The influence of a school-based intervention programme regarding adherence to a healthy diet in children and adolescents from disadvantaged areas in Greece: the DIATROFI study

Impact of a school-based food assistance program on household food insecurity in Greece, 2012-2019: a multi-year evaluation of the DIATROFI program

Background

Childhood food insecurity can persist among low socioeconomic areas in high-income countries. Universal Free School Meal (UFSM) programs are designed to respond to this pressing issue. This study aimed to conduct a multi-year evaluation of the DIATROFI Program's impact on household food insecurity in Greece.

Methods

This study utilized data from 18,716 students (618 kindergarten to high schools), from low socioeconomic areas participating in the school-level UFSM Program DIATROFI between 2012 and 2019. Parents of students completed annual baseline and follow-up paper-based self-completed questionnaires. The primary outcome was household food insecurity, measured using the Food Security Survey Module (FSSM) at both questionnaires, and evaluated through mixed linear and logistic regression models with repeated measurements.

Findings

Students' median age was 9 years old (Interquartile range (IQR): 6.5, 12.0), 51.6% (n = 9658) were girls, and 82.2% (n = 15,382) lived in low/medium socioeconomic affluence households. Households with food insecurity reduced from 51.5% (n = 9630) to 47.6% (n = 8901) after one school year. Food insecurity score declined steadily for four years of consecutive participation, compared to baseline score (one-year b:-0.26; 95% Confidence Interval (CI):-0.30, -0.22, and four-year -1.28; -1.53, -1.03). The likelihood of retaining food insecure status reduced from 17% after one-year participation (Odds Ratio (OR): 0.83; 95% CI: 0.79, 0.87) to 36% after four-year participation (0.64; 0.49, 0.82). The Program's impact on household food insecurity alleviation was greater among households with low parental education and low socioeconomic affluence.

Interpretation

The DIATROFI Program effectively improved household food security during and after the Greek socioeconomic crisis. School-level UFSM programs targeting underprivileged students can improve household food insecurity, with a more pronounced effect with increased years of participation, and among economically disadvantaged households.

Funding

The DIATROFI Program was funded through various national and private organizations, including national prefecture authorities, Greek payment authorities, philanthropic/charitable organizations, and private companies.

Food Insecurity in Greece and across the Globe: A Narrative Literature Review

Food insecurity comprises a major global public health threat, as its effects are detrimental to the mental, physical, and social aspects of the health and well-being of those experiencing it. We performed a narrative literature review on the magnitude of global food insecurity with a special emphasis on Greece and analyzed the major factors driving food insecurity, taking into consideration also the effect of the COVID-19 pandemic. An electronic search of international literature was conducted in three databases. More than 900 million people worldwide experience severe food insecurity, with future projections showing increasing trends. Within Europe, Eastern and Southern European countries display the highest food insecurity prevalence rates, with Greece reporting a prevalence of moderate or severe food insecurity ranging between 6.6% and 8% for the period 2019-2022. Climate change, war, armed conflicts and economic crises are major underlying drivers of food insecurity. Amidst these drivers, the COVID-19 pandemic had a profound impact on food insecurity levels around the globe, through halting economic growth, disrupting food supply chains and increasing unemployment and poverty. Tackling food insecurity through addressing its key drivers is essential to any progress towards succeeding the Sustainable Development Goal of "Zero Hunger".

Effects of a School-Based Gardening, Cooking, and Nutrition Cluster Randomized Controlled Trial on Unprocessed and Ultra-Processed Food Consumption

BACKGROUND

School-based gardening and nutrition education interventions report improvements in dietary intake, notably through fruit and vegetables. However, gardening, cooking, and nutrition randomized controlled trials are limited in evaluating dietary quality, and none have examined processed food consumption to date.

OBJECTIVES

The study examined the effects of Texas Sprouts (TX Sprouts), a gardening, cooking, and nutrition education intervention, compared with control on unprocessed and ultra-processed food (UPF) consumption in predominately low-income Hispanic children.

METHODS

TX Sprouts was a school-based cluster randomized controlled trial that consisted of 16 elementary schools randomly assigned to either the TX Sprouts intervention (n = 8 schools) or control (delayed intervention; n = 8 schools) over 3 y (2016-2019). TX Sprouts schools received an outdoor teaching garden and 18 1-h lessons taught by trained educators throughout the school year. Dietary intake data via 2 24-h dietary recalls were collected on a random subsample (n = 468) at baseline and postintervention. All foods and beverages were categorized using the NOVA food classification system (e.g., unprocessed, processed, ultra-processed). Generalized linear mixed effects modeling tested changes in percent calories and grams of NOVA groups between the intervention and control estimates with schools as random clusters.

RESULTS

Of the sample, 63% participated in the free and reduced-price lunch program, and 57% were Hispanic, followed by non-Hispanic White (21%) and non-Hispanic Black (12%). The intervention, compared to the control, resulted in an increase in consumption of unprocessed foods (2.3% compared with -1.8% g; P < 0.01) and a decrease in UPF (-2.4% compared with 1.4% g; P = 0.04). In addition, Hispanic children in the intervention group had an increase in unprocessed food consumption and a decrease in UPF consumption compared to non-Hispanic children (-3.4% compared with 1.5% g; P < 0.05).

CONCLUSIONS

Study results suggest that school-based gardening, cooking, and nutrition education interventions can improve dietary intake, specifically increasing unprocessed food consumption and decreasing UPF consumption. This trial was registered at clinicaltrials.gov as NCT02668744.

Pythagorean Self-Awareness Intervention Promoted Healthy Dietary Patterns, Controlled Body Mass Index, and Reduced Self-Reported Stress Levels of Primary School Children: Α One-Arm Pilot Study

Stress is common in childhood and an important factor that affects behavior later in adulthood. The aim of this study was to assess the effects of the Pythagorean Self-Awareness Intervention (PSAI), a holistic "cognitive reconstruction" technique to assess primary school children's stress levels, adherence to the Mediterranean diet, and body mass index. Secondary outcome measures included relations with peers, sleep, and hair cortisol concentrations. This one-arm pilot study took place in a primary school, from February to June 2019. Participants were 32 pupils attending the second grade of primary school who received the 8-week PSAI to adopt healthy behaviors and lifestyle. Self-report measures were applied for the evaluation of various variables at the beginning and the end of the eight-week intervention. There were statistically significant reductions in stress levels (p = 0.00), nightmares' frequency (p = 0.00), body mass index (p = 0.03), and bully scale (p = 0.00), and improvement in Mediterranean diet quality (p = 0.00). Hair cortisol concentrations increased (p = 0.02). The social scale significantly increased. Bedtime remained the same after the intervention. This pilot trial showed that the PSAI promoted healthy dietary patterns, controlled children's body mass index, and reduced their self-reported stress levels. Further research on the implementation of this holistic program on children is suggested, in well-powered randomized controlled trials.

Methodological Aspects of Diet Quality Indicators in Childhood: A Mapping Review

Diet quality indicators (DQIns) are tools that aim to assess an individual's overall diet quality. Previous reviews focused mainly on health-related outcomes but did not provide detailed information about components, assessment variables, or important methodological issues for the development and application of DQIns in the pediatric age. The current mapping review aims to provide comprehensive guidance regarding DQIns developed through a priori methodology in children aged ≤14 y that have been applied worldwide. A mapping review was conducted, whereby 1665 original articles describing the development, modifications, and updates of DQIns, published up to June 26, 2020, in English and Spanish, were retrieved. A total of 139 articles were identified and classified into 13 subgroups. There were 10 overall DQIns: Healthy Eating Indexes (n = 25), Dietary Diversity Scores (n = 20), Diet Quality Indexes (n = 16), Food Variety Scores (n = 11), Healthy and Unhealthy Scores (n = 11), Feeding and Eating Indexes (n = 10), Diet Quality Scores (n = 5), Nutritional Adequacy and Micronutrients Indexes (n = 5), Dietary Guidelines Indexes (n = 5), and Other Healthy Diet Indexes (n = 13). Three additional subgroups of dietary and lifestyle indicators found were Mediterranean Diet Indexes (n = 10), Diet-Lifestyle Indexes (n = 5), and Breakfast Quality Indexes (n = 3). This compilation of DQIns will help researchers select the most appropriate tool for future epidemiological studies by considering a careful selection of information about the assessment components, scoring methods, and key methodological issues. The main limitations of this review are that, due to its nature, a risk-of-bias assessment was not performed and the article screening was completed in 2 databases (PubMed/MEDLINE and Scopus). More research is needed to identify health-related outcomes associated with DQIns in the pediatric population, using clearer and more standardized methodological criteria.

Dietary patterns and food insecurity of students participating in a food aid programme: the Mediterranean perspective

BACKGROUND

To explore the effect of household food insecurity on dietary patterns of children and adolescents participating in a school food-aid programme in regions of Greece with low socioeconomic status.

METHODS

A cross-sectional study was conducted during the school year 2013-14, among 406 schools in low socioeconomic status regions of Greece. Dietary habits and sociodemographic characteristics of students and their families were recorded. Factor analysis was used in order to derive children's and adolescents' dietary patterns and analysis of covariance was performed to examine the effect of households' food insecurity level on those patterns. A total of 31 399 students participated in the study; 16 652 children (5-11 years) and 14 747 adolescents (12-18 years).

RESULTS

Factor analysis identified five dietary patterns in both age groups, explaining the 49.1% (children) and 53.0% (adolescents) of the total variation in intake. After adjusting for various factors, the household's food insecurity was significantly associated with the majority of the derived patterns in both age groups, with most pronounced differences being observed for the consumption of red meat, poultry and fish, fruits, as well as red processed meat, cereals and dairy products, which was lower among children and adolescents with food insecurity. Children with food insecurity consumed significantly more unhealthy food, such as chips, fast food, sugared drinks, sweets, French fries and mayonnaise sauce.

CONCLUSIONS

Promotion of healthy eating to households facing food insecurity is of crucial importance, giving emphasis in the design of low cost, yet highly nutritious programmes.

Effectiveness of a school food aid programme in improving household food insecurity; a cluster randomized trial

BACKGROUND

Aim of this cluster randomized trial was to examine the impact of a school feeding programme combining healthy meals provision and educational activities to reduce food insecurity.

METHODS

Schools participating in the DIATROFI Program in Greece during the 2014-2015 school year were randomly allocated between a multicomponent intervention (MI: each student received a daily healthy meal along with educational actions; 28 schools) and an educational intervention (EI; 23 schools). A linear-mixed model was used to examine intervention effect on change from baseline in the food insecurity score, as measured via the Food Security Survey Module (FSSM). The analysis was based on 1442 pre-post intervention questionnaire pairs in the MI group and 986 in the EI group.

RESULTS

The reduction in food insecurity score in the MI group was statistically significantly greater compared to the EI group, by 9.8% or -0.31 [95% confidence interval (CI) -0.61 to -0.01] FSSM units after adjusting for potential confounders. MI intervention was significantly more effective compared to EI, among students in food insecure households (mean -0.44, 95% CI -0.84 to -0.04), students in households facing hunger (mean -1.04, 95% CI -1.91 to -0.17) and overweight/obese students (mean -0.36, 95% CI -0.72 to -0.01).

CONCLUSION

For interventions aiming to address childhood food insecurity, public health focus should be oriented towards school-based programmes combining food assistance with activities that promote healthy nutrition.

Irrational beliefs trigger depression and anxiety symptoms, and associated with increased inflammation and oxidative stress markers in the 10-year diabetes mellitus risk: the ATTICA epidemiological study

Purpose

To investigate the combined role of irrational beliefs, anxiety and depression in the 10-year incidence of type 2 diabetes, and the underlying effect of biochemical, and socio-behavioural factors.

Methods

Within the context of the ATTICA cohort study (2002-2012), 853 participants without evidence of CVD [453 men (45 ± 13 years) and 400 women (44 ± 18 years)] underwent psychological evaluation through the Irrational Beliefs Inventory (IBI) (range 0-88), the Zung Self-Rating-Depression-Scale (ZDRS) and the State-Trait-Anxiety-Inventory (STAI). Diagnosis of diabetes at follow-up examination was based on the criteria of the American Diabetes Association (ADA).

Results

Mean IBI score was 53 ± 10 in men and 51 ± 11 in women (p = 0.68). Participants with high irrational beliefs who also had anxiety symptoms had a 93% excess risk of developing diabetes during the 10-year follow-up (Hazard Ratio 1.93; 95%CI 1.34, 2.78) as compared to those without anxiety. Moreover, diabetes risk was 73% higher among individuals with high levels of irrational beliefs and depression as compared to those where depression was absent (1.73; 1.21, 2.46). Lower education status, family history of diabetes, hypercholesterolemia, high BMI, as well as tumor necrosis factor and total antioxidant capacity were revealed as mediating risk factors related to the tested associations.

Conclusion

Irrational beliefs among apparently healthy adults trigger depression and anxiety symptomatology, and through the increased inflammation and oxidative stress profile, were associated with increased diabetes risk. This observation moves psychological research a step forward in supporting and guiding primary prevention of mental health and metabolic conditions.

Household food spending, parental and childhood's diet quality, in financial crisis: a cross-sectional study in Greece

BACKGROUND

Over the past decade, the financial crisis has affected harshly the household income of Greek people. This study aimed to investigate whether the effect of the financial crisis on food spending has affected the dietary habits in the family environment.

METHODS

Under a cross-sectional study conducted during 2014-2016, 1145 children and their parents completed questionnaires examining socio-economic and dietary characteristics. The MedDietScore and the KIDMED Score were used to assess parental and childhood adherence to the Mediterranean diet, respectively.

RESULTS

The parents who reported that the financial crisis has affected food spending used to consume weekly fewer fruits (3.26 ± 0.94 vs. 3.41 ± 0.90, P = 0.016), carbohydrate foods (3.16 ± 0.57 vs. 2.99 ± 0.55, P < 0.001) and legumes (3.28 ± 0.76 vs. 3.14 ± 0.67, P = 0.001) and more nutrient-poor/energy-dense foods (2.55 ± 0.98 vs. 2.20 ± 0.82, P < 0.001) compared with non-affected parents. Their children showed a decreased weekly consumption of vegetables (2.82 ± 0.90 vs. 2.97 ± 0.98, P = 0.019) and increased weekly consumption of nutrient-poor/energy-dense foods (2.38 ± 0.97 vs. 2.19 ± 0.80, P < 0.001). The affected parents had a lower MedDietScore than non-affected parents (25.76 ± 8.10 vs. 27.03 ± 8.11, P = 0.034). No difference was revealed on the KIDMED Score (P = 0.294).

CONCLUSIONS

The constrained food spending due to financial crisis has an independent and inverse impact on parent's diet quality while keeping unaffected preadolescent's diet quality. This finding highlights the role of parents as a protective 'wall' against the deterioration of their children's diet quality. The modification on the prices of healthy food and the provision of food aid particularly in economically disadvantaged households is underlined.

Predictors of Cognitive Performance Among Infants Treated for Brain Tumors: Findings From a Multisite, Prospective, Longitudinal Trial

PURPOSE

Infants treated for CNS malignancies experience a significantly poorer response to treatment and are particularly at risk for neuropsychological deficits. The literature is limited and inconsistent regarding cognitive outcomes among this group. We investigated predictors of cognitive outcomes in children treated for brain tumors during infancy as part of a large, prospective, multisite, longitudinal trial.

PATIENTS AND METHODS

One hundred thirty-nine infants with a newly diagnosed CNS tumor were treated with chemotherapy, with or without focal proton or photon radiation therapy (RT). Cognitive assessments were conducted at baseline, 6 months, 1 year, and then annually for 5 years. The median length of follow-up was 816 days (26.8 months). Neurocognitive testing included assessment of intellectual functioning (intellectual quotient [IQ]), parent ratings of executive functioning and emotional and behavioral functioning, and socioeconomic status.

RESULTS

At baseline, IQ, parent-reported working memory, and parent-reported adaptive functioning were worse than normative expectations. Baseline cognitive difficulties were associated with younger age at diagnosis and lower socioeconomic status. Linear mixed models did not demonstrate a decline in IQ over time. There were increased parent-reported attention and executive problems over time. Increased concerns were related to supratentorial tumor location and CSF diversion. There were no differences in cognitive outcomes based on treatment exposure (chemotherapy-only v chemotherapy with RT and proton v photon focal RT).

CONCLUSION

Even before adjuvant therapy, young children with brain tumors experience cognitive difficulties that can affect quality of life. Changes in cognitive functioning over time were dependent on tumor location and surgical factors rather than adjuvant therapy. These findings may serve to guide treatment planning and indicate targets for cognitive monitoring and intervention.

The impact of, and views on, school food intervention and policy in young people aged 11-18 years in Europe: A mixed methods systematic review

Understanding the social and environmental influencers of eating behaviours has the potential to improve health outcomes for young people. This review aims to explore the effectiveness of school nutrition interventions and the perceptions of young people experiencing a nutrition focused intervention or change in school food policy. A comprehensive systematic search identified studies published between 1 December 2007 to 20 February 2020. Twenty-seven studies were included: 22 quantitative studies of nutrition related outcomes and five qualitative studies reporting views and perceptions of young people (combined sample of 22,138 participants, mean ages 12-18 years). The primary outcome was nutrition knowledge/dietary behaviours, with secondary outcomes exploring body mass index (BMI) and wellbeing. Due to the heterogeneity of studies, a narrative results description is presented. The findings demonstrate that school nutrition programmes can be effective in reducing sugar, sugar sweetened beverages (SSB) and saturated fat and increasing fruit and vegetable (FV) intake. The lived experiences of young people in a school context provide valuable insights that should be considered in the development of effective school food policy and interventions. This review affirms the significant role that schools can play in supporting good nutrition in all young people and provides opportunities to inform the school food agenda.

Characteristics of successful primary school-based experiential nutrition programmes: a systematic literature review

OBJECTIVE

Diet and nutrition in childhood has been associated with the risk of chronic disease later in life. The aim of this review was to identify key characteristics of successful experiential nutrition interventions aimed to change nutrition-related cognitive and behavioural outcomes in primary schoolchildren.

DESIGN

A systematic literature review was undertaken using search terms ('food security', 'school', 'nutrition' and 'program') applied to five scientific databases (CINAHL, Scopus, Web of Science, Medline and Academic Search complete), with outcomes defined as nutrition-related knowledge, attitudes and/or dietary behaviours.

PARTICIPANTS

Primary school-aged children exposed to interventions conducted, at least partially, on school grounds.

RESULTS

A total of 3800 articles were identified from the initial search and manual searching, of which sixty-seven articles were eligible for inclusion. Forty-two articles met the criteria of being successful, defined as achieving significant differences in outcomes of interest, accompanied by a demonstrated reach. Interventions included school gardens (n 9), food provision (n 5), taste testing (n 8), cooking classes (n 10) and multicomponent programmes (n 10). Nutrition education (when combined with taste testing), cooking-related activities and gardening interventions increased children's willingness to taste unfamiliar foods including new fruits and vegetables, improved their cooking and food preparation skills and increased nutritional knowledge.

CONCLUSIONS

This review provides evidence that nutrition education programmes in primary schoolchildren that are experiential in nature are most likely to be successful if they include multiple strategies, have parental involvement and focus specifically on vegetable intake.

Using Photovoice to Improve Healthy Eating for Children Participating in an Obesity Prevention Program

Background: Children have benefited from participation in obesity prevention programs. Aims: The objectives of this study were to evaluate the impact of a healthy eating intervention for children in after-school programs and to use photovoice to document change in eating behavior. Methods: Forty-two children in three after-school programs participated. Children participated in lessons from an existing program to learn about healthy eating. A mixed methods study was conducted, using surveys to assess parent and child perceptions, and photovoice to capture children’s perceptions of how they and their family changed eating habits. Member-checking was used to verify themes in the data. Twenty parents completed surveys evaluating the program. Results: Findings indicated that children learned program information, were interested in eating healthier (more fruits and vegetables), and quantitative data revealed there was a pre-post trend for eating more fruits at home. They reported that using the photovoice method helped them to monitor their behavior and helped them improve personal and family eating habits. Member checking confirmed themes. A majority of parents were satisfied with the program and reported that their children were discussing what they learned at home. Conclusions: Findings suggested that the photovoice methodology helped children to change in a positive way, increasing their agency in improving their own health and that of their family. Assessing longitudinal change in attitudes about healthy eating and eating behaviors will provide information about whether children maintain gains in knowledge and healthy eating over time.

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

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

Healthier Food and Beverage Interventions in Schools: Four Community Guide Systematic Reviews

CONTEXT

Healthy eating during childhood is important for optimal growth and helps reduce the risk of obesity, which has potentially serious health consequences. Changing the school food environment may offer one way to improve students' dietary intake. This manuscript reports 4 Community Guide systematic reviews examining the effectiveness of interventions in schools promoting healthy eating and weight.

EVIDENCE ACQUISITION

School obesity prevention programs aiming to improve diet were identified from a 2013 Agency for Health Care Research and Quality systematic review and an updated search (August 2012-January 4, 2017). In 2017-2018, Community Guide systematic review methods were used to assess effectiveness as determined by dietary behavior and weight changes.

EVIDENCE SYNTHESIS

Interventions improving school meals or offering fruits and vegetables (n=27 studies) are considered effective. Evidence is insufficient to determine the effectiveness of interventions supporting healthier snack foods and beverages outside of school meal programs given inconsistent findings (n=13 studies). Multicomponent interventions to increase availability of healthier foods and beverages are considered effective. These interventions must include 1 component from school meals or fruit and vegetable programs and interventions supporting healthier snack foods and beverages (n=12 studies). There is insufficient evidence to determine the effectiveness of interventions to increase water access because only 2 studies met inclusion criteria.

CONCLUSIONS

A total of 2 school-based dietary interventions have favorable effects for improving dietary habits and modest effects for improving or maintaining weight. More evidence is needed regarding interventions with insufficient findings. These reviews may inform researchers and school administrators about healthy eating and obesity prevention interventions.

Locally implemented prevention programs may reverse weight trajectories in half of children with overweight/obesity amid low child-staff ratios: results from a quasi-experimental study in France

Background

The aims of the present study were to assess changes in weight status between the first and last year of primary education among children with overweight/obesity in response to locally implemented school-based prevention programs, and to assess the influence of process indicators, expressed as child-staff ratios (CSRs), on these changes.

Methods

To meet the study objectives, a quasi-experimental design was used. Four municipalities that systematically monitored the weight status of schoolchildren and participated in the “Vivons en Forme” program agreed to provide the data available in their school medical service records. The local implementers involved in training sessions were mainly municipal staff in charge of serving midday school meals, which is compulsory in France, and those in charge of designing and facilitating creative, interactive activities at school between and after classes. CSRs were determined by occupation (school catering service/facilitator of extracurricular activities) and training session (healthy eating/physical activity) in each municipality program, and classified as low (1–5 children per adult) or moderate.

Results

During the 4 years of primary education, weight status improved in half of the children with overweight/obesity, and worsened in 6.6% of children with overweight/normal weight. In children who remained overweight, the BMI z-score diminished over time. Estimates of the positive 4-year weight changes were related to low CSRs in locally implemented variations of the program. Estimates increased with age and were significantly higher in low-to-moderate CSR multicomponent interventions than moderate CSR single-component intervention (reference). The moderate CSR multicomponent intervention had a similar effect as the reference. The estimated negative weight change decreased with age.

Conclusions

Our findings suggest that training ancillary school staff in experiential-focused interventions for healthy eating and physical activity in locally implemented school-based programs contributed positively to reducing childhood obesity during the four years of primary education without interfering with educational activities. The results also provide preliminary evidence that low CSRs could be pivotal for optimal outcomes, especially in deprived areas.

Schoolteachers' Nutrition Knowledge, Beliefs, and Attitudes Before and After an E-Learning Program

OBJECTIVE

Το explore teachers' nutrition knowledge, beliefs, and attitudes and to examine the effectiveness of an electronic learning (e-learning) program in teachers' nutrition knowledge.

DESIGN

Cross-sectional and experimental design.

SETTING

The study took place in Greece, while schoolteachers were invited by e-mail.

PARTICIPANTS

Teachers of primary and secondary education, with no exclusion criteria, were enrolled in the study between March, 2015 and 2016.

MAIN OUTCOME MEASURES

Schoolteachers' nutrition knowledge, beliefs, and attitudes.

INTERVENTION

Teachers completed a 36-item nutrition questionnaire and then a subgroup participated in an e-learning program. After the intervention, teachers completed the same questionnaire.

ANALYSIS

Principal component analysis and multivariate logistic regression were used for data analysis.

RESULTS

A total of 1,094 teachers completed the questionnaire; 619 participated in the e-learning program. Teachers showed moderate nutrition knowledge scores (ie, 65% correct answers) before the intervention, whereas their attitudes regarding acting as role models and their belief in the importance of the role of nutrition were associated with 74% (odds ratio, 1.28; 95% confidence interval, 1.13-1.45) and 79% (odds ratio, 1.21; 95% confidence interval, 1.07-1.37) increased possibility of having good nutrition knowledge, respectively. The e-learning program was effective in strengthening teachers' nutrition knowledge (P < .001) and improving their beliefs and attitudes (P < .05).

CONCLUSIONS AND IMPLICATIONS

Future research is needed to validate the current results, which can be used to design and implement similar educational programs to teachers as a means of creating health-promoting schools.

Socio-economic and cultural disparities in diet among adolescents and young adults: a systematic review

OBJECTIVE

To explore dietary differences according to socio-economic and sociocultural characteristics of adolescents and young adults.

DESIGN

A systematic review was conducted.

SETTING

The main search source was MEDLINE, consulted between January 2012 and March 2017. Quality of selected studies was assessed based on dietary measurement method, sample selection, socio-economic indicator choice and statistical modelling.

PARTICIPANTS

Cross-sectional and longitudinal studies, assessing relationships between socio-economic status and dietary intake (patterns, scores and food groups) in the 10- to 40-year-old general population of high-income countries, were selected.

RESULTS

Among the 7250 reports identified, forty were selected, seventeen of which were of high quality; their conclusions, related only to adolescents, were combined and presented. The most favourable dietary patterns, higher dietary scores, greater consumption of fruits, vegetables and dairy products, and lower consumption of sugary sweetened beverages and energy-dense foods, were associated with better parental socio-economic status, particularly in terms of higher education. Migrant status was associated with plant-based patterns, greater consumption of fruits and vegetables and of sugary sweetened beverages and energy-dense foods. For the other food groups, and for young adults, very few high-quality studies were found.

CONCLUSIONS

The socio-economic gradient in adolescent diets requires confirmation by higher-grade studies of a wider set of food groups and must be extended to young adult populations. Future nutritional interventions should involve the most vulnerable adolescent populations, taking account of socio-economic status and migration.

National Dietary Guidelines of Greece for children and adolescents: a tool for promoting healthy eating habits

Objective:

Dietary guidelines are an essential policy tool for facilitating optimal dietary patterns and healthy eating behaviours. We report: (i) the methodological approach adopted for developing the National Dietary Guidelines of Greece (NDGGr) for Infants, Children and Adolescents; and (ii) the guidelines for children aged 1–18 years.

Design:

An evidence-based approach was employed to develop food-based recommendations according to the methodologies of the WHO, FAO and European Food Safety Authority. Physical activity recommendations were also compiled. Food education, healthy eating tips and suggestions were also provided.

Setting:

The NDGGr encompass food-based nutritional and physical activity recommendations for promoting healthy dietary patterns and eating behaviours and secondarily to serve as a helpful tool for the prevention of childhood overweight and obesity.

Results:

The NDGGr include food-based recommendations, food education and health promotion messages regarding: (i) fruits; (ii) vegetables; (iii) milk and dairy products; (iv) cereals; (v) red and white meat; (vi) fish and seafood; (vii) eggs; (viii) legumes; (ix) added lipids, olives, and nuts; (x) added sugars and salt; (xi) water and beverages, and (xii) physical activity. A Nutrition Wheel, consisting of the ten most pivotal key messages, was developed to enhance the adoption of optimal dietary patterns and a healthy lifestyle. The NDGGr additionally provide recommendations regarding the optimal frequency and serving sizes of main meals, based on the traditional Greek diet.

Conclusions:

As a policy tool for promoting healthy eating, the NDGGr have been disseminated in public schools across Greece.

A Systematic Review of the Evaluation of Interventions to Tackle Children's Food Insecurity

PURPOSE OF REVIEW

To synthesise the research which has sought to evaluate interventions aiming to tackle children's food insecurity and the contribution of this research to evidencing the effectiveness of such interventions.

RECENT FINDINGS

The majority of studies in this review were quantitative, non-randomised studies, including cohort studies. Issues with non-complete outcome data, measurement of duration of participation in interventions, and accounting for confounds are common in these evaluation studies. Despite the limitations of the current evidence base, the papers that were reviewed provide evidence for multiple positive outcomes for children participating in attended and subsidy interventions, inter alia, reductions in food insecurity, poor health and obesity. However, current evaluations may overlook key areas of impact of these interventions on the lives and outcomes of participating children. This review suggests that the current evidence base which evaluates food insecurity interventions for children is both mixed and limited in scope and quality. In particular, the outcomes measured are narrow, and many papers have methodological limitations. With this in mind, a systems-based approach to both implementation and evaluation of food poverty interventions is recommended.

How family socioeconomic status, peer behaviors, and school-based intervention on healthy habits influence adolescent eating behaviors

Psychologists in schools can play an important role in developing policies and programs to promote healthy eating habits. This study analyses the contributions of family socioeconomic status, peer influence (schoolmates’ food consumption), and school-based nutrition interventions to explain adolescent eating behaviors. Data were obtained from the 2014 Health behaviour in school-aged children survey in Spain, with a sample of 6,851 adolescents (11- to 16-years-old). The results suggest that school-based healthy-eating programs could improve by considering parental education level and by implementing interventions focused on the peer social network. Policies that limit access to unhealthy products in schools – rather than simply offering healthy foods alongside unhealthy products – could be more effective.

Communication Strategies to Improve Healthy Food Consumption among Schoolchildren: Focus on Milk

This work provides an updated picture of communication strategies developed to improve healthy dietary habits in schoolchildren, with a focus on the importance of milk consumption. The paper has investigated two main areas: the definition of the main orientations and key points of research approach relative to the communication methods, with special attention to multiple strategies and the identification of their peculiarities to increase daily milk consumption. The school environment is considered as a unique environment to help increase the adoption of a correct dietary habit and lifestyle; it increases physical activity by facilitating the flow of health-related information. In this regard, several studies have highlighted the importance and effectiveness of school-based interventions on a large-scale, also considering multiple contexts, early interventions as well as the involvement of teachers, students and families. The effective actions range from interventions on prices and the availability of desirable and undesirable foods to educational programmes that improve food knowledge and the choices of students and/or their parents. From the nutritional point of view, milk is an important component of a well-balanced diet—especially for children—because it contains essential nutrients. It is a substantial contributor to the daily energy intake; however, its consumption often declines with aging and becomes insufficient. Therefore, developing strategies to increase its consumption is an important objective to reach.

Exploring the association between low socioeconomic status and cardiovascular disease risk in healthy Greeks, in the years of financial crisis (2002-2012): The ATTICA study

BACKGROUND

Despite recent declines in mortality, cardiovascular disease (CVD) remains the leading cause of death in Europe today. Given the fact that many of the biological risk factors have already been identified, researchers still search for different modifiable factors that may influence CVD risk, among which SES gathers a great part of interest.

AIMS

To explore the effect of low socioeconomic status (SES) on a 10-year cardiovascular disease (CVD) incidence, in the years of financial crisis.

METHODS

This population-based study was carried out in the province of Attica, where Athens is a major metropolis. During 2001-2002, information from 1528 men (18-87years old) and 1514 women (18-89years old) was collected. Educational level and annual income were used to define their SES. After a 10-year of follow-up period (2002-2012), CVD incidence was recorded.

RESULTS

Low compared to high SES class, at the ages above 45years, was independently associated with increased 10-year CVD incidence [adjusted odds ratio and 95% confidence interval: 2.7 (1.5, 4.9)] but not among the younger participants. SES was also negatively associated with psychological components (all p-values<0.001), diabetes mellitus (p=0.002), obesity (p=0.087) and physical activity (p=0.056).

CONCLUSION

There is evidence for a consistent reverse relation between SES and the incidence of CVD and for higher CVD risk factors among less privileged individuals. The striking differences by SES underscore the critical need to improve screening, early detection, and treatment of CVD-related conditions for people of lower SES, emphasizing in the middle-aged groups.

School-based Interventions to Reduce Sedentary Behaviour in Children: A Systematic Review

INTRODUCTION

Prolonged, uninterrupted periods of sedentary time may be associated with increased risk of Type II diabetes, cardiovascular disease and all-cause mortality even if the minimum recommended levels of daily physical activity are achieved. It is reported that children spend approximately 80% of their day engaged in sedentary behaviours. Since children spend a large portion of their waking time at school, school-based interventions targeting excessive or interrupted periods of sedentary time have been investigated in a number of studies. However, results of the effectiveness of studies to-date have been inconsistent.

AIM

To conduct a systematic review to evaluate the effectiveness of school-based interventions designed to reduce sedentary behaviour on objectively measured sedentary time in children.

METHODS

Five electronic databases were searched to retrieve peer-reviewed studies published in English up to and including August 2015. Studies that reported objectively measured sedentary time before and after a school-based intervention to reduce sedentary time were included in the review. Risk of bias was assessed using the Cochrane Collaboration method.

RESULTS

Our search identified eleven papers reporting eight interventions. Studies focused on the physical environment, the curriculum, individual in-class activities, homework activities or a combination of these strategies. Three studies reported decreases in sedentary time following intervention. Study follow-up periods ranged from immediately post-intervention to 12 months. None of the studies were judged to have a low risk of bias.

CONCLUSIONS

Multicomponent interventions which also include the use of standing desks may be an effective method for reducing children's sedentary time in a school-based intervention. However, longer term trials are needed to determine the sustained effectiveness of such interventions on children's sedentary time.

Promotion of healthy nutrition among students participating in a school food aid program: a randomized trial

OBJECTIVES

To evaluate the potential benefits on students' eating habits, of incorporating healthy nutrition education as part of a school food aid program.

METHODS

146 schools participating in the DIATROFI Program in Greece during the 2013-2014 school year were randomly allocated to the environmental intervention (received a healthy daily meal) and the multicomponent intervention (MI) group (in addition to the meal, a healthy nutrition educational program was applied). The analysis, based on 3627 pre-post intervention questionnaire pairs, was stratified for children (ages 4-11 years) and adolescents (ages 12-18 years).

RESULTS

Children participating in the MI group displayed 25 % higher odds of increasing the weekly consumption of milk/yoghurt and fruits, 61 % higher odds of improving BMI from overweight/obese to normal and 2.5 times higher odds of improving from underweight to normal. For adolescents in the MI group, the odds of increasing the consumption of vegetables were 40 % higher. In both intervention groups, approximately one in four overweight/obese adolescents reached normal weight.

CONCLUSIONS

Educational programs on healthy nutrition might be considered worth implementing in the framework of school food aid programs.