and external support needed for the HSS to be effective and sustainable. Results will help inform how to bridge the gap between the research on school-based health programs and routine practice in schools.

Trial registration

Registered prospectively at ClinicalTrials.gov ID: NCT04984421, registered July 30, 2021

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11663-2.

The Contribution of Foods and Beverages of Low Nutritional Value to the Diets of Swedish Adolescents, by Food Group, Time and Place. A Nationally Representative Study

Adolescence is a time in life when lifestyle behaviours are acquired. One indicator of poor diet quality is the intake of foods and beverages with a relatively low nutritional value. Using the Australian classification of such foods, termed "discretionary", we classified the intakes of Swedish adolescents who participated in the Riksmaten Adolescent 2016-17 national dietary survey. From selected schools, 3099 adolescents in age groups 11-12, 14-15 and 17-18 years provided two 24-h recalls. Intakes and healthy dietary scores were calculated. Plasma ferritin, folate and 25(OH)D were available for a third. Almost 40% of total energy came from discretionary foods/beverages. Adolescents with higher intakes were more likely to be female, older, from a low socioeconomic position-household and born in Sweden. Most discretionary foods/beverages were consumed on weekend days and during in-between meals, outside of the home and at school. Percent energy from discretionary intake was associated with healthy dietary scores but not nutritional status. A substantial amount of energy was obtained from discretionary foods/beverages, and we found that consumption is pervasive across sociodemographic factors, time and place. Addressing this pattern will require a comprehensive approach to food environments and behaviours to reach all adolescents in an equitable manner.

Free school meals as an opportunity to target social equality, healthy eating, and school functioning: experiences from students and teachers in Norway

Background

There are no national arrangements for free school meals provision in Norway despite this being an important opportunity to improve children’s and adolescents’ nutritional status and ultimately their physical and cognitive development. During a one academic year (2014–2015), a group of Norwegian sixth graders were served a free healthy school meal in a project called ‘The School Meal Project’.

Objective

To explore students’ and teachers’ experiences of receiving free school meals after the free school meal in 2015 and 5 years later.

Design

In-depth, semi-structured interviews with separate groups in 2015 and in 2020 were conducted face to face or via telephone or digital platforms. The findings are based on 13 students (aged 12–16) and 5 teacher interviews.

Findings

Thematic analysis identified four main themes that describe the perceived benefits of receiving free school meals: 1) the meal as a social event where students made new friends and learned new skills; 2) as an aid to forming healthy eating habits; and as an opportunity to 3) improve school functioning and 4) increase social equality among students.

Discussion

Our analysis suggests that the free school meal may influence healthy behaviors not only at the individual level but also at the social-, physical-, and macro-levels. Methodological limitations, including self-selection bias, should be considered when interpreting our findings.

Conclusion

This study provides unique insights into the social benefits for students of receiving free school meals. Our findings illustrate the potential of free school meals: eating healthy foods, sharing a meal together, and interaction between students and teachers at mealtime, to promote health, learning, and equality. In order to maximize these benefits through national implementation of free school meals, more understanding is needed of possible facilitators and barriers related to the provision and uptake of free school meals.

Barriers and facilitators to successful implementation of sustainable school meals: a qualitative study of the OPTIMAT™-intervention

Background

There is an urgent need to align human diets with goals for environmental sustainability and population health. The OPTIMAT™-intervention study was developed to implement and evaluate a nutritionally adequate and climate-friendly 4-week lunch menu in Swedish primary schools. This study aimed to explore pupils’ and kitchen staff’s experiences of the intervention and to identify barriers and facilitators to successful implementation of sustainable school meals.

Methods

An inductive manifest qualitative method was used. Nine focus group discussions (FGDs) were conducted, six with pupils in grades 5 (ages 10–11) and 8 (ages 14–15) (n = 29) and three with kitchen staff (n = 13). Data were analyzed using qualitative content analysis.

Results

Five main categories and 11 subcategories at a manifest level emerged. The five main categories were: 1) Experiences with the new menu, unfolding variations in how the new menu was received and kitchen staff’s experiences of working with it; 2) The meaning of diet sustainability, comprising pupils’ and kitchen staff’s perceptions about diet sustainability as a concept and part of their everyday lives; 3) Factors influencing plant-based food acceptance, covering aspects such as the influence of sensory factors, habits and peer pressure; 4) Opportunities to increase plant-based eating, including factors related to pupils’ and kitchen staff’s ideas for how to increase plant-based food acceptance; and 5) Need for a supportive environment to achieve dietary change, comprising pupils’ and kitchen staff’s thoughts on the importance of more knowledge, resources and involvement of stakeholders to eat more plant-based meals in schools.

Conclusions

Successful implementation of sustainable school meals would require more knowledge among pupils and kitchen staff. Staff also need more training in cooking of sustainable meals. Barriers among pupils could be tackled by introducing new plant-based meals more gradually and by more carefully considering the seasoning, naming and aesthetics of dishes. An increased leadership support for change and involvement of stakeholders from multiple levels within society will be key in the transition to sustainable school meals at scale.

Trial registration

The trial registration for the OPTIMAT™-intervention may be found at clinicaltrials.gov (NCT04168632 Fostering Healthy and Sustainable Diets Through School Meals (OPTIMAT)).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-021-01158-z.

Fast Eating Is Associated with Increased BMI among High-School Students

Fast self-reported eating rate (SRER) has been associated with increased adiposity in children and adults. No studies have been conducted among high-school students, and SRER has not been validated vs. objective eating rate (OBER) in such populations. The objectives were to investigate (among high-school student populations) the association between OBER and BMI z-scores (BMIz), the validity of SRER vs. OBER, and potential differences in BMIz between SRER categories. Three studies were conducted. Study 1 included 116 Swedish students (mean ± SD age: 16.5 ± 0.8, 59% females) who were eating school lunch. Food intake and meal duration were objectively recorded, and OBER was calculated. Additionally, students provided SRER. Study 2 included students (n = 50, mean ± SD age: 16.7 ± 0.6, 58% females) from Study 1 who ate another objectively recorded school lunch. Study 3 included 1832 high-school students (mean ± SD age: 15.8 ± 0.9, 51% females) from Sweden (n = 748) and Greece (n = 1084) who provided SRER. In Study 1, students with BMIz ≥ 0 had faster OBER vs. students with BMIz < 0 (mean difference: +7.7 g/min or +27%, p = 0.012), while students with fast SRER had higher OBER vs. students with slow SRER (mean difference: +13.7 g/min or +56%, p = 0.001). However, there was “minimal” agreement between SRER and OBER categories (κ = 0.31, p < 0.001). In Study 2, OBER during lunch 1 had a “large” correlation with OBER during lunch 2 (r = 0.75, p < 0.001). In Study 3, fast SRER students had higher BMIz vs. slow SRER students (mean difference: 0.37, p < 0.001). Similar observations were found among both Swedish and Greek students. For the first time in high-school students, we confirm the association between fast eating and increased adiposity. Our validation analysis suggests that SRER could be used as a proxy for OBER in studies with large sample sizes on a group level. With smaller samples, OBER should be used instead. To assess eating rate on an individual level, OBER can be used while SRER should be avoided.

Stakeholder Generated Ideas for Alternative School Food Provision Models in Australia Using the Nominal Group Technique

Good nutrition is important for children's learning, growth, and development, yet food intake during school hours does not align with recommendations. In Australia, most school children currently bring a packed lunch from home, but what if there was a different way? This project aimed to engage a diverse range of stakeholders to (1) generate, refine and prioritize ideas for novel models of food provision to Australian children within school hours, and (2) to determine and rank the potential barriers and facilitators to changing the school food provision system. This study used nominal group technique virtual workshops-three idea generation workshops (n = 21 participants) and one consensus workshop (n = 11 participants). School lunch prepared onsite was the top ranked food provision model option based on impact and achievability. Potential barriers (n = 26) and facilitators (n = 28) to changing the school food system were generated. The top ranked barrier and facilitator related to government support. This study highlights that there is an opportunity to explore partnerships and utilize existing skills and infrastructure to introduce a universal school-provided lunch model in Australia. The next steps should focus on building the business case capturing the social value of investing in school lunches, including considering parent-paid and subsidized options.

What do children, parents and staff think about a healthy lifestyles intervention delivered in primary schools? a qualitative study

OBJECTIVE

Primary schools are crucial settings for early weight management interventions but effects on children's weight are small and evidence shows that deficiencies in intervention implementation may be responsible. Very little is known about the roles of multiple stakeholders in the process of implementation. We used a multiple-stakeholder qualitative research approach to explore the implementation of an intervention developed to improve the diet and increase the levels of physical activity for children living in some of the most deprived areas of England.

DESIGN

For this qualitative study, interviews and focus groups were carried out using semi-structured topic guides. Data were analysed thematically.

SETTING

Seven primary schools (pupils aged 4 to 11) in Manchester, England.

PARTICIPANTS

We conducted 14 focus groups with children aged 5 to 10 years and interviews with 19 staff members and 17 parents.

INTERVENTION

Manchester Healthy Schools (MHS) is a multicomponent intervention, developed to improve diet and physical activity in schools with the aim of reducing and preventing childhood obesity.

RESULTS

Three themes were developed from the data: common understandings of health and health behaviours; congruence and consistency of messages; negotiations of responsibility.

CONCLUSION

All participant groups had a common conceptualisation of health as having physical and psychological components and that action could be taken in childhood to change behaviours that protect long-term health. When parents and staff felt a shared sense of responsibility for children's health and levels of congruence between home and school norms around diet and physical activity were high, parents and children were more likely to accept the policies implemented as part of MHS. Effective two-way communication between home and school is therefore vital for successful implementation of this intervention.

Sustainable and acceptable school meals through optimization analysis: an intervention study

Background

School meals hold considerable potential to shape children’s diets and reduce food-related greenhouse gas emissions (GHGE)—in the short and long term. This study applied linear optimization to develop a GHGE-reduced, nutritionally adequate, and affordable school lunch menu. The effects on food waste, consumption and pupils’ satisfaction with the meals were evaluated.

Methods

A pre-post design was employed to assess the effects of implementing an optimized lunch menu on daily food waste, consumption, and pupils’ school meal satisfaction in three schools (grades 0–9) from one Swedish municipality. A food list containing amounts, prices, nutrient content, and GHGE-values of all foods used for a previously served (baseline) four-week lunch menu was created. Using linear programming, this food list was optimized for minimum deviation and constrained to ensure nutritional adequacy and a reduced climate impact. The optimized food list was developed into a new (intervention) four-week lunch menu by a professional meal planner, following the baseline menu as closely as possible. The baseline and intervention menus were served for four weeks, respectively, with a two week break in between. Prepared, wasted and leftover food were weighed daily by the school kitchen staff during both periods. Interrupted time series analysis assessed mean and slope differences in daily food waste and consumption between the two periods. School lunch satisfaction was assessed with an online questionnaire at baseline and during the intervention.

Results

Optimization resulted in a food list that was 40% lower in GHGE, met all nutrient recommendations for school meals, and cost 11% less compared to baseline. The intervention menu was served as planned, with only minor changes required (for practical reasons). Plate waste, serving waste, consumption and school lunch satisfaction did not differ significantly from baseline, in any of the schools.

Conclusions

The findings demonstrate that school meals can successfully be improved regarding health and environmental sustainability using linear optimization, without negative effects on food waste, consumption or cost. This approach offers the necessary flexibility to tailor menus towards different priorities and could therefore be transferred to other types of meal services.

Trial registration

The trial is registered at clinicaltrials.gov (NCT04168632 Fostering Healthy and Sustainable Diets Through School Meals (OPTIMAT).