Delivering in-school interventions to improve dietary behaviours amongst 11- to 16-year-olds: A systematic review

School-based healthy eating interventions for adolescents aged 10-19 years: an umbrella review

BACKGROUND

The benefits of healthy eating are well known, yet adolescent diet is often poor. School based interventions offer a promising option to promote healthy eating, however, evidence is unclear.

AIM

This umbrella review synthesised the current evidence on school-based interventions for healthy eating in adolescents (10-19 years old).

METHODS

Using Joanna Briggs Institute (JBI) umbrella review guidelines, a systematic search was conducted on 11 electronic databases (PubMed, CINHAL, EMBASE, Science Direct, PsycINFO, MEDLINE, Scopus, ERIC, Web of Science, Cochrane Register of Systemic Review and JBI Evidence Synthesis) to identify reviews published between January 2000 and December 2023. Methodological quality was assessed using JBI critical appraisal tool. A narrative synthesis was conducted informed by the World Health Organisation's Health Promoting School (HPS) framework that categorises school-based interventions into three components i.e., health education, school environment changes, and family and community involvement.

RESULTS

Seventeen reviews were identified (including 347 unique primary studies) that were published between 2008 and 2023. 87% of the reviews were based on interventions in high- income countries, limiting applicability to low- and middle-income countries. Fourteen reviews were rated as high, two as moderate, and one was rated as low methodological quality. Evidence from 71% of the reviews (n = 14 reviews, 13 = high methodological quality) found that multi-component interventions (i.e., interventions incorporating more than two components of the HPS framework) improved adolescents' knowledge and behaviour concerning healthy eating. At the individual level, tech-driven healthy eating curricula effectively improved eating behaviours of adolescents. These individual-level interventions proved to be more effective and sustainable when supported by system-level changes, such as modifying school environments including increased availability of healthy foods and involving parents to promote healthy eating for adolescents. However, limited evidence from only three reviews suggests mixed feasibility for technology-based interventions and lower feasibility for multi-component interventions. The lack of information on stakeholder involvement in intervention design is another critical evidence gap.

CONCLUSION

School-based multi-component healthy eating interventions that combine individual-level interventions with system-level changes are effective in promoting healthy eating behaviours among adolescents. Future reviews should assess the effectiveness of participatory approaches in intervention design, feasibility and scale-up studies, and analysing evidence from low- and middle-income countries.

Effectiveness of nutrition interventions in Australian secondary schools: A systematic review

ISSUE ADDRESSED

Dietary intake of Australian adolescents is suboptimal. Schools are an ideal setting for health promotion initiatives to develop healthy lifestyle behaviours among adolescents. However, we do not know which nutrition-focused, school-based interventions are effective at improving health outcomes in adolescents in Australia. Therefore, the aim was to evaluate the effect of nutrition interventions on health outcomes in Australian secondary school students.

METHODS

MEDLINE, EMBASE, CINAHL, ERIC and Informit were systematically searched on 4th November 2022. Studies in any language evaluating nutrition interventions implemented in Australian secondary schools were included. Studies evaluating interventions conducted in primary schools or outside the school setting were excluded, as were any grey literature, systematic reviews and meta-analyses. Screening and data extraction were performed in duplicate. Quality was assessed using the Mixed Methods Appraisal Tool.

RESULTS

Thirteen studies (n = 27 224) reporting on nutrition interventions implemented in Australian secondary schools were included. Studies were conducted in five different states and a capital territory within Australia and were mostly randomised controlled trials. Most studies reported a significant improvement on nutrition-related health outcome measures (dietary behaviour n = 6, nutritional knowledge and attitudes n = 4 and anthropometric n = 1).

CONCLUSIONS

This review found limited studies reporting on nutrition interventions in Australian secondary schools. However, most were shown to be effective in improving nutrition-related health outcomes. SO WHAT?: Since there were limited studies in peer-reviewed journals, more research in this area is needed to confirm the effectiveness of nutrition interventions in Australian secondary schools and to assess long-term effects on student's health outcomes.

Improvement of Adherence to the Mediterranean Diet through a Nutrition Education Teaching Pack for Teachers within the "School Fruit Scheme" Program: An Italian Long-Term Trial in School Children

A previous short time span study related to the effectiveness of a teaching pack (TP) in improving the adherence to the Mediterranean Diet (MD) showed positive results. The present study was aimed at investigating and confirming those results, with a follow up data collection, in the same sample, a year after the baseline intervention. Pre- and post-intervention assessments were conducted. Weight and height were measured. Eating patterns/lifestyle were assessed by the KIDMED test and questionnaires. Thirteen schools in three areas with low, medium and high prevalence of overweight/obesity (North, Center and South respectively) were involved, with a representative baseline cluster sample of 494 fourth class children (8-10 years old) in 2015. An intervention group and a control group were recruited in each school; the intervention group (n = 395) got the intervention, the control group (n = 99) did not. The children's KIDMED score changes were the main outcome measures. Differences in percentages of adherence and in yes/no answers on the KIDMED test, at baseline and after one year, for both the intervention and the control groups, were assessed through contingency tables and statistical tests. Improvements in the high and low adherence rates to MD were observed (high adherence: 24.4% to 43.3%; low adherence: 15.0% to 3.9%, p < 0.0001). The percentages of subjects with optimal adherence improved in both sexes (females: 25.5% to 49.5%, p < 0.0001; males: 23.1% to 36.6%, p < 0.0001) in all the geographical areas and ponderal status classes. Accompanying free distribution of fruit and vegetables with a nutritional intervention led by trained teachers with a cross-curricular approach can be successful in promoting healthy eating in children.

Relationship between Diet Quality and Socioeconomic and Health-Related Factors in Adolescents by Gender

Adolescence is a key period for consolidating heathy lifestyles and proper eating habits that can last into adulthood. To analyze the diet quality of Spanish adolescents and its association with socioeconomic factors and health behaviors by gender, a cross-sectional study was conducted using data from the DESKcohort project, consisting of a biannual panel survey on health, health behaviors, and associated determinants, collected in secondary education centers. The study population consisted of 7319 students aged 12 to 18 years. Data were collected from October 2019 to March 2020. The dependent variable was diet quality score according to the Spanish adaptation of the Healthy Eating Index (S-HEI). The independent variables included were socioeconomic factors and health behaviors. We conducted linear regression separately by gender. Diet quality score was significantly higher for girls than for boys (68 and 65, respectively, p < 0.001). For both genders, poorer diet quality was associated with a low level of physical activity [-0.9 (95% CI = -1.6:-0.2) in boys, -1.2 (95% CI = -1.9:-0.4) in girls], alcohol use [-2.5 (95% CI = -3.7:-1.3) in boys, -1.0 (95% CI = -1.9:0.0) in girls], poor self-perceived health [-1.1 (95% CI = -2.4:0.2) in boys, -3.5 (95% CI = -4.6:-2.4) in girls], and having attended Intermediate Level Training Cycles [-2.9 (95% CI = -4.3:-1.5) in boys, -1.9 (95% CI = -3.5:-0.3) in girls]. In girls, poorer diet quality also was associated with low mood [-1.1 (95% CI = -1.9:-0.3)]. The variance was 9% in boys and 12% in girls. Our results highlight the need to consider socioeconomic and health-related factors, as well as gender, when conducting interventions to promote healthy eating among adolescents.

Process Evaluation of Food Game: A Gamified School-Based Intervention to Promote Healthier and More Sustainable Dietary Choices

Food Game is a gamified school-based intervention that aims to promote healthier dietary choices (i.e., adherence to the Mediterranean diet) and more sustainable behaviors among high school students in an urban area in Northern Italy. The program consists of an offline and online competition in which groups of students participate in peer-led activities to design and communicate products promoting health and sustainability. This study aimed to examine how the program works in practice, understand its mechanisms of change and assess any variation in student outcomes. A mixed methods process evaluation was conducted. Students completed a three-wave longitudinal survey and participated in focus groups. Program staff and teachers were also interviewed. Qualitative and quantitative data analyses indicate that Food Game?s gamification strategy was successful in engaging students, who felt stimulated by the game, its embedded competition and the self-organized group work. Although no significant change in adherence to the Mediterranean diet was found, pro-environmental behaviors, attitudes and perceived peer approval on healthy eating increased over time. Findings provide preliminary support for Food Game as an acceptable and engaging intervention though there is yet not sufficient evidence that it is also promotes healthier and more sustainable behaviors. The results contribute to the limited evidence base for offline gamified school-based interventions and offer insight into the applicability of the gamification approach as a key motivational strategy in other prevention settings and contexts. Suggestions on how to strengthen the program include dosage increase and addition of activities to promote change on relevant school and community factors.

Survey of South Carolina Public School Personnel Perspectives on Barriers and Facilitators to Regular Physical Activity and Healthy Eating Behaviors in Schools

BACKGROUND

In South Carolina (SC), 42% of youth are overweight or obese. Two sets of modifiable behaviors contributing to obesity are physical activity (PA) and dietary habits. School-based interventions have successfully improved these behaviors. The purpose of this study was to identify SC public school personnel perspectives on the most common barriers and facilitators to regular PA and healthy eating behaviors in schools.

METHODS

A needs assessment survey was conducted with school personnel statewide. There were 17 questions on the survey that addressed: (1) demographic information about participants' educational backgrounds, (2) barriers to regular PA and healthy eating behaviors in schools, and (3) facilitators to regular PA and healthy eating behaviors in schools. Univariate and bivariate descriptive statistical analyses were performed using IBM SPSS Statistics 27.

RESULTS

Participants (N = 1311) indicated insufficient time for regular PA (n = 514, 39.2%) and limited access to healthy foods for healthy eating (n = 271, 20.7%) as main barriers. The primary facilitators were support from administrators for regular PA (n = 264, 20.1%) and support from cafeteria staff for healthy eating (n = 234, 17.8%). Further analyses explored how factors compared based on roles in schools, academic levels, and school district classifications.

CONCLUSIONS

Results suggest that overarching barriers and facilitators to school-based interventions addressing childhood obesity exist, so common strategies to mitigate challenges and maximize supports can be used in schools. Future studies are needed to examine how decreasing barriers and enhancing facilitators affect the implementation and outcomes of these school-based interventions.

The Impact of Modifying Food Service Practices in Secondary Schools Providing a Routine Meal Service on Student's Food Behaviours, Health and Dining Experience: A Systematic Review and Meta-Analysis

The education sector is recognised as an ideal platform to promote good nutrition and decision making around food and eating. Examining adolescents in this setting is important because of the unique features of adolescence compared to younger childhood. This systematic review and meta-analysis examine interventions in secondary schools that provide a routine meal service and the impact on adolescents’ food behaviours, health and dining experience in this setting. The review was guided by Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Checklist and Cochrane Handbook recommendations. Studies published in English searched in four databases and a hand search yielded 42 interventions in 35 studies. Risk of bias was assessed independently by two reviewers. Interventions were classified using the NOURISHING framework, and their impact analysed using meta-analysis, vote-counting synthesis or narrative summary. The meta-analysis showed an improvement in students selecting vegetables (odds ratio (OR): 1.39; 1.12 to 1.23; p = 0.002), fruit serves selected (mean difference (MD): 0.09; 0.09 to 0.09; p < 0.001) and consumed (MD: 0.10; 0.04 to 0.15; p < 0.001), and vegetable serves consumed (MD: 0.06; 0.01 to 0.10; p = 0.024). Vote-counting showed a positive impact for most interventions that measured selection (15 of 25; 41% to 77%; p = 0.002) and consumption (14 of 24; 39% to 76%; p = 0.013) of a meal component. Interventions that integrate improving menu quality, assess palatability, accessibility of healthier options, and student engagement can enhance success. These results should be interpreted with caution as most studies were not methodologically strong and at higher risk of bias. There is a need for higher quality pragmatic trials, strategies to build and measure sustained change, and evaluation of end-user attitudes and perceptions towards intervention components and implementation for greater insight into intervention success and future directions (PROSPERO registration: CRD42020167133).

The Effect of a Product Placement Intervention on Pupil's Food and Drink Purchases in Two Secondary Schools: An Exploratory Study

Limited research exists on the effectiveness of product placement in secondary schools. We explored the impact of re-positioning sweet-baked goods, fruit, sugar-sweetened beverages (SSBs) and water on pupil's lunchtime purchases in two secondary schools in North-East England. We employed a stepped-wedge design with two clusters and four time periods. The intervention(s) involved re-positioning selected food and drinks to increase and decrease accessibility of 'healthier' and 'less healthy' items, respectively. Unidentifiable smartcard data measured the change in number of pupil's purchasing the above items. McNemar tests were undertaken on paired nominal data in Stata(v15). In School A, pupils purchasing fruit pots from control to intervention increased (n = 0 cf. n = 81; OR 0, 95% CI 0 to 0.04); post-intervention, this was not maintained. In School B, from control to intervention pupil's purchasing sweet-baked goods decreased (n = 183 cf. n = 147; OR 1.2, 95% CI 1 to 1.6). This continued post-intervention (n = 161 cf. n = 122; OR 1.3, 95% CI 1.0 to 1.7) and was similar for SSBs (n = 180 cf. n = 79; OR 2.3, 95% CI 1.7 to 3.0). We found no evidence of other changes. There is some evidence that product placement may positively affect pupil's food and drink purchases. However, there are additional aspects to consider, such as, product availability, engaging canteen staff and the individual school context.

Describing South Carolina Public School Administrators' Perceptions and Experiences Related to School-Based Interventions and Strategies to Promote Healthy Physical Activity and Eating Behaviors: A Qualitative Study

BACKGROUND

School-based interventions and strategies targeting physical activity (PA) and eating patterns have successfully addressed unhealthy behaviors contributing to excess weight in school-age children. The purpose of this study was to investigate South Carolina (SC) public school administrators' perceptions of and experiences with weight-related issues in schools and associated barriers and facilitators to awareness, selection, and implementation of school-based healthy PA and eating interventions and strategies.

METHODS

This qualitative descriptive study, guided by the Social Ecological Model and the Steps in Quality Intervention Development Model, involved semistructured interviews with SC public school administrators from all academic levels (N = 28). Data were analyzed using thematic analysis.

RESULTS

Four themes were identified from interviews (N = 28): weight-related terminology or stigma, experiences with school-based healthy PA and eating interventions and strategies, barriers to school-based healthy PA and eating interventions and strategies, and facilitators to school-based healthy PA and eating interventions and strategies.

CONCLUSIONS

Schools are well-positioned to provide interventions and strategies to improve PA and dietary habits leading to childhood obesity. School administrators, while knowledgeable and experienced with weight-related issues and school-based interventions and strategies, encounter barriers and facilitators that impact offerings and delivery. Understanding these challenges and supports is important in the development, adaptation, and implementation of school-based interventions and strategies focused on healthy PA and eating behaviors.

An in-school social norms approach intervention for reducing unhealthy snacking behaviours amongst 11-12-year-olds

OBJECTIVES

Adolescents tend to overestimate the extent of peers' unhealthy snacking consumption and such misperceptions have been associated with increased personal unhealthy snacking. This study aims to test whether a Social Norms Approach (SNA) intervention which challenges these misperceptions of peers' unhealthy snacking will have a positive effect on students' personal unhealthy snacking behaviours, related attitudes, and behavioural intentions.

DESIGN

A quasi-experimental study tested the effectiveness of an in-school SNA intervention (n = 163) compared to a control condition (n = 95) among 11-12-year-old students.

METHOD

Both conditions received healthy eating information, while students in the SNA intervention received additional normative feedback (outlining the discrepancies between perceived and actual unhealthy snacking of the majority based on baseline data) delivered through an interactive poster-making session. Students completed self-reported measures of personal unhealthy snacking, related-attitudes, behavioural intentions, and normative perceptions (descriptive and injunctive) at baseline, post-intervention, and at a 3-month follow-up.

RESULTS

Students who received SNA feedback were significantly less likely to overestimate peers' unhealthy snacking attitudes post-intervention (F(1,232) = 16.405, p < .001), and at 3-month follow-up consumed fewer unhealthy snacks (F(1,232) = 6.133, p = .014) and had less positive attitudes towards unhealthy snacking (F(1,198) = 8.779, p = .003). The changes in personal snacking attitudes at 3-month follow-up were mediated by changes in normative misperceptions about peers' unhealthy snacking attitudes post-intervention, which indicated that the reductions in normative misperceptions following SNA messages mediated the effect of the intervention.

CONCLUSION

The results indicate that in-school SNA interventions which challenge normative misperceptions constitute a promising strategy for reducing unhealthy snacking in young adolescents.

How do we harness adolescent values in designing health behaviour change interventions? A qualitative study

OBJECTIVES

Adolescent health behaviours do not support optimal development. Adolescents are reportedly difficult to engage in health behaviour improvement initiatives. Little is known about what adolescents value in relation to diet and physical activity or how best to target these in health interventions. This study explored adolescents' values in relation to diet and physical activity and how these values can inform health intervention design.

DESIGN

Qualitative semi-structured interviews explored adolescents' lives, what they thought about diet and physical activity and what might support them to improve their health behaviours.

METHODS

A total of 13 group interviews were conducted with 54 adolescents aged 13-14 years, of whom 49% were girls and 95% identified as White British. Participants were recruited from a non-selective secondary school in a large southern UK city. Inductive thematic analysis was used to identify key adolescent values.

RESULTS

Adolescents valued being with their friends, doing what they enjoyed and were good at; being healthy was important to them but only if achievable without compromising other things that are important to them. The need to be healthy was not aligned with adolescents' basic psychological needs, nor their strongly held priorities and values.

CONCLUSIONS

Health is not a motivating factor for adolescents; therefore, interventions designed solely to improve health are unlikely to engage them. Instead, interventions that align with the values and priorities specified by adolescents are more likely to be effective in supporting them to eat well and be more active.

Engaging adolescents in changing behaviour (EACH-B): a study protocol for a cluster randomised controlled trial to improve dietary quality and physical activity

BACKGROUND

Poor diet and lack of physical activity are strongly linked to non-communicable disease risk, but modifying them is challenging. There is increasing recognition that adolescence is an important time to intervene; habits formed during this period tend to last, and physical and psychological changes during adolescence make it an important time to help individuals form healthier habits. Improving adolescents' health behaviours is important not only for their own health now and in adulthood, but also for the health of any future children. Building on LifeLab-an existing, purpose-built educational facility at the University of Southampton-we have developed a multi-component intervention for secondary school students called Engaging Adolescents in Changing Behaviour (EACH-B) that aims to motivate and support adolescents to eat better and be more physically active.

METHODS

A cluster randomised controlled trial is being conducted to evaluate the effectiveness of the EACH-B intervention. The primary outcomes of the intervention are self-reported dietary quality and objectively measured physical activity (PA) levels, both assessed at baseline and at 12-month follow-up. The EACH-B intervention consists of three linked elements: professional development for teachers including training in communication skills to support health behaviour change; the LifeLab educational module comprising in-school teaching of nine science lessons linked to the English National Curriculum and a practical day visit to the LifeLab facility; and a personalised digital intervention that involves social support and game features that promote eating better and being more active. Both the taught module and the LifeLab day are designed with a focus on the science behind the messages about positive health behaviours, such as diet and PA, for the adolescents now, in adulthood and their future offspring, with the aim of promoting personal plans for change. The EACH-B research trial aims to recruit approximately 2300 secondary school students aged 12-13 years from 50 schools (the clusters) from Hampshire and neighbouring counties. Participating schools will be randomised to either the control or intervention arm. The intervention will be run during two academic years, with continual recruitment of schools throughout the school year until the sample size is reached. The schools allocated to the control arm will receive normal schooling but will be offered the intervention after data collection for the trial is complete. An economic model will be developed to assess the cost-effectiveness of the EACH-B intervention compared with usual schooling.

DISCUSSION

Adolescents' health needs are often ignored and they can be difficult to engage in behaviour change. Building a cheap, sustainable way of engaging them in making healthier choices will benefit their long-term health and that of their future children.

TRIAL REGISTRATION

ISRCTN 74109264 . Registered on 30 August 2019. EACH-B is a cluster randomised controlled trial, funded by the National Institute for Health Research (RP-PG-0216-20004).