The effects of the HEALTHY study intervention on middle school student dietary intakes

Feasibility of a food-based diabetes self-management education intervention for food insecure patients with type 2 diabetes: a convergent mixed methods study

OBJECTIVE

To assess the feasibility of a food-based diabetes self-management education and support (DSMES) intervention delivered to persons with type 2 diabetes (T2DM) and food insecurity.

DESIGN

This single arm pre-/post convergent mixed methods study tested the feasibility of a 3-month intervention using food boxes, recipes, DSMES and dietitian visits. Feasibility benchmarks assessed were acceptability (> 50 % participants satisfied), demand (> 50 % used program components) and implementation (75 % adherence, 80 % retention). Assessments included: self-reported food security, health-related quality of life, diabetes self-efficacy, socio-demographic and dietary intake, height, weight, and HbA1c and one in-depth interview with participants and key staff. Enrollment, recruitment and retention rates were summarised; qualitative data were analysed using structured thematic analysis (participant interviews) and key point summaries (staff interviews). Quantitative/qualitative data integration was conducted using a joint display.

SETTING

Food bank and Federally Qualified Health Center in the Southwestern U.S.

PARTICIPANTS

English- or Spanish-speaking adults with T2DM and food insecurity.

RESULTS

In total, 247 patients with T2DM and food insecurity were recruited, seventy-one expressed interest and twenty-five consented. Twenty-one participants completed study measurements. 71 % (n 15) received six home food deliveries and ≥ 1 dietitian visit. A priori benchmarks were approached or met within each feasibility criterion - most participants found the intervention to be acceptable, used most or all intervention components, and reported some challenges within intervention implementation (e.g. timing of food deliveries). Data integration provided deeper understanding of reported intervention implementation challenges, yet high adherence to the intervention.

CONCLUSIONS

The intervention was feasible. Next steps include a clinical trial to establish intervention efficacy.

Strategies for enhancing the implementation of school-based policies or practices targeting diet, physical activity, obesity, tobacco or alcohol use

BACKGROUND

Several school-based interventions are effective in improving child diet and physical activity, and preventing excessive weight gain, and tobacco or harmful alcohol use. However, schools are frequently unsuccessful in implementing such evidence-based interventions.

OBJECTIVES

1. To evaluate the benefits and harms of strategies aiming to improve school implementation of interventions to address student diet, physical activity, tobacco or alcohol use, and obesity. 2. To evaluate the benefits and harms of strategies to improve intervention implementation on measures of student diet, physical activity, obesity, tobacco use or alcohol use; describe their cost or cost-effectiveness; and any harms of strategies on schools, school staff or students.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search was between 1 September 2016 and 30 April 2021 to identify any relevant trials published since the last published review.

SELECTION CRITERIA

We defined 'Implementation' as the use of strategies to adopt and integrate evidence-based health interventions and to change practice patterns within specific settings. We included any trial (randomised controlled trial (RCT) or non-randomised controlled trial (non-RCT)) conducted at any scale, with a parallel control group that compared a strategy to implement policies or practices to address diet, physical activity, overweight or obesity, tobacco or alcohol use by students to 'no intervention', 'usual' practice or a different implementation strategy.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Given the large number of outcomes reported, we selected and included the effects of a single outcome measure for each trial for the primary (implementation) and secondary (student health behaviour and obesity) outcomes using a decision hierarchy. Where possible, we calculated standardised mean differences (SMDs) to account for variable outcome measures with 95% confidence intervals (CI). For RCTs, we conducted meta-analyses of primary and secondary outcomes using a random-effects model, or in instances where there were between two and five studies, a fixed-effect model. The synthesis of the effects for non-randomised studies followed the 'Synthesis without meta-analysis' (SWiM) guidelines.

MAIN RESULTS

We included an additional 11 trials in this update bringing the total number of included studies in the review to 38. Of these, 22 were conducted in the USA. Twenty-six studies used RCT designs. Seventeen trials tested strategies to implement healthy eating, 12 physical activity and six a combination of risk factors. Just one trial sought to increase the implementation of interventions to delay initiation or reduce the consumption of alcohol. All trials used multiple implementation strategies, the most common being educational materials, educational outreach and educational meetings. The overall certainty of evidence was low and ranged from very low to moderate for secondary review outcomes. Pooled analyses of RCTs found, relative to a control, the use of implementation strategies may result in a large increase in the implementation of interventions in schools (SMD 1.04, 95% CI 0.74 to 1.34; 22 RCTs, 1917 participants; low-certainty evidence). For secondary outcomes we found, relative to control, the use of implementation strategies to support intervention implementation may result in a slight improvement on measures of student diet (SMD 0.08, 95% CI 0.02 to 0.15; 11 RCTs, 16,649 participants; low-certainty evidence) and physical activity (SMD 0.09, 95% CI -0.02 to 0.19; 9 RCTs, 16,389 participants; low-certainty evidence). The effects on obesity probably suggest little to no difference (SMD -0.02, 95% CI -0.05 to 0.02; 8 RCTs, 18,618 participants; moderate-certainty evidence). The effects on tobacco use are very uncertain (SMD -0.03, 95% CIs -0.23 to 0.18; 3 RCTs, 3635 participants; very low-certainty evidence). One RCT assessed measures of student alcohol use and found strategies to support implementation may result in a slight increase in use (odds ratio 1.10, 95% CI 0.77 to 1.56; P = 0.60; 2105 participants). Few trials reported the economic evaluations of implementation strategies, the methods of which were heterogeneous and evidence graded as very uncertain. A lack of consistent terminology describing implementation strategies was an important limitation of the review.

AUTHORS' CONCLUSIONS

The use of implementation strategies may result in large increases in implementation of interventions, and slight improvements in measures of student diet, and physical activity. Further research is required to assess the impact of implementation strategies on such behavioural- and obesity-related outcomes, including on measures of alcohol use, where the findings of one trial suggest it may slightly increase student risk. Given the low certainty of the available evidence for most measures further research is required to guide efforts to facilitate the translation of evidence into practice in this setting.

Theoretical and practical approaches for dietary behavior change in urban socioeconomically disadvantaged adolescents: a systematic review

CONTEXT

There is limited evidence on strategies used to promote dietary behavior changes in socioeconomically disadvantaged urban adolescents and on their effectiveness.

OBJECTIVE

A synthesis of nutrition interventions used in this group of adolescents is provided in this systematic review.

DATA SOURCES

Five electronic databases (PubMed, Web of Science, CINAHL, PsycINFO, and ERIC) were searched until November 2020 to identify relevant studies.

DATA EXTRACTION

Forty-six manuscripts (n = 38 intervention studies) met the inclusion criteria. Quality was assessed with the Effective Public Health Practice Project Quality Assessment Tool. A qualitative synthesis summarizing data on study characteristics was conducted.

DATA ANALYSIS

Studies were classified by intervention type as those focusing on hedonic determinants of dietary intake (n = 1), environmental changes to promote a specific dietary intake (n = 3), cognitive determinants (n = 29), and multicomponent strategies (n = 13). The social cognitive theory was the most applied theoretical framework, either alone or combined with other frameworks. Most of the intervention studies targeted multiple dietary outcomes, and success was not always reported for each.

CONCLUSIONS

Despite the heterogeneity of the studies and lack of combination of dietary outcomes into dietary scores or patterns to evaluate changes on the individuals' whole diets, long-term, theory-driven interventions targeting a single dietary factor seem promising in obtaining sustainable dietary behavior changes.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42020188219.

Shifting From Tokenism to Meaningful Adolescent Participation in Research for Obesity Prevention: A Systematic Scoping Review

Background: Traditionally, adolescent participation in research has been tokenistic. Adolescents are rarely afforded the opportunity to influence decision-making in research designed to prevent obesity. Engaging adolescents in meaningful decision-making may enhance research translation. This review aimed to analyze the current modes and nature of adolescent participation in obesity prevention research decision-making. Methods: A systematic scoping review was conducted using Arksey and O'Malley's six-stage framework. Six major databases were searched for peer-reviewed primary research studies with adolescent participation related to obesity, physical activity, and diet. Modes of adolescent participation were categorized based on the Lansdown-UNICEF conceptual framework for measuring outcomes of adolescent participation. The framework outlines three modes of meaningful participation: (i) consultative, which involves taking opinions and needs into consideration; (ii) collaborative, where adolescents are partners in the decision-making process; and (iii) adolescent-led participation where adolescents have the capacity to influence the process and outcomes. The degree of involvement in research cycles was classified based on the National Health and Medical Research Council consumer engagement framework. Five stages of the research cycle were determined: identify, design and develop, conduct, analyze and disseminate. Results: In total, 126 papers describing 71 unique studies were identified. Of these, 69% (49/71) took place in the USA, and 85% (52/61) were conducted in minority or underserved communities, while males were more likely to be under-represented. In 49% (35/71) of studies, participation was consultative and 9% (6/71) of studies involved an adolescent-led approach. Furthermore, 87% (62/71) of studies incorporated adolescent participation in one or more of the research cycle's formative phases, which involve eliciting views, opinions and idea generation. Only 11% of studies engaged adolescents in all five stages of the research cycle where adolescents could have more influence over the research process. Conclusion: Meaningful adolescent participation in the obesity prevention research cycle is limited. Empowering and mobilizing equal partnership with adolescents should be at the forefront of all adolescent-related obesity prevention research.

Changes in Dietary Magnesium Intake and Risk of Type 2 Diabetes Mellitus in Middle School Students: Using Data from the HEALTHY Study

BACKGROUND

The HEALTHY Study was a multicomponent school-based intervention, designed to prevent type 2 diabetes mellitus (T2DM) in middle-school students.

OBJECTIVES

We examined whether the difference in dietary magnesium intake, BMI percentile, and plasma glucose and insulin concentrations from 6th to 8th grade were related in the intervention schools and in the control schools that participated in the HEALTHY Study.

METHODS

A total of 2181 ethnically diverse students, from 11.3 to 13.7 y of age, with completed dietary records, BMI percentile, and plasma glucose and insulin concentrations at 6th and 8th grades were included. Dietary magnesium intake was self-reported using the Block Kids FFQ. A hierarchical multiple regression model was used to determine whether the differences in dietary magnesium intake, BMI percentile, and plasma glucose and insulin concentrations from 6th to 8th grades were related, while adjusting for dietary calcium intake and total energy intake.

RESULTS

The difference in dietary magnesium intake was significantly related to changes in BMI percentile from 6th to 8th grade in intervention and in control schools [intervention: β: -0.07; 95% CI: -0.58, -0.02; P = 0.03; R2 (regression coefficient effect size): 0.14; 95% CI for R2: 0.10, 0.17; control: β: -0.08; 95% CI: -0.63, -0.09; P = 0.01; R2: 0.12; 95% CI for R2: 0.08, 0.15]. The difference in dietary magnesium intake was not related to plasma glucose and insulin concentrations in intervention and in control schools.

CONCLUSIONS

We conclude that a multicomponent intervention was associated with reduced risk of T2DM, and that this association may be modulated, in part, by magnesium. The differences in dietary magnesium intake from 6th to 8th grade were negatively related to changes in BMI percentile among middle-school students.

School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6 to 18

BACKGROUND

Physical activity among children and adolescents is associated with lower adiposity, improved cardio-metabolic health, and improved fitness. Worldwide, fewer than 30% of children and adolescents meet global physical activity recommendations of at least 60 minutes of moderate to vigorous physical activity per day. Schools may be ideal sites for interventions given that children and adolescents in most parts of the world spend a substantial amount of time in transit to and from school or attending school.

OBJECTIVES

The purpose of this review update is to summarise the evidence on effectiveness of school-based interventions in increasing moderate to vigorous physical activity and improving fitness among children and adolescents 6 to 18 years of age. Specific objectives are: • to evaluate the effects of school-based interventions on increasing physical activity and improving fitness among children and adolescents; • to evaluate the effects of school-based interventions on improving body composition; and • to determine whether certain combinations or components (or both) of school-based interventions are more effective than others in promoting physical activity and fitness in this target population.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, BIOSIS, SPORTDiscus, and Sociological Abstracts to 1 June 2020, without language restrictions. We screened reference lists of included articles and relevant systematic reviews. We contacted primary authors of studies to ask for additional information.

SELECTION CRITERIA

Eligible interventions were relevant to public health practice (i.e. were not delivered by a clinician), were implemented in the school setting, and aimed to increase physical activity among all school-attending children and adolescents (aged 6 to 18) for at least 12 weeks. The review was limited to randomised controlled trials. For this update, we have added two new criteria: the primary aim of the study was to increase physical activity or fitness, and the study used an objective measure of physical activity or fitness. Primary outcomes included proportion of participants meeting physical activity guidelines and duration of moderate to vigorous physical activity and sedentary time (new to this update). Secondary outcomes included measured body mass index (BMI), physical fitness, health-related quality of life (new to this update), and adverse events (new to this update). Television viewing time, blood cholesterol, and blood pressure have been removed from this update.  DATA COLLECTION AND ANALYSIS: Two independent review authors used standardised forms to assess each study for relevance, to extract data, and to assess risk of bias. When discrepancies existed, discussion occurred until consensus was reached. Certainty of evidence was assessed according to GRADE. A random-effects meta-analysis based on the inverse variance method was conducted with participants stratified by age (children versus adolescents) when sufficient data were reported. Subgroup analyses explored effects by intervention type.

MAIN RESULTS

Based on the three new inclusion criteria, we excluded 16 of the 44 studies included in the previous version of this review. We screened an additional 9968 titles (search October 2011 to June 2020), of which 978 unique studies were potentially relevant and 61 met all criteria for this update. We included a total of 89 studies representing complete data for 66,752 study participants. Most studies included children only (n = 56), followed by adolescents only (n = 22), and both (n = 10); one study did not report student age. Multi-component interventions were most common (n = 40), followed by schooltime physical activity (n = 19), enhanced physical education (n = 15), and before and after school programmes (n = 14); one study explored both enhanced physical education and an after school programme. Lack of blinding of participants, personnel, and outcome assessors and loss to follow-up were the most common sources of bias.  Results show that school-based physical activity interventions probably result in little to no increase in time engaged in moderate to vigorous physical activity (mean difference (MD) 0.73 minutes/d, 95% confidence interval (CI) 0.16 to 1.30; 33 studies; moderate-certainty evidence) and may lead to little to no decrease in sedentary time (MD -3.78 minutes/d, 95% CI -7.80 to 0.24; 16 studies; low-certainty evidence). School-based physical activity interventions may improve physical fitness reported as maximal oxygen uptake (VO₂max) (MD 1.19 mL/kg/min, 95% CI 0.57 to 1.82; 13 studies; low-certainty evidence). School-based physical activity interventions may result in a very small decrease in BMI z-scores (MD -0.06, 95% CI -0.09 to -0.02; 21 studies; low-certainty evidence) and may not impact BMI expressed as kg/m² (MD -0.07, 95% CI -0.15 to 0.01; 50 studies; low-certainty evidence). We are very uncertain whether school-based physical activity interventions impact health-related quality of life or adverse events.

AUTHORS' CONCLUSIONS

Given the variability of results and the overall small effects, school staff and public health professionals must give the matter considerable thought before implementing school-based physical activity interventions. Given the heterogeneity of effects, the risk of bias, and findings that the magnitude of effect is generally small, results should be interpreted cautiously.

Perceptions and Impact of a Youth-led Childhood Obesity Prevention Intervention among Youth-leaders

Objective

To evaluate the impact of a youth-led nutrition intervention on youth-leaders themselves.

Design

Mixed methods, including: in-depth interviews and a quasi-experimental quantitative study comparing youth-leaders and nonparticipant comparison youth.

Analysis

Qualitative analysis using direct content analysis. Difference-in-differences analyses assessing quantitative program impact.

Results

Youth-leaders perceived that the intervention impacted themselves, the youth-participants, and their respective social networks. Youth-leaders experienced greater increases in intentions to eat healthfully (p=0.04), and greater decreases in support for healthy eating from their friends (p=0.01), than the comparison group.

Conclusions/Implications

Youth-leaders reported multiple levels of intervention impact, and increased intentions for healthy eating; however, additional research is needed to enhance impact on behavioral outcomes.

Evaluation of the 'H2NOE Water Schools' programme to promote water consumption in elementary school children - a non-randomised controlled cluster trial

Objective:

This study evaluated a simple environmental intervention called ‘Water Schools’ in Lower Austria providing free refillable water bottles and educational material.

Design:

Non-randomised controlled cluster trial with three measurements: at baseline (T0), after the intervention at 9 months (T1) and after 1-year follow-up (T2).

Setting:

Half-day elementary schools in Lower Austria (Austria).

Participants:

Third-grade pupils from twenty-two schools in the intervention group (IG) and thirty-two schools in the control group (CG) participated in the study. Data were analysed for 569 to 598 pupils in the IG and for 545 to 613 in the CG, depending on the time of measurement.

Results:

The consumption of tap water increased in the IG from baseline to T1 and then decreased again at T2, but this was similar in the CG (no statistically significant difference in the time trend between the IG and CG). Similar results were seen for tap water consumption in the mornings. The proportion of children who only drank tap water on school mornings increased significantly from baseline to T1 in the IG compared to the CG (P = 0·020). No difference in the changes over time occurred between the groups for the proportion of pupils drinking approximately one bottle of tap water during school mornings.

Conclusions:

Not only the children in the IG but also those in the CG drank more tap water after 1 school year than at the beginning. The measurement of drinking habits in the CG may have been intervention enough to bring about changes or to initiate projects.

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

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

Interventions to Promote Healthy Meals in Full-Service Restaurants and Canteens: A Systematic Review and Meta-Analysis

Out-of-home eating is increasing, but evidence about its healthiness is limited. The present systematic review and meta-analysis aimed to elucidate the effectiveness of full-service restaurant and canteen-based interventions in increasing the dietary intake, food availability, and food purchase of healthy meals. Studies from 2000-2020 were searched in Medline, Scopus, and Cochrane Library using the PRISMA checklist. A total of 35 randomized controlled trials (RCTs) and 6 non-RCTs were included in the systematic review and analyzed by outcome, intervention strategies, and settings (school, community, workplace). The meta-analysis included 16 RCTs (excluding non-RCTs for higher quality). For dietary intake, the included RCTs increased healthy foods (+0.20 servings/day; 0.12 to 0.29; p < 0.001) and decreased fat intake (-9.90 g/day; -12.61 to -7.19; p < 0.001), favoring the intervention group. For food availability, intervention schools reduced the risk of offering unhealthy menu items by 47% (RR 0.53; 0.34 to 0.85; p = 0.008). For food purchases, a systematic review showed that interventions could be partially effective in improving healthy foods. Lastly, restaurant- and canteen-based interventions improved the dietary intake of healthy foods, reduced fat intake, and increased the availability of healthy menus, mainly in schools. Higher-quality RCTs are needed to strengthen the results. Moreover, from our results, intervention strategy recommendations are provided.

Dietary magnesium intake in relation to body mass index and glycemic indices in middle school students from the HEALTHY Study

BACKGROUND

Data on dietary magnesium intake on the risk of type 2 diabetes mellitus (T2DM) among children and adolescents is limited.

AIM

We examined whether dietary magnesium intake was related to body mass index (BMI) percentile, and glycemic indices at baseline and at end of the HEALTHY Study for both intervention and control schools. The HEALTHY Study was a multi-component, school-based intervention, to prevent T2DM in children and adolescents from 6th to 8th grades.

METHODS

A secondary data analyses of 2181 ethnically diverse students with completed dietary records, BMI percentile, and plasma insulin and glucose concentrations at baseline (6th grade) and end of study (8th grade) were included from the HEALTHY Study. Dietary magnesium intake was self-reported using the Block Kids Food Frequency Questionnaire. A hierarchical multiple regression model was used to determine the relationships between dietary magnesium intake, BMI percentile, and glycemic indices at baseline and end of the HEALTHY Study, adjusting for magnesium intake from supplements, total energy intake, and fitness level.

RESULTS

Dietary magnesium intake was related to BMI percentile at baseline and at end of the HEATHY Study (β = -0.05, 95% CI = -0.02 to 0, p = 0.04; β = -0.06, 95% CI = -0.02 to -0.003, p = 0.004); R ² [regression coefficient effect size] = 0.03; R ² = 0.06). Dietary magnesium intake was not related to plasma insulin and glucose concentrations at baseline and end of the HEALTHY Study.

CONCLUSION

Dietary magnesium intake was inversely related to BMI percentile among middle school students from the HEALTHY Study. Research is required to evaluate the dose-response relationship between fruit and vegetable consumption (good sources of magnesium) and risk of T2DM in children and adolescents. This relationship also needs to be explored among different BMI categories.

Interventions to increase the consumption of water among children: A systematic review and meta-analysis

The aim of this study was to conduct a systematic review and meta-analysis on the effectiveness of interventions to increase children's water consumption. A systematic literature search was conducted in seven electronic databases. Studies published in English before 18 February 2019 that evaluated any type of intervention that measured change in water consumption among children aged 2 to 12 years by applying any type of design were included. Of the 47 interventions included in the systematic review, 24 reported a statistically significant increase in water consumption. Twenty-four interventions (17 randomized controlled trials and seven studies with other controlled designs) were included in the meta-analysis. On average, children in intervention groups consumed 29 mL/d (confidence interval [CI] = 13-46 mL/d) more water than did children in control groups. This effect was larger in eight interventions focused specifically on diet (MD = 73 mL/d, CI = 20-126 mL/d) than in 16 interventions focused also on other lifestyle factors (MD = 15 mL/d, CI = 1-29 mL/d). Significant subgroup differences were also found by study setting and socioecological level targeted but not by children's age group, intervention strategy, or study design. In conclusion, there is evidence that, on average, lifestyle interventions can lead to small increases in children's daily water consumption. More research is needed to further understand the specific intervention elements that have the greatest effect.

Identification and evaluation of risk of generalizability biases in pilot versus efficacy/effectiveness trials: a systematic review and meta-analysis

BACKGROUND

Preliminary evaluations of behavioral interventions, referred to as pilot studies, predate the conduct of many large-scale efficacy/effectiveness trial. The ability of a pilot study to inform an efficacy/effectiveness trial relies on careful considerations in the design, delivery, and interpretation of the pilot results to avoid exaggerated early discoveries that may lead to subsequent failed efficacy/effectiveness trials. "Risk of generalizability biases (RGB)" in pilot studies may reduce the probability of replicating results in a larger efficacy/effectiveness trial. We aimed to generate an operational list of potential RGBs and to evaluate their impact in pairs of published pilot studies and larger, more well-powered trial on the topic of childhood obesity.

METHODS

We conducted a systematic literature review to identify published pilot studies that had a published larger-scale trial of the same or similar intervention. Searches were updated and completed through December 31st, 2018. Eligible studies were behavioral interventions involving youth (≤18 yrs) on a topic related to childhood obesity (e.g., prevention/treatment, weight reduction, physical activity, diet, sleep, screen time/sedentary behavior). Extracted information included study characteristics and all outcomes. A list of 9 RGBs were defined and coded: intervention intensity bias, implementation support bias, delivery agent bias, target audience bias, duration bias, setting bias, measurement bias, directional conclusion bias, and outcome bias. Three reviewers independently coded for the presence of RGBs. Multi-level random effects meta-analyses were performed to investigate the association of the biases to study outcomes.

RESULTS

A total of 39 pilot and larger trial pairs were identified. The frequency of the biases varied: delivery agent bias (19/39 pairs), duration bias (15/39), implementation support bias (13/39), outcome bias (6/39), measurement bias (4/39), directional conclusion bias (3/39), target audience bias (3/39), intervention intensity bias (1/39), and setting bias (0/39). In meta-analyses, delivery agent, implementation support, duration, and measurement bias were associated with an attenuation of the effect size of - 0.325 (95CI - 0.556 to - 0.094), - 0.346 (- 0.640 to - 0.052), - 0.342 (- 0.498 to - 0.187), and - 0.360 (- 0.631 to - 0.089), respectively.

CONCLUSIONS

Pre-emptive avoidance of RGBs during the initial testing of an intervention may diminish the voltage drop between pilot and larger efficacy/effectiveness trials and enhance the odds of successful translation.

Cost-Effectiveness of Water Promotion Strategies in Schools for Preventing Childhood Obesity and Increasing Water Intake

OBJECTIVE

This study aimed to estimate the cost-effectiveness and impact on childhood obesity of installation of chilled water dispensers ("water jets") on school lunch lines and to compare water jets' cost, reach, and impact on water consumption with three additional strategies.

METHODS

The Childhood Obesity Intervention Cost Effectiveness Study(CHOICES) microsimulation model estimated the cost-effectiveness of water jets on US childhood obesity cases prevented in 2025. Also estimated were the cost, number of children reached, and impact on water consumption of the installation of water jets and three other strategies.

RESULTS

Installing water jets on school lunch lines was projected to reach 29.6 million children (95% uncertainty interval [UI]: 29.4 million-29.8 million), cost $4.25 (95% UI: $2.74-$5.69) per child, prevent 179,550 cases of childhood obesity in 2025 (95% UI: 101,970-257,870), and save $0.31 in health care costs per dollar invested (95% UI: $0.15-$0.55). In the secondary analysis, installing cup dispensers next to existing water fountains was the least costly but also had the lowest population reach.

CONCLUSIONS

Installating water jet dispensers on school lunch lines could also save almost half of the dollars needed for implementation via a reduction in obesity-related health care costs. School-based interventions to promote drinking water may be relatively inexpensive strategies for improving child health.

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

Context

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

Objective

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

Data Sources

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

Study Selection

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

Data Extraction

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

Results

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

Conclusions

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

Systematic Review Registration

PROSPERO registration number CRD42014004432.

Factors Associated with Identification and Consumption of Whole-Grain Foods in a Low-Income Population

BACKGROUND

US Dietary Guidelines include recommendations to increase whole-grain consumption, but most Americans, especially low-income adults, fail to consume adequate amounts.

OBJECTIVES

The aim of this study was to determine major factors that may affect whole-grain consumption among low-income adults.

METHODS

A mixed methods approach including a whole-grain food identification activity and in-depth interview was used to determine the factors that influence whole-grain consumption based on the constructs of the integrative behavioral model. Participants were recruited from food pantries in the northeastern United States. Descriptive statistics were conducted for demographic data and survey scores, and logistic regression was used to examine differences in whole-grain accuracy by demographic characteristics.

RESULTS

Low-income adults (n = 169) completed a quantitative survey, with a subset (n = 60) recruited for an in-depth qualitative interview. When completing the whole-grain identification activity, most low-income adults identified popcorn incorrectly as refined grain (71%), whereas the refined-grain food commonly identified as whole grain was white rice (42%). Less than half of low-income adults (46%) identified the majority of whole-grain foods correctly. Age, race, and education were not associated with the ability to identify whole-grain foods correctly. However, younger adults (aged 18-49 y) were less likely to identify popcorn as a whole-grain food (OR = 0.42, P = 0.02) compared with older adults (aged ≥50 y). According to the qualitative results, additional barriers, such as perceived cost, may also affect whole-grain food consumption among low-income adults.

CONCLUSIONS

Low-income adults' ability to correctly identify whole-grain foods and having a perception that whole-grain foods are higher in cost may be the overarching barriers to consuming adequate amounts. Future efforts should focus on strategies improving identification and seeking affordable whole-grain foods to increase whole-grain consumption in low-income adults.

Environmental interventions to reduce the consumption of sugar-sweetened beverages and their effects on health

BACKGROUND

Frequent consumption of excess amounts of sugar-sweetened beverages (SSB) is a risk factor for obesity, type 2 diabetes, cardiovascular disease and dental caries. Environmental interventions, i.e. interventions that alter the physical or social environment in which individuals make beverage choices, have been advocated as a means to reduce the consumption of SSB.

OBJECTIVES

To assess the effects of environmental interventions (excluding taxation) on the consumption of sugar-sweetened beverages and sugar-sweetened milk, diet-related anthropometric measures and health outcomes, and on any reported unintended consequences or adverse outcomes.

SEARCH METHODS

We searched 11 general, specialist and regional databases from inception to 24 January 2018. We also searched trial registers, reference lists and citations, scanned websites of relevant organisations, and contacted study authors.

SELECTION CRITERIA

We included studies on interventions implemented at an environmental level, reporting effects on direct or indirect measures of SSB intake, diet-related anthropometric measures and health outcomes, or any reported adverse outcome. We included randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after (CBA) and interrupted-time-series (ITS) studies, implemented in real-world settings with a combined length of intervention and follow-up of at least 12 weeks and at least 20 individuals in each of the intervention and control groups. We excluded studies in which participants were administered SSB as part of clinical trials, and multicomponent interventions which did not report SSB-specific outcome data. We excluded studies on the taxation of SSB, as these are the subject of a separate Cochrane Review.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies for inclusion, extracted data and assessed the risks of bias of included studies. We classified interventions according to the NOURISHING framework, and synthesised results narratively and conducted meta-analyses for two outcomes relating to two intervention types. We assessed our confidence in the certainty of effect estimates with the GRADE framework as very low, low, moderate or high, and presented 'Summary of findings' tables.

MAIN RESULTS

We identified 14,488 unique records, and assessed 1030 in full text for eligibility. We found 58 studies meeting our inclusion criteria, including 22 RCTs, 3 NRCTs, 14 CBA studies, and 19 ITS studies, with a total of 1,180,096 participants. The median length of follow-up was 10 months. The studies included children, teenagers and adults, and were implemented in a variety of settings, including schools, retailing and food service establishments. We judged most studies to be at high or unclear risk of bias in at least one domain, and most studies used non-randomised designs. The studies examine a broad range of interventions, and we present results for these separately.Labelling interventions (8 studies): We found moderate-certainty evidence that traffic-light labelling is associated with decreasing sales of SSBs, and low-certainty evidence that nutritional rating score labelling is associated with decreasing sales of SSBs. For menu-board calorie labelling reported effects on SSB sales varied.Nutrition standards in public institutions (16 studies): We found low-certainty evidence that reduced availability of SSBs in schools is associated with decreased SSB consumption. We found very low-certainty evidence that improved availability of drinking water in schools and school fruit programmes are associated with decreased SSB consumption. Reported associations between improved availability of drinking water in schools and student body weight varied.Economic tools (7 studies): We found moderate-certainty evidence that price increases on SSBs are associated with decreasing SSB sales. For price discounts on low-calorie beverages reported effects on SSB sales varied.Whole food supply interventions (3 studies): Reported associations between voluntary industry initiatives to improve the whole food supply and SSB sales varied.Retail and food service interventions (7 studies): We found low-certainty evidence that healthier default beverages in children's menus in chain restaurants are associated with decreasing SSB sales, and moderate-certainty evidence that in-store promotion of healthier beverages in supermarkets is associated with decreasing SSB sales. We found very low-certainty evidence that urban planning restrictions on new fast-food restaurants and restrictions on the number of stores selling SSBs in remote communities are associated with decreasing SSB sales. Reported associations between promotion of healthier beverages in vending machines and SSB intake or sales varied.Intersectoral approaches (8 studies): We found moderate-certainty evidence that government food benefit programmes with restrictions on purchasing SSBs are associated with decreased SSB intake. For unrestricted food benefit programmes reported effects varied. We found moderate-certainty evidence that multicomponent community campaigns focused on SSBs are associated with decreasing SSB sales. Reported associations between trade and investment liberalisation and SSB sales varied.Home-based interventions (7 studies): We found moderate-certainty evidence that improved availability of low-calorie beverages in the home environment is associated with decreased SSB intake, and high-certainty evidence that it is associated with decreased body weight among adolescents with overweight or obesity and a high baseline consumption of SSBs.Adverse outcomes reported by studies, which may occur in some circumstances, included negative effects on revenue, compensatory SSB consumption outside school when the availability of SSBs in schools is reduced, reduced milk intake, stakeholder discontent, and increased total energy content of grocery purchases with price discounts on low-calorie beverages, among others. The certainty of evidence on adverse outcomes was low to very low for most outcomes.We analysed interventions targeting sugar-sweetened milk separately, and found low- to moderate-certainty evidence that emoticon labelling and small prizes for the selection of healthier beverages in elementary school cafeterias are associated with decreased consumption of sugar-sweetened milk. We found low-certainty evidence that improved placement of plain milk in school cafeterias is not associated with decreasing sugar-sweetened milk consumption.

AUTHORS' CONCLUSIONS

The evidence included in this review indicates that effective, scalable interventions addressing SSB consumption at a population level exist. Implementation should be accompanied by high-quality evaluations using appropriate study designs, with a particular focus on the long-term effects of approaches suitable for large-scale implementation.

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

Childhood obesity is a global health concern, which has both short- and long-term health consequences for the individual, and is a potential burden on health care services and the wider economy. The school environment is a setting where changes can be applied to dietary behaviours, as schools have direct and intensive contact with children. This systematic review evaluated school-based interventions designed to improve dietary behaviours among adolescents (11- to 16-year-olds). The aims were to review types of interventions delivered, dietary behaviours targeted, and interventions' effectiveness in improving dietary behaviour and associated intervention components. Twenty-nine school-based interventional studies with this population were identified for review. The data were synthesized by identifying and comparing individual studies' results, intervention components, and characteristics. Interventions appeared more effective when they involved peers, used educational media to deliver health messages, increased availability of healthy foods in school, and incorporated computer-based individualized feedback with normative information on eating behaviours. A limitation of the review was the lack of description in certain reviewed studies and the nonfeasibility of conducting a meta-analysis owing to study heterogeneity. Future interventions with this population could consider including the aforementioned components, gender-specific feedback, and both short- and long-term follow-ups as change may not be apparent immediately and to determine if changes are sustained.

Physical activity of 15-17 years old adolescents in different educational settings: a Polish-Czech study

OBJECTIVES

The aim of this study was to analyze adolescents' physical activity (PA) in two different educational settings, and to estimate the association between meeting PA recommendations and specific characteristics of adolescents' lifestyle.

METHODS

The study was carried out in the Moravia region of the Czech Republic and in the Silesia-Opole region of Poland. In total, 1,846 participants completed the long International Physical Activity Questionnaire (IPAQ-long) using the online Indares system.

RESULTS

Results showed that the Polish sample was significantly more physically active than the Czech one concerning school PA (p < 0.001; η² = 0.07). Comparing by gender, significant differences were found in vigorous PA (p < 0.001; η² = 0.05) and moderate PA (p < 0.001; η² = 0.08) in both samples. The recommendations for vigorous PA are met by 45.9% of Czech boys and 33.4% of girls; and by 64.5% of Polish boys and 51.3% of girls. Participation in organized PA was the main correlate to achieve the recommendations of vigorous PA in both Czech (p < 0.001; CI = 4.47-9.25) and Polish adolescents (p < 0.001; CI = 1.99-5.37).

CONCLUSIONS

The Polish educational model seems to be more effective for enhancing higher levels of PA among youth, as it provides pupils with a wider offer of organized PA. Girls were found to be less active than boys at high PA intensities in both countries, therefore, more effort must be put on involving them in organized PA.

Effects of total fat intake on bodyweight in children

BACKGROUND

As part of efforts to prevent childhood overweight and obesity, we need to understand the relationship between total fat intake and body fatness in generally healthy children.

OBJECTIVES

To assess the effects and associations of total fat intake on measures of weight and body fatness in children and young people not aiming to lose weight.

SEARCH METHODS

For this update we revised the previous search strategy and ran it over all years in the Cochrane Library, MEDLINE (Ovid), MEDLINE (PubMed), and Embase (Ovid) (current to 23 May 2017). No language and publication status limits were applied. We searched the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov for ongoing and unpublished studies (5 June 2017).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in children aged 24 months to 18 years, with or without risk factors for cardiovascular disease, randomised to a lower fat (30% or less of total energy (TE)) versus usual or moderate-fat diet (greater than 30%TE), without the intention to reduce weight, and assessed a measure of weight or body fatness after at least six months. We included prospective cohort studies if they related baseline total fat intake to weight or body fatness at least 12 months later.

DATA COLLECTION AND ANALYSIS

We extracted data on participants, interventions or exposures, controls and outcomes, and trial or cohort quality characteristics, as well as data on potential effect modifiers, and assessed risk of bias for all included studies. We extracted body weight and blood lipid levels outcomes at six months, six to 12 months, one to two years, two to five years and more than five years for RCTs; and for cohort studies, at baseline to one year, one to two years, two to five years, five to 10 years and more than 10 years. We planned to perform random-effects meta-analyses with relevant subgrouping, and sensitivity and funnel plot analyses where data allowed.

MAIN RESULTS

We included 24 studies comprising three parallel-group RCTs (n = 1054 randomised) and 21 prospective analytical cohort studies (about 25,059 children completed). Twenty-three studies were conducted in high-income countries. No meta-analyses were possible, since only one RCT reported the same outcome at each time point range for all outcomes, and cohort studies were too heterogeneous to combine.Effects of dietary counselling to reduce total fat intake from RCTsTwo studies recruited children aged between 4 and 11 years and a third recruited children aged 12 to 13 years. Interventions were combinations of individual and group counselling, and education sessions in clinics, schools and homes, delivered by dieticians, nutritionists, behaviourists or trained, supervised teachers. Concerns about imprecision and poor reporting limited our confidence in our findings. In addition, the inclusion of hypercholesteraemic children in two trials raised concerns about applicability.One study of dietary counselling to lower total fat intake found that the intervention may make little or no difference to weight compared with usual diet at 12 months (mean difference (MD) -0.50 kg, 95% confidence interval (CI) -1.78 to 0.78; n = 620; low-quality evidence) and at three years (MD -0.60 kg, 95% CI -2.39 to 1.19; n = 612; low-quality evidence). Education delivered as a classroom curriculum probably decreased BMI in children at 17 months (MD -1.5 kg/m2, 95% CI -2.45 to -0.55; 1 RCT; n = 191; moderate-quality evidence). The effects were smaller at longer term follow-up (five years: MD 0 kg/m2, 95% CI -0.63 to 0.63; n = 541; seven years; MD -0.10 kg/m2, 95% CI -0.75 to 0.55; n = 576; low-quality evidence).Dietary counselling probably slightly reduced total cholesterol at 12 months compared to controls (MD -0.15 mmol/L, 95% CI -0.24 to -0.06; 1 RCT; n = 618; moderate-quality evidence), but may make little or no difference over longer time periods. Dietary counselling probably slightly decreased low-density lipoprotein (LDL) cholesterol at 12 months (MD -0.12 mmol/L, 95% CI -0.20 to -0.04; 1 RCT; n = 618, moderate-quality evidence) and at five years (MD -0.09, 95% CI -0.17 to -0.01; 1 RCT; n = 623; moderate-quality evidence), compared to controls. Dietary counselling probably made little or no difference to HDL-C at 12 months (MD -0.03 mmol/L, 95% CI -0.08 to 0.02; 1 RCT; n = 618; moderate-quality evidence), and at five years (MD -0.01 mmol/L, 95% CI -0.06 to 0.04; 1 RCT; n = 522; moderate-quality evidence). Likewise, counselling probably made little or no difference to triglycerides in children at 12 months (MD -0.01 mmol/L, 95% CI -0.08 to 0.06; 1 RCT; n = 618; moderate-quality evidence). Lower versus usual or modified fat intake may make little or no difference to height at seven years (MD -0.60 cm, 95% CI -2.06 to 0.86; 1 RCT; n = 577; low-quality evidence).Associations between total fat intake, weight and body fatness from cohort studiesOver half the cohort analyses that reported on primary outcomes suggested that as total fat intake increases, body fatness measures may move in the same direction. However, heterogeneous methods and reporting across cohort studies, and predominantly very low-quality evidence, made it difficult to draw firm conclusions and true relationships may be substantially different.

AUTHORS' CONCLUSIONS

We were unable to reach firm conclusions. Limited evidence from three trials that randomised children to dietary counselling or education to lower total fat intake (30% or less TE) versus usual or modified fat intake, but with no intention to reduce weight, showed small reductions in body mass index, total- and LDL-cholesterol at some time points with lower fat intake compared to controls. There were no consistent effects on weight, high-density lipoprotein (HDL) cholesterol or height. Associations in cohort studies that related total fat intake to later measures of body fatness in children were inconsistent and the quality of this evidence was mostly very low. Most studies were conducted in high-income countries, and may not be applicable in low- and middle-income settings. High-quality, longer-term studies are needed, that include low- and middle-income settings to look at both possible benefits and harms.

Thirsty? Choose Water! Behavioural interventions and water stations in secondary schools a two-by-two factorial randomised controlled trial

Background

Childhood overweight and obesity is a significant public health issue. A key contributing factor is sugar sweetened beverages (SSBs) consumption. Evidence suggests that secondary school students are frequent consumers of SSBs, with high daily consumption. The promotion of water consumption and provision of chilled water stations can reduce SSBs consumption. The Thirsty Choose Water! study will evaluate the effectiveness of two interventions, a behavioural intervention, Thirsty? Choose Water! behavioural intervention (TCW-BI), that target students through the domains of the health promoting high schools framework, and the second intervention is the installation and promotion of chilled water stations.

Methods/design

This community trial will recruit 60 secondary schools from across three Local Health Districts (LHDs) within New South Wales (NSW). A two-by-two factorial study design will be used to determine the effect of the Thirsty? Choose Water! behavioural intervention (TCW-BI), and the installation of chilled water stations. The recruited secondary schools will be randomised and non-blinded to one of four study arms receiving either the TCW-BI or chilled water stations, both interventions, or neither (control group). Baseline measures will be collected including student self-report surveys which will gather data regarding knowledge, attitudes and consumption of water and SSBs, a school profile and an environmental scan. Student surveys will be repeated post the intervention and at follow-up. Regular water meter readings will determine the water flow from the chilled water stations across the study period.

Discussion

There is an increasing body of evidence which suggests that decreasing consumption of SSBs can impact positively on childhood overweight and obesity. However, in the Australian context there are limited studies on how this may occur in the secondary school setting. This study will add to this evidence base and establish the effectiveness of TCW-BI and chilled water stations, either alone or combination on increasing water consumption in adolescents. Information about barriers and facilitators to implementation will be documented. Packages to support the implementation of the TCW-BI as a state-wide initiative will be developed.

Trial registration

Australian and New Zealand Clinical Trials Register ACTRN12618000526279 April 2018.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5685-1) contains supplementary material, which is available to authorized users.

Effects of total fat intake on bodyweight in children

BACKGROUND

As part of efforts to prevent childhood overweight and obesity, we need to understand the relationship between total fat intake and body fatness in generally healthy children.

OBJECTIVES

To assess the effects of total fat intake on measures of weight and body fatness in children and young people not aiming to lose weight.

SEARCH METHODS

For this update we revised the previous search strategy and ran it over all years in the Cochrane Library, MEDLINE (Ovid), MEDLINE (PubMed), and Embase (Ovid) (current to 23 May 2017). No language and publication status limits were applied. We searched the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov for ongoing and unpublished studies (5 June 2017).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in children aged 24 months to 18 years, with or without risk factors for cardiovascular disease, randomised to a lower fat (30% or less of total energy (TE)) versus usual or moderate-fat diet (greater than 30%TE), without the intention to reduce weight, and assessed a measure of weight or body fatness after at least six months. We included prospective analytical cohort studies in these children if they related baseline total fat intake to weight or body fatness at least 12 months later. We duplicated inclusion decisions and resolved disagreement by discussion with other authors.

DATA COLLECTION AND ANALYSIS

We extracted data on participants, interventions or exposures, controls and outcomes, and trial or cohort quality characteristics, as well as data on potential effect modifiers, and assessed risk of bias for all included studies. We extracted outcome data using the following time point ranges, when available: RCTs: baseline to six months, six to 12 months, one to two years, two to five years and more than five years; cohort studies: baseline to one year, one to two years, two to five years, five to 10 years and more than 10 years. We planned to perform random-effects meta-analyses with relevant subgrouping, and sensitivity and funnel plot analyses where data allowed.

MAIN RESULTS

We included 24 studies comprising three parallel-group RCTs (n = 1054 randomised) and 21 prospective analytical cohort studies (about 25,059 children completed). Twenty-three were conducted in high-income countries. No meta-analyses were possible, since only one RCT reported the same outcome at each time point range for all outcomes, and cohort studies were too heterogeneous.For the RCTs, concerns about imprecision and poor reporting limited our confidence in our findings. In addition, the inclusion of hypercholesteraemic children in two trials raised concerns about applicability. Lower versus usual or modified total fat intake may have made little or no difference to weight over a six- to twelve month period (mean difference (MD) -0.50 kg, 95% confidence interval (CI) -1.78 to 0.78; 1 RCT; n = 620; low-quality evidence), nor a two- to five-year period (MD -0.60 kg, 95% CI -2.39 to 1.19; 1 RCT; n = 612; low-quality evidence). Compared to controls, lower total fat intake (30% or less TE) probably decreased BMI in children over a one- to two-year period (MD -1.5 kg/m2, 95% CI -2.45 to -0.55; 1 RCT; n = 191; moderate-quality evidence), with no other differences evident across the other time points (two to five years: MD 0.00 kg/m2, 95% CI -0.63 to 0.63; 1 RCT; n = 541; greater than five years; MD -0.10 kg/m2, 95% CI -0.75 to 0.55; 1 RCT; n = 576; low-quality evidence). Lower fat intake probably slightly reduced total cholesterol over six to 12 months compared to controls (MD -0.15 mmol/L, 95% CI -0.24 to -0.06; 1 RCT; n = 618; moderate-quality evidence), but may make little or no difference over longer time periods. Lower fat intake probably slightly decreased low-density lipoprotein (LDL) cholesterol over six to 12 months (MD -0.12 mmol/L, 95% CI -0.20 to -0.04; 1 RCT; n = 618, moderate-quality evidence) and over two to five years (MD -0.09, 95% CI -0.17 to -0.01; 1 RCT; n = 623; moderate-quality evidence), compared to controls. However, lower total fat intake probably made little or no difference to HDL-C over a six- to 12-month period (MD -0.03 mmol/L, 95% CI -0.08 to 0.02; 1 RCT; n = 618; moderate-quality evidence), nor a two- to five-year period (MD -0.01 mmol/L, 95% CI -0.06 to 0.04; 1 RCT; n = 522; moderate-quality evidence). Likewise, lower total fat intake probably made little or no difference to triglycerides in children over a six- to 12-month period (MD -0.01 mmol/L, 95% CI -0.08 to 0.06; 1 RCT; n = 618; moderate-quality evidence). Lower versus usual or modified fat intake may make little or no difference to height over more than five years (MD -0.60 cm, 95% CI -2.06 to 0.86; 1 RCT; n = 577; low-quality evidence).Over half the cohort analyses that reported on primary outcomes suggested that as total fat intake increases, body fatness measures may move in the same direction. However, heterogeneous methods and reporting across cohort studies, and predominantly very low-quality evidence, made it difficult to draw firm conclusions and true relationships may be substantially different.

AUTHORS' CONCLUSIONS

We were unable to reach firm conclusions. Limited evidence from three trials that randomised children to a lower total fat intake (30% or less TE) versus usual or modified fat intake, but with no intention to reduce weight, showed small reductions in body mass index, total- and LDL-cholesterol at some time points with lower fat intake compared to controls, and no consistent differences in effects on weight, high-density lipoprotein (HDL) cholesterol or height. Associations in cohort studies that related total fat intake to later measures of body fatness in children were inconsistent and the quality of this evidence was mostly very low. Twenty-three out of 24 included studies were conducted in high-income countries, and may not be applicable in low- and middle-income settings. High-quality, longer-term studies are needed, that include low- and middle-income settings and look at both possible benefits and risks.

Strategies for enhancing the implementation of school-based policies or practices targeting risk factors for chronic disease

BACKGROUND

A number of school-based policies or practices have been found to be effective in improving child diet and physical activity, and preventing excessive weight gain, tobacco or harmful alcohol use. Schools, however, frequently fail to implement such evidence-based interventions.

OBJECTIVES

The primary aims of the review are to examine the effectiveness of strategies aiming to improve the implementation of school-based policies, programs or practices to address child diet, physical activity, obesity, tobacco or alcohol use.Secondary objectives of the review are to: Examine the effectiveness of implementation strategies on health behaviour (e.g. fruit and vegetable consumption) and anthropometric outcomes (e.g. BMI, weight); describe the impact of such strategies on the knowledge, skills or attitudes of school staff involved in implementing health-promoting policies, programs or practices; describe the cost or cost-effectiveness of such strategies; and describe any unintended adverse effects of strategies on schools, school staff or children.

SEARCH METHODS

All electronic databases were searched on 16 July 2017 for studies published up to 31 August 2016. We searched the following electronic databases: Cochrane Library including the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; MEDLINE In-Process & Other Non-Indexed Citations; Embase Classic and Embase; PsycINFO; Education Resource Information Center (ERIC); Cumulative Index to Nursing and Allied Health Literature (CINAHL); Dissertations and Theses; and SCOPUS. We screened reference lists of all included trials for citations of other potentially relevant trials. We handsearched all publications between 2011 and 2016 in two specialty journals (Implementation Science and Journal of Translational Behavioral Medicine) and conducted searches of the WHO International Clinical Trials Registry Platform (ICTRP) (http://apps.who.int/trialsearch/) as well as the US National Institutes of Health registry (https://clinicaltrials.gov). We consulted with experts in the field to identify other relevant research.

SELECTION CRITERIA

'Implementation' was defined as the use of strategies to adopt and integrate evidence-based health interventions and to change practice patterns within specific settings. We included any trial (randomised or non-randomised) conducted at any scale, with a parallel control group that compared a strategy to implement policies or practices to address diet, physical activity, overweight or obesity, tobacco or alcohol use by school staff to 'no intervention', 'usual' practice or a different implementation strategy.

DATA COLLECTION AND ANALYSIS

Citation screening, data extraction and assessment of risk of bias was performed by review authors in pairs. Disagreements between review authors were resolved via consensus, or if required, by a third author. Considerable trial heterogeneity precluded meta-analysis. We narratively synthesised trial findings by describing the effect size of the primary outcome measure for policy or practice implementation (or the median of such measures where a single primary outcome was not stated).

MAIN RESULTS

We included 27 trials, 18 of which were conducted in the USA. Nineteen studies employed randomised controlled trial (RCT) designs. Fifteen trials tested strategies to implement healthy eating policies, practice or programs; six trials tested strategies targeting physical activity policies or practices; and three trials targeted tobacco policies or practices. Three trials targeted a combination of risk factors. None of the included trials sought to increase the implementation of interventions to delay initiation or reduce the consumption of alcohol. All trials examined multi-strategic implementation strategies and no two trials examined the same combinations of implementation strategies. The most common implementation strategies included educational materials, educational outreach and educational meetings. For all outcomes, the overall quality of evidence was very low and the risk of bias was high for the majority of trials for detection and performance bias.Among 13 trials reporting dichotomous implementation outcomes-the proportion of schools or school staff (e.g. classes) implementing a targeted policy or practice-the median unadjusted (improvement) effect sizes ranged from 8.5% to 66.6%. Of seven trials reporting the percentage of a practice, program or policy that had been implemented, the median unadjusted effect (improvement), relative to the control ranged from -8% to 43%. The effect, relative to control, reported in two trials assessing the impact of implementation strategies on the time per week teachers spent delivering targeted policies or practices ranged from 26.6 to 54.9 minutes per week. Among trials reporting other continuous implementation outcomes, findings were mixed. Four trials were conducted of strategies that sought to achieve implementation 'at scale', that is, across samples of at least 50 schools, of which improvements in implementation were reported in three trials.The impact of interventions on student health behaviour or weight status were mixed. Three of the eight trials with physical activity outcomes reported no significant improvements. Two trials reported reductions in tobacco use among intervention relative to control. Seven of nine trials reported no between-group differences on student overweight, obesity or adiposity. Positive improvements in child dietary intake were generally reported among trials reporting these outcomes. Three trials assessed the impact of implementation strategies on the attitudes of school staff and found mixed effects. Two trials specified in the study methods an assessment of potential unintended adverse effects, of which, they reported none. One trial reported implementation support did not significantly increase school revenue or expenses and another, conducted a formal economic evaluation, reporting the intervention to be cost-effective. Trial heterogeneity, and the lack of consistent terminology describing implementation strategies, were important limitations of the review.

AUTHORS' CONCLUSIONS

Given the very low quality of the available evidence, it is uncertain whether the strategies tested improve implementation of the targeted school-based policies or practices, student health behaviours, or the knowledge or attitudes of school staff. It is also uncertain if strategies to improve implementation are cost-effective or if they result in unintended adverse consequences. Further research is required to guide efforts to facilitate the translation of evidence into practice in this setting.

The impact of an innovative web-based school nutrition intervention to increase fruits and vegetables and milk and alternatives in adolescents: a clustered randomized trial

Background

The increase in overweight and obesity in adolescents and its health-related consequences highlight the need to develop strategies, which could help them adopt healthy eating habits. The objective of this study was to evaluate the impact of an innovative web-based school nutrition intervention (Team Nutriathlon) aimed at promoting the consumption of vegetables and fruit (V/F) and milk and alternatives (M/A) in high school students and to identify facilitators and/or barriers influencing its success.

Methods

Ten classes of first and second year secondary students (grades 7 and 8) from the Québec City region were randomized into two groups (control n = 89 and intervention n = 193). Participants in the intervention (Team Nutriathlon) were to increase their consumption of V/F and M/A using an innovative web-based platform, developed for this study, over 6 weeks. The control group followed the regular school curriculum. The number of servings of V/F and M/A consumed by students per day was compared between the two groups before, during, immediately after and 10 weeks after the intervention using a web-based platform. Main outcome measures included V/F and M/A servings and facilitators and/or barriers of program success. Repeated measures linear fixed effects models were used to assess the impact of Team Nutriathlon on V/F and M/A consumption. A P-value of <0.05 was considered significant.

Results

Students in the intervention reported a significant increase of 3 servings and 1.8 servings per day of V/F and M/A, respectively, compared to the control group (P < 0.05); however, this was only observed in the short-term. Some factors contributing to the success of Team Nutriathlon included the team aspect of the program, use of the technology and recording results outside of classroom hours.

Conclusion

Team Nutriathlon represents an innovative web-based nutrition program which positively impacts V/F and M/A consumption among high school students. Using web-based or technological platforms may help youth adopt healthy eating habits that will have implications later in adulthood; however, further studies are needed to determine their long-term effects.

Trial registration

NCT03117374 (retrospectively registered).

College Cafeteria Signage Increases Water Intake but Water Position on the Soda Dispenser Encourages More Soda Consumption

OBJECTIVES

To evaluate the effects of improved water location visibility and water dispenser position on the soda dispenser on undergraduate students' beverage choices.

METHODS

Two focus groups with pilot intervention surveys before and after, adding a small sign above the soda dispensers' water button for 6 weeks in a large US university's all-you-can-eat, prepaid dining hall (measured with chi-square tests and logistic and ordinal logistic regression).

RESULTS

Focus groups included 15 students. Survey participants included 357 students before and 301 after the intervention. After the intervention, more students reported ever having drunk water with the meal (66.4% to 77.0%; P = .003) and water consumption frequency increased (P = .005). Postintervention, the odds of drinking water increased by 1.57. Preference for other drinks was the main reason for not drinking water. A total of 59% of students had ever changed their preference from water to soda.

CONCLUSIONS AND IMPLICATIONS

The clear indication of the water's location increased students' reported water consumption. Further investigation is needed into how a non-independent water dispenser influences students' beverage choice. Clearly labeled, independent water dispensers are recommended.

Formative Research to Design a Promotional Campaign to Increase Drinking Water among Central American Latino Youth in an Urban Area

Latinos consume more sugary drinks and less water than other demographic groups. Our objective was to understand beverage choice motivations and test promotional concepts that can encourage Central American Latino urban youth to drink more water. Two rounds of focus group discussions were conducted (n = 10 focus groups, 61 participants, 6-18 years old). Data were transcribed verbatim and analyzed using inductive and deductive coding approaches. Youth motivations for drinking water were shaped by level of thirst, weather, energy, and perceptions of health benefits. Youth were discouraged from drinking water due to its taste and perceptions of the safety and cleanliness of tap water. Youth beverage preference depended on what their friends were drinking. Availability of water versus other beverages at home and other settings influenced their choice. Promotional materials that included mixed language, informative messages about the benefits of drinking water, and celebrities or athletes who were active, energized, and drinking water were preferred. A promotional campaign to increase water consumption among these Latino youth should include bicultural messages to underscore the power of water to quench true thirst, highlight the health benefits of drinking water, and address the safety of tap water.

School food environments associated with adiposity in Canadian children

BACKGROUND/OBJECTIVES

Targeting obesogenic features of children's environment that are amenable to change represents a promising strategy for health promotion. The school food environment, defined as the services and policies regarding nutrition and the availability of food in the school and surrounding neighborhood, is particularly important given that students travel through the school neighborhood almost daily and that they consume a substantial proportion of their calories at school.

SUBJECTS/METHODS

As part of the Quebec Adipose and Lifestyle Investigation in Youth (QUALITY) cohort study, we assessed features of school indoor dietary environment and the surrounding school neighborhoods, when children were aged 8-10 years (2005-2008). School principals reported on food practices and policies within the schools. The density of convenience stores and fast-food outlets surrounding the school was computed using a Geographical Information System. Indicators of school neighborhood deprivation were derived from census data. Adiposity outcomes were measured in a clinical setting 2 years later, when participants were aged 10-12 years (2008-2011). We conducted cluster analyses to identify school food environment types. Associations between school types and adiposity were estimated in linear regression models.

RESULTS

Cluster analysis identified three school types with distinct food environments. Schools were characterized as: overall healthful (45%); a healthful food environment in the surrounding neighborhood, but an unhealthful indoor food environment (22%); or overall unhealthful (33%). Less healthful schools were located in more deprived neighborhoods and were associated with greater child adiposity.

CONCLUSIONS

Despite regulatory efforts to improve school food environments, there is substantial inequity in dietary environments across schools. Ensuring healthful indoor and outdoor food environments across schools should be included in comprehensive efforts to reduce obesity-related health disparities.

Systematic Review of School-Based Interventions to Modify Dietary Behavior: Does Intervention Intensity Impact Effectiveness?

BACKGROUND

Owing to the associations between diet and health, it is important that effective health promotion strategies establish healthful eating behaviors from an early age. We reviewed the intensity of school-based interventions aimed to modify dietary behavior in preadolescent and adolescents and related intervention characteristics to effectiveness.

METHODS

Our systematic literature search of 8 databases sought to identify interventions measuring dietary intake in school settings to students aged 9 to 18. We evaluated these studies for effectiveness, intensity, intervention category, and follow-up measures.

RESULTS

Of the 105 interventions 81 were found to be effective immediately postintervention, irrespective of intensity. Studies that were 6 weeks to 5 months in duration, targeted students' environment or group (alone or in combination), and reached students only in schools were more effective. Only one-fifth of interventions conducted a follow-up measure, and a majority showed a loss of effectiveness from postintervention to follow-up.

CONCLUSIONS

We identified characteristics of effective interventions. These findings may inform the development of future interventions targeting dietary behavior in preadolescents and adolescents in the school-based setting.

Pertinence of the recent school-based nutrition interventions targeting fruit and vegetable consumption in the United States:a systematic review

BACKGROUND

Schools are the major locations for implementing children's dietary behavior related educational or interventional programs. Recently, there has been an increase in school-based nutrition interventions. The objective of this systematic review was to overview the evidence for the effectiveness of school-based nutrition intervention on fruit and vegetable consumption.

METHODS

PubMed was used to search for articles on school-based nutrition interventions that measured students' fruit and vegetable consumption. Our search yielded 238 articles.The article was included if published in a peer-reviewed journal, written in English language,administered in the United States, and conducted among a population-based sample of children in Kindergarten through eighth grade. A total of 14 publications met the inclusion criteria.

RESULTS

Eight articles successfully showed the positive effect on increasing fruit and or vegetable consumption while the other six did not. Several factors, including (but not limited to) intervention duration, type of theory used, style of intervention leadership, and positively affecting antecedents of fruit and vegetable consumption were compared; however, no dominant factor was found to be shared among the studies with significant findings. Given that the criteria for selection were high, the lack of consistency between interventions and positive outcomes was surprising.

CONCLUSION

With high levels of scrutiny and budget constraints on school nutrition, it is imperative that more research be conducted to identify the effective intervention components.

Negative, Null and Beneficial Effects of Drinking Water on Energy Intake, Energy Expenditure, Fat Oxidation and Weight Change in Randomized Trials: A Qualitative Review

Drinking water has heterogeneous effects on energy intake (EI), energy expenditure (EE), fat oxidation (FO) and weight change in randomized controlled trials (RCTs) involving adults and/or children. The aim of this qualitative review of RCTs was to identify conditions associated with negative, null and beneficial effects of drinking water on EI, EE, FO and weight, to generate hypotheses about ways to optimize drinking water interventions for weight management. RCT conditions that are associated with negative or null effects of drinking water on EI, EE and/or FO in the short term are associated with negative or null effects on weight over the longer term. RCT conditions that are associated with lower EI, increased EE and/or increased FO in the short term are associated with less weight gain or greater weight loss over time. Drinking water instead of caloric beverages decreases EI when food intake is ad libitum. Drinking water increases EE in metabolically-inflexible, obese individuals. Drinking water increases FO when blood carbohydrate and/or insulin concentrations are not elevated and when it is consumed instead of caloric beverages or in volumes that alter hydration status. Further research is needed to confirm the observed associations and to determine if/what specific conditions optimize drinking water interventions for weight management.

Grab a Cup, Fill It Up! An Intervention to Promote the Convenience of Drinking Water and Increase Student Water Consumption During School Lunch

OBJECTIVES

We evaluated a low-cost strategy for schools to improve the convenience and appeal of drinking water.

METHODS

We conducted a group-randomized, controlled trial in 10 Boston, Massachusetts, schools in April through June 2013 to test a cafeteria-based intervention. Signage promoting water and disposable cups were installed near water sources. Mixed linear regression models adjusting for clustering evaluated the intervention impact on average student water consumption over 359 lunch periods.

RESULTS

The percentage of students in intervention schools observed drinking water during lunch nearly doubled from baseline to follow-up compared with controls (+ 9.4%; P < .001). The intervention was associated with a 0.58-ounce increase in water intake across all students (P < .001). Without cups, children were observed drinking 2.4 (SE = 0.08) ounces of water from fountains; with cups, 5.2 (SE = 0.2) ounces. The percentage of intervention students observed with sugar-sweetened beverages declined (-3.3%; P < .005).

CONCLUSIONS

The current default of providing water through drinking fountains in cafeterias results in low water consumption. This study shows that an inexpensive intervention to improve drinking water's convenience by providing cups can increase student water consumption.

Prevalence of Inadequate Hydration Among US Children and Disparities by Gender and Race/Ethnicity: National Health and Nutrition Examination Survey, 2009-2012

OBJECTIVES

We evaluated the hydration status of US children and adolescents.

METHODS

The sample included 4134 participants aged 6 to 19 years in the National Health and Nutrition Examination Survey from 2009 to 2012. We calculated mean urine osmolality and the proportion with inadequate hydration (urine osmolality > 800 mOsm/kg). We calculated multivariable regression models to estimate the associations between demographic factors, beverage intake, and hydration status.

RESULTS

The prevalence of inadequate hydration was 54.5%. Significantly higher urine osmolality was observed among boys (+92.0 mOsm/kg; 95% confidence interval [CI] = 69.5, 114.6), non-Hispanic Blacks (+67.6 mOsm/kg; 95% CI = 31.5, 103.6), and younger children (+28.5 mOsm/kg; 95% CI = 8.1, 48.9) compared with girls, Whites, and older children, respectively. Boys (OR = 1.76; 95% CI = 1.49, 2.07) and non-Hispanic Blacks (odds ratio [OR] = 1.34; 95% CI = 1.04, 1.74) were also at significantly higher risk for inadequate hydration. An 8-fluid-ounce daily increase in water intake was associated with a significantly lower risk of inadequate hydration (OR = 0.96; 95% CI = 0.93, 0.98).

CONCLUSIONS

Future research should explore drivers of gender and racial/ethnic disparities and solutions for improving hydration status.

Factors affecting fruit and vegetable school lunch waste in Wisconsin elementary schools participating in Farm to School programmes

OBJECTIVE

To examine characteristics potentially associated with school lunch fruit and vegetable waste, both overall and pre/post implementation of the Healthy, Hunger-Free Kids Act.

DESIGN

Multi-year (2010-2013) cross-sectional study using pre- and post-meal digital photographs of students' school lunch trays to estimate fruit and vegetable availability and consumption. Fruit and vegetable items were categorized for factors suspected to impact waste: prior farm to school years, placement (main menu, salad bar), procurement (local, conventional), preparation (cooked, raw) and meal component (entrée, side, topping). Analyses to assess within-category differences in waste volume were performed using a Tobit model.

SETTING

Wisconsin elementary schools participating in farm to school programmes, USA.

SUBJECTS

Children in third to fifth grade.

RESULTS

Many within-factor differences were detected overall and/or across time. Cooked fruits were wasted less than raw, while cooked vegetables were wasted more than raw. Where identified, locally sourced items were wasted more than conventionally sourced (+0·1 cups, P<0·0001) and salad bar items more than main menu items (+0·01 cups, P<0·0001). Increasing prior farm to school years decreased waste (-0·02 cups, P<0·0001). Items previously tried were wasted at the same volume whether reported as liked or not. New school lunch meal pattern requirement implementation did not uniformly impact fruit and vegetable waste across all categories and there was no change in waste for seven of fifteen assessed categories.

CONCLUSIONS

Many factors impact elementary students' school lunch waste. These factors may be helpful for school food-service authorities to consider when planning school menus.

The social environment of schools and adolescent nutrition: associations between the school nutrition climate and adolescents' eating behaviors and body mass index

BACKGROUND

The aim of this study was to determine the association between the school nutrition climate and students' eating behaviors and body mass index (BMI).

METHODS

Data were collected as part of Youth'07, a nationally representative health survey of high school students in New Zealand. Overall, 9107 randomly selected students from 96 randomly selected schools participated. School-level measures were created by aggregating students' reports within schools. Analyses were conducted using multilevel modeling, accounting for student-level characteristics.

RESULTS

There was a positive association between the school nutrition climate and students' consumption of fruits and vegetables. This relationship was statistically significant after controlling for the background characteristics of students. There were no associations between the school nutrition climate and students' junk food consumption or BMI.

CONCLUSIONS

The school nutrition climate appears to have a positive influence on adolescents' healthy eating behaviors (fruit and vegetable intake), but a limited effect on unhealthy eating behaviors and ultimately body weight. This may reflect the pervasiveness of junk food in the environments of adolescents outside of school and the difficulty in limiting its consumption.

A systematic review investigating interventions that can help reduce consumption of sugar-sweetened beverages in children leading to changes in body fatness

BACKGROUND

Both the prevalence of childhood obesity and the consumption of sugar-sweetened beverages (SSBs) have increased globally. The present review describes interventions that reduce the consumption of SSBs in children and determines whether this leads to subsequent changes in body fatness.

METHODS

Three databases were searched from 2000 to August 2013. Only intervention control trials, ≥6 months in duration, which aimed to reduce the consumption of SSBs in >100 children aged 2-18 years, and reporting changes in body fatness, were included. The quality of selected papers was assessed.

RESULTS

Eight studies met inclusion criteria. Six interventions achieved significant (P < 0.05) reductions in SSB intake, although this was not always sustained. In the two interventions providing replacement drinks, significant differences in body mass index (12- or 18-month follow-up) were reported (P = 0.001 and 0.045). The risk of being overweight/obesity was reduced (P < 0.05) in three of the five education programmes but in one programme only for girls who were overweight at baseline and in one programme only for pupils perceived to be at greater risk at baseline. In the one study that included both provision of water and education, the risk of being overweight was reduced by 31% (P = 0.04) in the intervention group.

CONCLUSIONS

The evidence suggests that school-based education programmes focusing on reducing SSB consumption, but including follow-up modules, offer opportunities for implementing effective, sustainable interventions. Peer support and changing the school environment (e.g. providing water or replacement drinks) to support educational programmes could improve their effectiveness. Home delivery of more suitable drinks has a big impact on reducing SSB consumption, with associated reductions in body weight.

Eating for the better: a social marketing review (2000-2012)

OBJECTIVE

The present study sought to identify both the ingredients for success and the potential impediments to social marketing effectiveness for healthy eating behaviour, focusing on studies conducted over the last 10 years.

DESIGN

A comprehensive literature review was undertaken examining seventeen databases to identify studies reporting the use of social marketing to address healthy eating. Thirty-four empirical studies were analysed to examine the effectiveness of social marketing interventions to improve healthy eating behaviour using Andreasen's (2002) social marketing benchmark criteria. Statistical analysis was undertaken to quantitatively evaluate whether effectiveness varied between study categories (subsets).

SETTING

Healthy eating empirical studies published from 2000 onwards.

SUBJECTS

Empirical studies that self-identified as social marketing.

RESULTS

Sixteen social marketing studies (subset 1) were identified in the review. These were systematic studies which sought to change behaviour through tailored solutions (e.g. use of marketing tools beyond communication was clearly evident) that delivered value to the target audience. For these sixteen studies, the mean number of criteria identified was five. Six studies met all six criteria. Positive change to healthy eating behaviour was found in fourteen of sixteen studies. The sixteen studies that met the definition of social marketing used significantly more of Andreasen's (2002) criteria and were more effective in achieving behavioural change than the eighteen studies in subset 2.

CONCLUSIONS

Social marketing is an involved process and it is important that studies identifying as social marketing adopt social marketing benchmark criteria. Social marketing when employed to its full extent offers the potential to change healthy eating.

The WHO Health Promoting School framework for improving the health and well-being of students and their academic achievement

BACKGROUND

The World Health Organization's (WHO's) Health Promoting Schools (HPS) framework is an holistic, settings-based approach to promoting health and educational attainment in school. The effectiveness of this approach has not been previously rigorously reviewed.

OBJECTIVES

To assess the effectiveness of the Health Promoting Schools (HPS) framework in improving the health and well-being of students and their academic achievement.

SEARCH METHODS

We searched the following electronic databases in January 2011 and again in March and April 2013: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL, Campbell Library, ASSIA, BiblioMap, CAB Abstracts, IBSS, Social Science Citation Index, Sociological Abstracts, TRoPHI, Global Health Database, SIGLE, Australian Education Index, British Education Index, Education Resources Information Centre, Database of Education Research, Dissertation Express, Index to Theses in Great Britain and Ireland, ClinicalTrials.gov, Current controlled trials, and WHO International Clinical Trials Registry Platform. We also searched relevant websites, handsearched reference lists, and used citation tracking to identify other relevant articles.

SELECTION CRITERIA

We included cluster-randomised controlled trials where randomisation took place at the level of school, district or other geographical area. Participants were children and young people aged four to 18 years, attending schools or colleges. In this review, we define HPS interventions as comprising the following three elements: input to the curriculum; changes to the school's ethos or environment or both; and engagement with families or communities, or both. We compared this intervention against schools that implemented either no intervention or continued with their usual practice, or any programme that included just one or two of the above mentioned HPS elements.

DATA COLLECTION AND ANALYSIS

At least two review authors identified relevant trials, extracted data, and assessed risk of bias in the trials. We grouped different types of interventions according to the health topic targeted or the approach used, or both. Where data permitted, we performed random-effects meta-analyses to provide a summary of results across studies.

MAIN RESULTS

We included 67 eligible cluster trials, randomising 1443 schools or districts. This is made up of 1345 schools and 98 districts. The studies tackled a range of health issues: physical activity (4), nutrition (12), physical activity and nutrition combined (18), bullying (7), tobacco (5), alcohol (2), sexual health (2), violence (2), mental health (2), hand-washing (2), multiple risk behaviours (7), cycle-helmet use (1), eating disorders (1), sun protection (1), and oral health (1). The quality of evidence overall was low to moderate as determined by the GRADE approach. 'Risk of bias' assessments identified methodological limitations, including heavy reliance on self-reported data and high attrition rates for some studies. In addition, there was a lack of long-term follow-up data for most studies.We found positive effects for some interventions for: body mass index (BMI), physical activity, physical fitness, fruit and vegetable intake, tobacco use, and being bullied. Intervention effects were generally small but have the potential to produce public health benefits at the population level. We found little evidence of effectiveness for standardised body mass index (zBMI) and no evidence of effectiveness for fat intake, alcohol use, drug use, mental health, violence and bullying others; however, only a small number of studies focused on these latter outcomes. It was not possible to meta-analyse data on other health outcomes due to lack of data. Few studies provided details on adverse events or outcomes related to the interventions. In addition, few studies included any academic, attendance or school-related outcomes. We therefore cannot draw any clear conclusions as to the effectiveness of this approach for improving academic achievement.

AUTHORS' CONCLUSIONS

The results of this review provide evidence for the effectiveness of some interventions based on the HPS framework for improving certain health outcomes but not others. More well-designed research is required to establish the effectiveness of this approach for other health topics and academic achievement.

Availability of drinking water in US public school cafeterias

This study examined the availability of free drinking water during lunchtime in US public schools, as required by federal legislation beginning in the 2011-2012 school year. Data were collected by mail-back surveys in nationally representative samples of US public elementary, middle, and high schools from 2009-2010 to 2011-2012. Overall, 86.4%, 87.4%, and 89.4% of students attended elementary, middle, and high schools, respectively, that met the drinking water requirement. Most students attended schools with existing cafeteria drinking fountains and about one fourth attended schools with water dispensers. In middle and high schools, respondents were asked to indicate whether drinking fountains were clean, and whether they were aware of any water-quality problems at the school. The vast majority of middle and high school students (92.6% and 90.4%, respectively) attended schools where the respondent perceived drinking fountains to be clean or very clean. Approximately one in four middle and high school students attended a school where the survey respondent indicated that there were water-quality issues affecting drinking fountains. Although most schools have implemented the requirement to provide free drinking water at lunchtime, additional work is needed to promote implementation at all schools. School nutrition staff at the district and school levels can play an important role in ensuring that schools implement the drinking water requirement, as well as promote education and behavior-change strategies to increase student consumption of water at school.

A food service intervention improves whole grain access at lunch in rural elementary schools

BACKGROUND

Whole grain (WG) options are often limited in schools, which may impact rural, low-income students who rely on school meals for a substantial portion of their food intake. This study examined the changes in the availability and quantity of WG and refined grain foods offered in schools participating in the Creating Healthy, Active and Nurturing Growing-up Environments (CHANGE) study, a randomized, controlled intervention among rural communities (4 intervention and 4 control).

METHODS

Foods were assessed using production records, recipes, and nutrition labels from breakfast and lunch over 1 week during fall 2008 and spring 2009. Key informant interviews were conducted with school food service directors in the spring 2009.

RESULTS

The CHANGE intervention schools significantly increased the average percent of school days WGs were offered (p = .047) and the amount of WGs offered/food item (ounces) at lunch compared with control schools (p = .02). There was a significant decrease in the percent of students with access to refined grains at lunch compared with control schools (p = .049), although there were no significant differences in WG availability during breakfast.

CONCLUSIONS

The CHANGE schools improved WG availability, enabling student's WG consumption to be closer to national recommendations.

Process evaluation results from the HEALTHY nutrition intervention to modify the total school food environment

The process evaluation of HEALTHY, a large multi-center trial to decrease type 2 diabetes mellitus in middle school children, monitored the implementation of the intervention to ascertain the extent that components were delivered and received as intended. The purpose of this article is to report the process evaluation findings concerning the extent to which the HEALTHY nutrition intervention was implemented during the HEALTHY trial. Overall, the observed fidelity of implementing nutrition strategies improved from baseline to the end of the study. By the last semester, all but two nutrition process evaluation goals were met. The most challenging goal to implement was serving high fiber foods, including grain-based foods and legumes. The easiest goals to implement were lowering the fat content of foods offered and offering healthier beverages. The most challenging barriers experienced by research dietitians and food service staff were costs, availability of foods and student acceptance. Forming strong relationships between the research dietitians and food service staff was identified as a key strategy to meet HEALTHY nutrition goals.

Modification of the school cafeteria environment can impact childhood nutrition. Results from the Wise Mind and LA Health studies

Recent changes in nutrition standards for the National School Lunch and School Breakfast Programs assume that modification of the nutritional serving practices of school cafeterias will result in improved childhood nutrition in the school environment. The primary aim of this paper is to summarize the findings from two recent cluster randomized controlled trials (Wise Mind and LA Health) that tested the hypothesis that modification of school cafeteria environments, including changes in nutrition standards, would yield beneficial changes in childhood nutrition and healthy eating in the school lunch environment. A secondary aim was to investigate the association of participant characteristics and changes in nutrition and healthy eating. A third aim was to investigate the relationships between the food intake of children and: (1) foods selected by the children and (2) food that was uneaten during the lunch meal (plate waste). The studies used similar approaches for modifying the school cafeteria environment and both studies used the digital photography method to measure changes in food intake, food selection, and plate waste. Both studies reported significant improvements in childhood nutrition, and the LA Health study reported improved healthy eating, following introduction of the cafeteria modification program in comparison to baseline and/or control arms. These studies confirm the hypothesis that interventions that modify the school cafeteria environment can beneficially impact childhood nutrition.

Lessons learned from the HEALTHY primary prevention trial of risk factors for type 2 diabetes in middle school youth

The HEALTHY trial was designed to take a primary prevention approach to risk factors for type 2 diabetes in youth, primarily obesity. The study involved over 6,000 students at 42 middle schools across the U.S. Half received an integrated intervention program of components addressing the school food environment, physical education, lifestyle behaviors, and promotional messaging. The intervention was designed to be more comprehensive than previous efforts, and the research was amply funded. Although the primary objective of reducing the percentage of overweight and obesity in schools that received the intervention program, as compared with control schools, was not obtained, key secondary outcomes indicated an intervention effect. In retrospect, senior investigators involved in the study's design, conduct, and analysis discuss weaknesses and strengths and offer recommendations for future research efforts that address prevention of childhood obesity from a public health perspective.

Getting back on tap: the policy context and cost of ensuring access to low-cost drinking water in Massachusetts schools

BACKGROUND

Adequate water intake may have important health benefits for schoolchildren. Layers of federal, state, and local policy are relevant to provision of water within schools. Recently passed state and federal laws require free drinking-water access for students during mealtimes.

PURPOSE

To review Massachusetts local district wellness policies related to water access, provide estimates of costs for three water-provision strategies, and discuss implications for policy relevant to adequate drinking-water access.

METHODS

Legal research was conducted using the LexisNexis legal database and government websites. Local wellness policies were double-coded using existing research tools. Costs of three water-delivery options were estimated using a 10-year school-district perspective.

RESULTS

Prior to 2010, most Massachusetts public school district wellness policies (92%-94%) did not address access to free drinking water. Ten-year costs per school for providing water during mealtimes to students, including dispenser unit, installation, water testing, water, cups, and labor, range between $12,544 and $27,922 (depending on water-delivery option) assuming the average Massachusetts school enrollment. Water-provision strategies relying on tap water are more economical than bottled water in the long term.

CONCLUSIONS

Policy recommendations and cost considerations deserve attention at the local, state, and federal levels. Recommendations are discussed to ensure access to safe, free drinking water for all students.

Increasing water availability during afterschool snack: evidence, strategies, and partnerships from a group randomized trial

BACKGROUND

Providing drinking water to U.S. children during school meals is a recommended health promotion strategy and part of national nutrition policy. Urban school systems have struggled with providing drinking water to children, and little is known about how to ensure that water is served, particularly in afterschool settings.

PURPOSE

To assess the effectiveness of an intervention designed to promote water as the beverage of choice in afterschool programs.

DESIGN

The Out of School Nutrition and Physical Activity Initiative (OSNAP) used a community-based collaboration and low-cost strategies to provide water after school. A group RCT was used to evaluate the intervention. Data were collected in 2010-2011 and analyzed in 2011.

SETTING/PARTICIPANTS

Twenty afterschool programs in Boston were randomized to intervention or control (delayed intervention).

INTERVENTION

Intervention sites participated in learning collaboratives focused on policy and environmental changes to increase healthy eating, drinking, and physical activity opportunities during afterschool time (materials available at www.osnap.org). Collaboration between Boston Public Schools Food and Nutrition Services, afterschool staff, and researchers established water-delivery systems to ensure children were served water during snack time.

MAIN OUTCOME MEASURES

Average ounces of water served to children per day was recorded by direct observation at each program at baseline and 6-month follow-up over 5 consecutive school days. Secondary measures directly observed included ounces of other beverages served, other snack components, and water-delivery system.

RESULTS

Participation in the intervention was associated with an increased average volume of water served (+3.6 ounces/day; p=0.01) during snack. On average, the intervention led to a daily decrease of 60.9 kcals from beverages served during snack (p=0.03).

CONCLUSIONS

This study indicates the OSNAP intervention, including strategies to overcome structural barriers and collaboration with key actors, can increase offerings of water during afterschool snack. OSNAP appears to be an effective strategy to provide water in afterschool settings that can be helpful in implementing new U.S. Department of Agriculture guidelines regarding water availability during lunch and afterschool snack.

Community-based interventions for enhancing access to or consumption of fruit and vegetables among five to 18-year olds: a scoping review

BACKGROUND

Low fruit and vegetable ( FV) consumption is a key risk factor for morbidity and mortality. Consumption of FV is limited by a lack of access to FV. Enhanced understanding of interventions and their impact on both access to and consumption of FV can provide guidance to public health decision-makers. The purpose of this scoping review is to identify and map literature that has evaluated effects of community-based interventions designed to increase FV access or consumption among five to 18-year olds.

METHODS

The search included 21 electronic bibliographic databases, grey literature, targeted organization websites, and 15 key journals for relevant studies published up to May 2011. Retrieved citations were screened in duplicate for relevance. Data extracted from included studies covered: year, country, study design, target audience, intervention setting, intervention strategies, interventionists, and reported outcomes.

RESULTS

The search located 19,607 unique citations. Full text relevance screening was conducted on 1,908 studies. The final 289 unique studies included 30 knowledge syntheses, 27 randomized controlled trials, 55 quasi-experimental studies, 113 cluster controlled studies, 60 before-after studies, one mixed method study, and three controlled time series studies. Of these studies, 46 included access outcomes and 278 included consumption outcomes. In terms of target population, 110 studies focused on five to seven year olds, 175 targeted eight to 10 year olds, 192 targeted 11 to 14 year olds, 73 targeted 15 to 18 year olds, 55 targeted parents, and 30 targeted teachers, other service providers, or the general public. The most common intervention locations included schools, communities or community centres, and homes. Most studies implemented multi-faceted intervention strategies to increase FV access or consumption.

CONCLUSIONS

While consumption measures were commonly reported, this review identified a small yet important subset of literature examining access to FV. This is a critically important issue since consumption is contingent upon access. Future research should examine the impact of interventions on direct outcome measures of FV access and a focused systematic review that examines these interventions is also needed. In addition, research on interventions in low- and middle-income countries is warranted based on a limited existing knowledge base.

Positive impact of a pre-school-based nutritional intervention on children's fruit and vegetable intake: results of a cluster-randomized trial

Objective

To assess the short-term impact of a nutritional intervention aimed at reducing childhood overweight in German pre-school children.

Design

Using a cluster-randomized study design with waiting-list controls, we tested a 6-month intervention administered once weekly by a nutrition expert consisting of joint meal preparation and activities for children and parents such as tasting and preparing nutritious, fresh foods. At baseline, 6 and 12 months, a parent-completed questionnaire assessed fruit and vegetable intakes (primary outcomes) and water and sugared drinks consumption (secondary outcomes). Direct measurement assessed BMI, skinfold thickness and waist-to-height-ratio. An intention-to-treat analysis used random-effects panel regression models to assess the intervention effect, adjusted for each child's age, gender, immigrant background and maternal education.

Setting

Eighteen pre-schools from three south German regions.

Subjects

Healthy children aged 3–6 years.

Results

Three hundred and seventy-seven (80 %) eligible pre-school children participated in the study. Of these, 348 provided sufficient data for analysis. The sample mean age was 4·26 (sd 0·78) years; the majority (53·2 %) were boys. Children's fruit and vegetable intakes increased significantly (P < 0·001 and P < 0·05, respectively); no significant changes in the consumption of water, sugared drinks or anthropometric measurements were noted.

Conclusions

Nutritional interventions in pre-schools have the potential to change eating behaviours in young children, which in the long term might reduce risk for developing overweight.