How effective are family-based and institutional nutrition interventions in improving children's diet and health? A systematic review

Developing and Validating the Preschool Nutrition Education Practices Survey

OBJECTIVE

Validate the Preschool Nutrition Education Practices Survey.

DESIGN

Iterative approach combining design-based research and Standards for Educational and Psychological Testing.

SETTING

Los Angeles, CA and Philadelphia, PA Early Care and Education (ECE) classrooms.

PARTICIPANTS

Expert panel members (n = 7); ECE teachers: interviews (n = 8), pilot survey (n = 31), and final survey (n = 136).

VARIABLES MEASURED

Early care and education nutrition education practices used in the classroom either during class time or mealtime.

ANALYSIS

Qualitative content analysis was implemented for content, response process, and consequences of testing validity evidence. Rasch rating scale analysis was conducted for the response process and internal structure validity and reliability evidence.

RESULTS

Qualitative field-testing produced strong content, response process, and consequences of testing validity evidence to inform survey modifications. Quantitative field-testing generated a psychometrically sound, well-targeted 12-item survey on a 4-point frequency scale with excellent item and person reliability (0.97 and 0.93 respectively) and separation (5.36 and 3.77 respectively); good Rasch Principal Components Analysis findings (60.3%); and productive item fit statistics (0.50-1.50 logits).

CONCLUSIONS AND IMPLICATIONS

Robust validity (content, response process, consequences of testing, internal structure) and reliability evidence were demonstrated for using the Preschool Nutrition Education Practices Survey to assess ECE teachers' use of nutrition education practices. Future research is needed to examine its relationship to other variables, such as nutrition teaching efficacy, and to determine its ability to detect change in ECE nutrition education practices over time and across groups.

An SMS chatbot digital educational program to increase healthy eating behaviors in adolescence: A multifactorial randomized controlled trial among 7,890 participants in the Danish National Birth Cohort

BACKGROUND

Few cost-effective strategies to shift dietary habits of populations in a healthier direction have been identified. We examined if participating in a chatbot health education program transmitted by Short Messages Service ("SMS-program") could improve adolescent dietary behaviors and body weight trajectories. We also explored possible added effects of maternal or peer involvement.

METHODS AND FINDINGS

We conducted a randomized controlled trial (RCT) among adolescents from the Danish National Birth Cohort (DNBC). Eligible were adolescents who during 2015 to 2016 at age 14 years had completed a questionnaire assessing height, weight, and dietary habits. Two thirds were offered participation in an SMS-program, whereas 1/3 ("non-SMS group") received no offer. The SMS program aimed to improve 3 key dietary intake behaviors: sugar-sweetened beverages (SSBs), fruit and vegetables (FV), and fish. The offered programs had 3 factorially randomized schemes; the aims of these were to test effect of asking the mother or a friend to also participate in the health promotion program, and to test the effect of a 4-week individually tailored SMS program against the full 12-week SMS program targeting all 3 dietary factors. Height and weight and intakes of SSB, FV, and fish were assessed twice by a smartphone-based abbreviated dietary questionnaire completed at 6 months (m) and 18 m follow-up. Main outcome measures were (1) body mass index (BMI) z-score; and (2) an abbreviated Healthy Eating Index (mini-HEI, 1 m window, as mean of z-scores for SSB, FV, and fish). Among the 7,890 randomized adolescents, 5,260 were assigned to any SMS program; 63% (3,338) joined the offered program. Among the 7,890 randomized, 74% (5,853) and 68% (5,370) responded to follow-ups at 6 m and 18 m, respectively. Effects were estimated by intention-to-treat (ITT) analyses and inverse probability weighted per-protocol (IPW-PP) analyses excluding adolescents who did not join the program. Mean (standard deviation (SD)) mini-HEI at baseline, 6 m and 18 m was -0.01 (0.64), 0.01 (0.59), and -0.01 (0.59), respectively. In ITT-analyses, no effects were observed, at any time point, in those who had received any SMS program compared to the non-SMS group, on BMI z-score (6 m: -0.010 [95% confidence interval (CI) -0.035, 0.015]; p = 0.442, 18 m: 0.002 [95% CI -0.029, 0.033]; p = 0.901) or mini-HEI (6 m: 0.016 [95% CI -0.011, 0.043]; p = 0.253, 18m: -0.016 [95% CI -0.045, 0.013]; p = 0.286). In IPW-PP analyses, at 6 m, a small decrease in BMI z-score (-0.030 [95% CI -0.057, -0.003]; p = 0.032) was observed, whereas no significant effect was observed in mini-HEI (0.027 [95% CI -0.002, 0.056]; p = 0.072), among those who had received any SMS program compared to the non-SMS group. At 18 m, no associations were observed (BMI z-score: -0.006 [95% CI -0.039, 0.027]; p = 0.724, and mini-HEI: -0.005 [95% CI -0.036, 0.026]; p = 0.755). The main limitations of the study were that DNBC participants, though derived from the general population, tend to have higher socioeconomic status than average, and that outcome measures were self-reported.

CONCLUSIONS

In this study, a chatbot health education program delivered through an SMS program had no effect on dietary habits or weight trajectories in ITT analyses. However, IPW-PP-analyses, based on those 63% who had joined the offered SMS program, suggested modest improvements in weight development at 6 m, which had faded at 18 m. Future research should focus on developing gender-specific messaging programs including "booster" messages to obtain sustained engagement.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02809196 https://clinicaltrials.gov/study/NCT02809196.

School food hero and the battle of the food foes: A story of public health policy, power imbalance and potential

This paper explores the impact of school food policy from the perspective of school food workers to offer an alternative account of why school food may not be having the desired impact on child health or food choices. Drawing upon the findings from an institutional ethnography carried out in three UK primary schools, we argue that school food is being asked to perform an unrealistic task of luring children and families away from more unhealthy food options, without being given adequate resources or powers to do this job effectively. We theorise that the narrative depicting school food as a hero, combatting the harms of poor dietary choices and poor health outcomes, is inappropriate as a countermeasure to mitigate the effects of wider food industry forces. We revisit the narrative to consider the power imbalances within society that structure dietary choices, presenting our findings and the wider policy review in the form of a story about the evolution of school food set against a shifting food environment. We conclude with recommendations for policy makers who want to see school food have a greater impact in improving child health.

Adolescents' experiences with the food selection at the sports arena in the area of Oslo, Norway: a focus group study

OBJECTIVE

To investigate adolescents' experiences with the food selection at the sport arena.

DESIGN

Four focus group interviews were conducted with 4-6 participants each. Interviews were recorded and transcribed verbatim. The transcripts were coded in NVivo and the analysis was guided by thematic analysis.

SETTING

Adolescents from handball and football clubs in Oslo and Viken, Norway, participated in the study.

PARTICIPANTS

A total of nine boys (11-14 years old) and ten girls (11-14 years old) participated in the study.

RESULTS

We identified four main themes: interest for healthy food; experiences with the food selection at the sports arena; factors influencing participants' food choices at the sports arena and expectations related to a healthy food selection at the sports arena. Adolescents across the focus groups experienced the food selection at the sports arena as unhealthy. Price, marketing and availability of unhealthy food were important factors that influenced their food choices at the sports arena. The trainer appeared to motivate the participants to eat healthy.

CONCLUSIONS

Participants wished for a healthier food selection at the sports arena. Cost of food emerged as a factor that influenced their food choices. Our study also indicates that marketing of unhealthy food and beverages should be restricted, to influence adolescence food choice towards healthier alternatives.

Process evaluation of the Yéego! Program to increase healthy eating and gardening among American Indian elementary school children

BACKGROUND

American Indian children are at increased risk for obesity and diabetes. School-based health promotion interventions are one approach to promoting healthy behaviors to reduce this risk, yet few studies have described their implementation and fidelity. We conducted a qualitative process evaluation of the Yéego! Healthy Eating and Gardening Program, a school-based intervention to promote healthy eating among Navajo elementary school children. The intervention included a yearlong integrated curriculum, as well as the construction and maintenance of a school-based garden.

METHODS

Our process evaluation included fidelity checklists completed by program staff and qualitative interviews with program staff and classroom teachers after the intervention was implemented. We used content analysis to identify themes.

RESULTS

We identified several themes related to evidence of delivery adherence, program satisfaction, and lessons learned about delivery. Intervention staff followed similar procedures to prepare for and deliver lessons, but timing, teaching styles, and school-level factors also impacted overall implementation fidelity. Teachers and students had positive perceptions of the program, especially lessons that were highly visual, experiential, and connected to Navajo culture and the surrounding community. Teachers and program staff identified ways to enhance the usability of the curriculum by narrowing the scope, relating content to student experiences, and aligning content with school curriculum standards.

CONCLUSIONS

The program was implemented with moderately high fidelity across contexts. We identified areas where modifications could improve engagement, acceptability, efficacy, and sustainability of the program. Our results have implications for the evaluation and dissemination of school-based health interventions to promote healthy eating among children, especially in American Indian communities.

The feasibility, acceptability and potential efficacy of a parental text message and social media program on children's vegetable consumption and movement behaviours: A pilot randomised controlled trial

ISSUE ADDRESSED

Australian children fall short of meeting the dietary, physical activity and sedentary behaviour guidelines. This study aimed to test the feasibility, acceptability and potential efficacy of a parental text message and social media program on, primarily, their school-aged children's vegetable consumption and movement behaviours, and, secondarily, their own.

METHODS

Between August and November 2022, we conducted a two-armed randomised controlled trial with 242 parents/caregivers of primary school-aged children in New South Wales. The 'Adventure & Veg' intervention ran for 8 weeks, promoting vegetable eating behaviours, local outdoor physical activity opportunities and ideas for reducing screen time. Feasibility and acceptability were assessed via recruitment and retention data, intervention metrics and self-reported participant data. Vegetable intake and movement behaviour data were collected via online-surveys and effect sizes were examined.

RESULTS

Most participants reported that they enjoyed receiving the text messages (88%) and the delivery frequency was acceptable (94%). Limitations to Facebook as a delivery platform were reported. The majority of participants used the text messages to influence the vegetable eating (65%) and movement (77%) behaviours of their child. Significant effects were observed among intervention child participants compared with control for mean daily vegetable consumption (0.45 serves, CI: .19; .71, p = .001, d = .5); weekly vegetable variety (1.85, CI: .25; 3.45, p < .001, d = .6); and weekly physical activity variety (.64 CI: .09; 1.19, p = .022, d = .3). Parents in the intervention group increased their daily vegetable intake by .44 serves (CI: .11; .78, p = .01, d = .4).

CONCLUSIONS

A parental text message and social media program has potential to support children's vegetable intake and movement behaviours. Further research is required to explore different online delivery methods to promote local outdoor activity options. SO WHAT?: The Adventure & Veg program holds promise as a stand-alone health promotion intervention or as a useful adjunct to current family or school-based healthy lifestyle programs.

Impact of a school-based nutrition educational intervention on knowledge related to iron deficiency anaemia in rural Karnataka, India: A mixed methods pre-post interventional study

OBJECTIVE

To understand the extent to which adolescent awareness about anaemia and anaemia prevention can be changed by nutrition messages received at school.

DESIGN

Mixed-methods pre-post intervention study.

SETTING

Three government schools in Bagalkot, Belagavi and Raichur districts of Karnataka, India.

POPULATION

Students of grade six and seven and teachers involved in implementing the intervention.

METHODS

An educational intervention was co-developed by school teachers and nutrition experts using locally adapted resource materials that consisted of lectures, role play and practical demonstrations. Seven half-hour educational sessions were delivered by school teachers over 7 weeks to 455 students. Pre- and post-intervention tests measured changes in adolescents' knowledge about anaemia. Semi-structured in-depth interviews with teachers and focus groups with students explored their reactions to the intervention.

MAIN OUTCOME MEASURES

Knowledge score related to anaemia.

RESULTS

The percentage of children with correct scores increased by 7.3-49.0 percentage points for the tested questions after implementation of the intervention. The mean knowledge score increased by 3.67 ± 0.17 (p < 0.01). During interviews, teachers and students highlighted high acceptance of the intervention and materials, an increase in awareness, a positive attitude towards changing behaviour around diet, an increase in the demand for iron and folic acid supplements and improved sharing of messages learned with peers and families. Challenges expressed included need for further training, time limitations and hesitancy in teaching about menstruation and pregnancy.

CONCLUSIONS

Educational interventions carried out for adolescents by teachers in schools are effective in improving awareness and attitude related to anaemia and its prevention.

Social Media Interventions for Nutrition Education Among Adolescents: Scoping Review

BACKGROUND

Adolescence is a critical period for reinforcing healthy dietary behaviors and supporting the development of cooking skills. Social media may be an avenue for supporting these behaviors, as it is popular among adolescents and can improve access to nutrition education interventions. This study sought to understand the optimal implementation of effective social media-based nutrition education interventions to inform the implementation of future social media-based nutrition education interventions.

OBJECTIVE

A scoping review of the characteristics, feasibility, effectiveness, and factors influencing social media-based nutrition education interventions for adolescents was conducted.

METHODS

We searched MEDLINE, Embase, CINAHL, Web of Science, and PsycINFO databases using a predefined search strategy. Primary research articles were independently screened and included if they involved adolescent populations (10-18 years old) and delivered nutrition education through social media. The information on intervention characteristics, feasibility, effectiveness, and factors influencing social media-based nutrition education interventions was extracted.

RESULTS

A total of 28 publications out of 20,557 met the eligibility criteria. Twenty-five nutrition interventions were examined by 28 studies. Fourteen interventions used homegrown social media platforms, 8 used Facebook, and 2 used Instagram. Feasibility outcomes were infrequently reported, and the cost of intervention delivery was not reported. Engagement with interventions was variable; high engagement was not required to elicit significant improvements in dietary behaviors. Tailoring interventions, offering practical content, meaningful peer support, and involving families and communities facilitated successful interventions. Strategies to address engagement and technical issues were varied.

CONCLUSIONS

Emerging evidence demonstrates that social media interventions for adolescent nutrition are acceptable and improve nutrition outcomes. Future interventions should strengthen peer support components and tailor delivery to specific populations. Further research should examine engagement, adherence, and the impact of interventions on behavioral and physical outcomes. This review is the first to examine the use of social media as the primary medium for nutrition education for adolescent populations. The analysis used in this review argues the importance of peer support in social media-based nutrition interventions and the need for user-centered design of the interventions.

Association Between Parental Education and Simultaneous Malnutrition Among Parents and Children in 45 Low- and Middle-Income Countries

IMPORTANCE

Parental education is known to be associated with the health status of parents and their offspring. However, the association between parental education and the simultaneous manifestation of multiple forms of malnutrition within households remains underinvestigated globally.

OBJECTIVE

To assess the association between parental education and the simultaneous manifestation of malnutrition of both parent and child (either overnutrition or undernutrition)-referred to as the double burden of malnutrition (DBM)-at the household level in mother-child and father-child pairs in low- and middle-income countries (LMICs).

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used data from the US Agency for International Development Demographic and Health Surveys (January 1, 2010, to December 31, 2021) to identify mother-child pairs and father-child pairs from LMICs. The eligibility criteria were as follows: (1) children aged 0 to 59 months; (2) nonpregnant mothers at the time of the survey in the sample of mother-child pairs; and (3) valid measures of the weight, height, and hemoglobin level for the child and at least 1 of their parents.

EXPOSURES

Highest level of parental education obtained and number of years of education completed.

MAIN OUTCOMES AND MEASURES

Four sets of multivariable logistic regression models were constructed to assess the association between parental education and DBM, and analysis was performed between March 10 and May 15, 2022.

RESULTS

This study included 423 340 mother-child pairs from 45 LMICs and 56 720 father-child pairs from 16 LMICs. The mean (SD) age of the mother-child pairs was 28.2 (6.1) and 1.9 (1.4) years, respectively; 48.8% of the children were female. We observed that 49.0% of mother-child pairs experienced DBM. Compared with mother-child pairs with no maternal education, higher maternal education was associated with a lower risk of DBM. For example, the odds ratio (OR) for tertiary maternal education was 0.71 (95% CI, 0.67-0.74). However, the association differed by DBM subtypes: higher maternal education was associated with a lower risk of both mothers and children being undernourished but with a higher risk of almost all DBM subtypes involving overnutrition. For example, compared with mother-child pairs with no maternal education, those with secondary education were less likely to develop simultaneous maternal and child undernutrition (OR, 0.83 [95% CI, 0.80-0.86]) but were more likely to experience simultaneous maternal and child overnutrition (OR, 2.20 [95% CI, 1.61-3.00]); similar results were observed for pairs with primary and tertiary education. The results in mother-child pairs remained consistent after controlling for paternal education. Among the father-child pairs, 26.5% had DBM, with fathers with tertiary education significantly more likely to experience simultaneous paternal overnutrition and child undernutrition (OR, 1.55 [95% CI, 1.23-1.95]) compared with pairs with no paternal education; they were also less likely to have both paternal and child undernutrition (OR, 0.70 [95% CI, 0.59-0.84]).

CONCLUSIONS AND RELEVANCE

In this study, maternal education and paternal education were independently associated with DBM, and the associations differed by DBM subtypes. These findings suggest that the different risks of malnutrition faced by households with various levels of education should thus be considered in policy evaluation.

Modelling population responses to workplace minimum dietary standards introduced as workers return after social lockdowns

BACKGROUND

Diet norms are the shared social behaviours and beliefs about diets. In many societies, including the UK, these norms are typically linked to unhealthy diets and impede efforts to improve food choices. Social interactions that could influence one another's food choices, were highly disrupted during the lockdowns in response to the COVID-19 pandemic. A return to workplaces and re-establishment of eating networks may present an opportunity to influence dietary norms by introducing minimum dietary standards to in workplaces, which could then spread through wider home and workplace networks.

METHODS

An agent-based model was constructed to simulate a society reflecting the structure of a city population (1000 households) to explore changes in personal and social diet-related norms. The model tracked individual meal choices as agents interact in home, work or school settings and recorded changes in diet quality (range 1 to 100). Scenarios were run to compare individuals' diet quality with the introduction of minimum dietary standards with degrees of working from home.

RESULTS

The more people mixed at work the greater the impact of minimum standards on improving diet norms. Socially isolated households remained unaffected by minimum standards, whereas household members exposed directly, in workplaces or schools, or indirectly, influenced by others in the household, had a large and linear increase in diet quality in relation to minimum standards (0.48 [95% CI 0.34, 0.62] per unit increase in minimum standards). Since individuals regressed to the new population mean, a small proportion of diets decreased toward lower population norms. The degree of return to work influenced the rate and magnitude of change cross the population (-2.4 points [-2.40, -2.34] in mean diet quality per 20% of workers isolating).

CONCLUSIONS

These model results illustrate the qualitative impact social connectivity could have on changing diets through interventions. Norms can be changed more in a more connected population, and social interactions spread norms between contexts and amplified the influence of, for example, workplace minimum standards beyond those directly exposed. However, implementation of minimum standards in a single type of setting would not reach the whole population and in some cases may decrease diet quality. Any non-zero standard could yield improvements beyond the immediate adult workforce and this could spill between social contexts, but would be contingent on population connectivity.

The impact of a family web-based nutrition intervention to increase fruit, vegetable, and dairy intakes: a single-blinded randomized family clustered intervention

BACKGROUND

The importance of adopting healthy eating habits at a young age to prevent obesity and chronic diseases justifies the need for effective interventions.

OBJECTIVE

This study evaluated the impact of a family web-based nutrition intervention on vegetable and fruit (V/F) and dairy product (DP) consumption, nutrient intakes, diet quality and BMI or BMI z-scores.

METHODS

Forty-three families with children aged 8-16 years were randomized to either the family web-based intervention, or web-based general nutrition guidelines (control) over 8 weeks. Nutritional variables were assessed with three-day dietary records while anthropometry (body weight and height) was assessed with standardized measures at baseline (PRE), immediately after the intervention (POST 1) and 3-6 months after the intervention (POST 2). Linear mixed models for repeated measures were used to assess the main effects and their interactions followed by post hoc tests.

RESULTS

The intervention had an effect on DP, total sugar, potassium, magnesium, and calcium in children (Group x Time, P = 0.02 to 0.03) and on DP, V/F juice, carbohydrates, total sugar, saturated fat, protein and calcium in parents (Group x Time, P = 0.01 to 0.03). Post hoc tests revealed children in the intervention group increased their DP intakes immediately after the intervention (POST1) but decreased at follow-up (POST2). No effect of the intervention on V/F, diet quality or BMI was observed.

CONCLUSION

Compared to general nutrition guidelines, this family web-based nutrition intervention had a modest effect on nutrient intakes, but beneficial effect on DP intakes in the short term.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT03798808 , Registered 10 january 2019 - Retrospectively registered.

Evaluating the Effectiveness of a Family-Based Virtual Childhood Obesity Management Program Delivered During the COVID-19 Pandemic in Canada: Prospective Study

BACKGROUND

Generation Health (GH) is a 10-week family-based lifestyle program designed to promote a healthy lifestyle for families with children who are off the healthy weight trajectory in British Columbia, Canada. GH uses a blended delivery format that involves 10 weekly in-person sessions, and self-guided lessons and activities on a web portal. The blended program was adapted to be delivered virtually due to the COVID-19 pandemic. Currently, the effectiveness of the virtual GH program compared with that of the blended GH program remains unclear.

OBJECTIVE

We aimed to (1) compare the effectiveness of the virtual GH program delivered during the COVID-19 pandemic with that of the blended GH program delivered prior to the pandemic for changing child physical activity, sedentary and dietary behaviors, screen time, and parental support-related behaviors for child physical activity and healthy eating, and (2) explore virtual GH program engagement and satisfaction.

METHODS

This study used a single-arm pre-post design. The blended GH program (n=102) was delivered from January 2019 to February 2020, and the virtual GH program (n=90) was delivered during the COVID-19 pandemic from April 2020 to March 2021. Families with children aged 8-12 years and considered overweight or obese (BMI ≥85th percentile according to age and sex) were recruited. Participants completed preintervention and postintervention questionnaires to assess the children's physical activity, dietary and sedentary behaviors, and screen time, and the parent's support behaviors. Intervention feedback was obtained by interviews. Repeated measures ANOVA was used to evaluate the difference between the virtual and blended GH programs over time. Qualitative interviews were analyzed using thematic analyses.

RESULTS

Both the virtual and blended GH programs improved children's moderate-to-vigorous physical activity (F_1,380=18.37; P<.001; ηp²=0.07) and reduced screen time (F_1,380=9.17; P=.003; ηp²=0.06). However, vegetable intake was significantly greater in the virtual GH group than in the blended GH group at the 10-week follow-up (F_1,380=15.19; P<.001; ηp²=0.004). Parents in both groups showed significant improvements in support behaviors for children's physical activity (F_1,380=5.55; P=.02; ηp²=0.002) and healthy eating (F_1,380=3.91; P<.001; ηp²=0.01), as well as self-regulation of parental support for children's physical activity (F_1,380=49.20; P<.001; ηp²=0.16) and healthy eating (F_1,380=91.13; P<.001; ηp²=0.28). Families in both groups were satisfied with program delivery. There were no significant differences in attendance for the weekly in-person or group video chat sessions; however, portal usage was significantly greater in the virtual GH group (mean 50, SD 55.82 minutes) than in the blended GH group (mean 17, SD 15.3 minutes; P<.001).

CONCLUSIONS

The study findings suggested that the virtual GH program was as effective as the blended program for improving child lifestyle behaviors and parental support-related behaviors. The virtual program has the potential to improve the flexibility and scalability of family-based childhood obesity management interventions.

Preliminary Effectiveness of a Strategy to Promote Healthy Lifestyle Habits in Schoolchildren

Purpose: To measure the preliminary effectiveness of a strategy to promote healthy lifestyle habits in schoolchildren, aged 6 to 12 years, living in the Andean region of Colombia, 2018–2021. Design and Methods: This is a Nursing Methodological Research, developed in phases: (1) Context and schoolchildren characterization; (2) Strategy design guided by the Whittemore and Grey criteria and the Bronfenbrenner ecological conceptual model; (3) Strategy validation with 11 experts; (4) Trial to evaluate preliminary effectiveness. We applied the strategy in seven different schools with the educational community including 955 schoolchildren between 6 and 12 years of age, 551 parents, 130 teachers and 7 members of the food staff. Results: Our health promotion strategy “Prosalud” has five components: citizenship feeding and nutrition, physical activity, and rest; environment protection, and directing one’s own life. It includes all the participants of the educational community. Conclusions: According to experts, the health promotion strategy “Prosalud” is valid to help promoting healthy lifestyle habits among schoolchildren. This strategy demonstrates its preliminary effectiveness in a group of school children from 6 to 12 years of age, their parents, teachers, and school food staff, in the Andean region of Colombia.

Swap Up Your Meal: A Mass Media Nutrition Education Campaign for Oklahoma Teens

To address a statewide need for obesity prevention, the Oklahoma Tobacco Settlement Endowment Trust launched Swap Up in 2021, a mass media nutrition education effort for teens, ages 13-18. Swap Up utilizes the SAVI messaging approach, an audience-centric message development framework that recognizes barriers to healthy living and offers realistic solutions. Five months into the campaign, an online survey was conducted (n = 200) to assess short-term program goals related to campaign delivery, engagement, and relevance. A secondary, long-term goal related to documenting and understanding self-reported changes in past month nutrition-related behaviors was also explored. A majority of participants (72%) reported aided awareness of the campaign brand logo/advertisements, and awareness (83%) of at least one main message. Nearly half (44%) of the participants reported at least one engagement with digital media. Main message recognition, perceived relevance, and self-reported nutritional behaviors were consistently highest among those reporting both campaign awareness and digital engagement. Ultimately, Swap Up reached and delivered nutrition education messages to Oklahoma teens within the first year of launch, as intended, and was associated with self-reported changes in recent behavior. This study provides evidence that SAVI offers a promising approach for nutrition education, and underscores why digital and social media engagement strategies are critical for mass media teen behavior change campaigns. Campaign implementation and evaluation are ongoing.

Accuracy of equations for predicting 24-h urinary potassium excretion from spot urine samples in Chinese children

Accurate assessments of potassium intake in children are important for the early prevention of CVD. Currently, there is no simple approach for accurate estimation of potassium intake in children. We aim to evaluate the accuracy of 24-h urinary potassium excretion (24UKV) estimation in children using three common equations: the Kawasaki, Tanaka and Mage formulas, in a hospital-based setting. A total of 151 participants aged 5-18 years were initially enrolled, and spot urine samples were collected in the whole 24-h duration to measure the concentrations of potassium and creatinine. We calculated the mean difference, absolute and relative difference and misclassification rate between measured 24UKV and the predicted ones using Kawasaki, Tanaka and Mage formulas in 129 participants. The mean measured 24UKV was 1193·3 mg/d in our study. Mean differences between estimated and measured 24UKV were 1215·6, -14·9 and 230·3 mg/d by the Kawasaki, Tanaka and Mage formulas, respectively. All estimated 24UKV were significantly different from the measured values in all the time point (all P < 0·05), except for the predicted values from Tanaka formula using morning, afternoon and evening spot urine. The proportions with relative differences over 40 % were 87·2%, 32·5% and 47·3 % for Kawasaki, Tanaka and Mage formulas, respectively. Misclassification rates were 91·5 % for Kawasaki, 44·4 % for Tanaka and 58·9 % for Mage formula at the individual level. Our findings showed that misclassification could occur on the individual level when using Kawasaki, Tanaka and Mage formulas to estimate 24UKV from spot urine in the child population.

Dose-Response Relationship of a Blended In-Person and Online Family-Based Childhood Obesity Management Program: Secondary Analysis of a Behavior Intervention

BACKGROUND

The Early Intervention Program (EIP) was a 10-week, blended, in-person and online lifestyle intervention for families with children who were off the healthy weight trajectory. The engagement pattern and the dose response of EIP have not been examined.

OBJECTIVE

The aims of this paper are to examine families' engagement patterns with the EIP and to evaluate the dose-response relationship between EIP engagement patterns and physical activity and healthy eating-related outcomes at 10 weeks.

METHODS

Families with children (8-12 years old) who are off the healthy weight trajectory (child BMI ≥85th percentile for age and sex) were recruited. Pre- and postintervention questionnaires assessed child lifestyle behaviors, parental support behaviors, family lifestyle habits, as well as parental physical activity and healthy-eating identity. Hierarchical cluster analysis of both in-person and online components was used to classify engagement patterns. Regression analysis assessed differences in outcomes by engagement groups.

RESULTS

Two distinct clusters of engagement groups were identified (N=66), which were in-person (IP; n=40, 61%) and in-person + online (IP+; n=26, 39%) engagement. Relative to the IP group at week 10, IP+ showed a greater child moderate-to-vigorous physical activity level (1.53, SD 0.56; P=.008), child physical activity confidence (1.04, SD 0.37; P=.007), parental support for child physical activity (5.54, SD 2.57; P=.04) and healthy eating (2.43, SD 1.16; P=.04), family habits for physical activity (3.02, SD 1.50; P=.049) and healthy eating (3.95, SD 1.84; P=.04), and parental identity for physical activity (2.82, SD 1.19; P=.02).

CONCLUSIONS

The online EIP portal complemented the in-person sessions. Additional engagement with the portal was associated with greater improvements in child physical activity and parental support behaviors, habits, and identity for physical activity.

Using predicted marginal effects to assess the impact of rurality and free and reduced lunch eligibility on a school-based nutrition intervention

PURPOSE

To estimate the impact of a school-based nutrition education intervention in rural schools and schools with high free and reduced lunch (FRL) eligibility rates.

METHODS

As part of the evaluation of the Healthy Schools Healthy Students intervention, 20 schools were randomized to control and intervention conditions. Pre (October 2017) and posttest (April 2018) data were analyzed using multi-level linear regression models to estimate the intervention effect for multiple outcomes controlling for school-level demographic characteristics. We report the predicted marginal effect overall and specifically for rural; high FRL; and rural, high-FRL schools.

RESULTS

We observed at least one significant intervention effect for food group knowledge, liking to eat fruit, beliefs about how healthy fruits are, non-taste test fruit preferences, liking to eat vegetables, beliefs about how healthy vegetables are, and taste test vegetable preferences. We observed differential intervention effects for all outcomes except taste test vegetable preferences based on rural and high-FRL status.

CONCLUSIONS

Interventions do not necessarily have the same impact on all participants. Sub-analyses can reveal these important differential effects, as they have important implications for policymakers, program implementers, and evaluators. Resources and interventions should be allocated where they will have the greatest impact.

Dialogue as a tool of nutrition literacy in an agricultural intervention programme in Odisha, India

BACKGROUND

An ongoing action research nutrition literacy programme based on Freire's approach of raising critical consciousness through the use of dialogue as a pedagogic tool is being implemented as part of a nutrition sensitive agricultural intervention in tribal Odisha. One hundred and eight adults, referred to as Community Hunger Fighters (CHFs) underwent two modules of a residential training programme of two and a half days each, spread over two months. Through discussion they explored the reasons behind the lack of diversity in their daily diets and identified the social, economic and cultural barriers to food intake in the context of their own poverty. They undertook collective exercises in nutrition sensitive agricultural planning. The transformative behaviour of the CHFs was captured through observation, interviews and focus group discussion with a set of qualitative indicators.

RESULTS

The methodology of dialogue as a pedagogic tool generated a discussion about food security among the community. CHFs identified key messages and shared them with fellow villagers in imaginative ways. The process of critical reflection and analysis helped understand gender disparities, the bottlenecks in food production, brought in life style changes to improve food intake and created a demand for technical training for improving agricultural productivity. Thirty eight had started a nutri-garden and several took on leadership roles on other issues of importance besides food security.

CONCLUSION

Dialogue as a pedagogic tool for nutrition literacy in an agricultural intervention programme has the potential to facilitate a process of critical reflection on the socio cultural and economic barriers to food production and consumption thereby leading to transformative action.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1186/s43170-022-00090-x.

Developing and Evaluating Newsletters for Parent Engagement in Sustainability via Active Garden Education (SAGE)

Physical activity and nutrition preschool programming must involve parents in positive long-term healthy habits. This paper describes parent outreach in the Sustainability via Active Garden Education (SAGE) study. Newsletters were sent home with children to promote family opportunities to increase physical activity and fruit and vegetable intake. The content was generated via a community advisory board participatory process. Messages linked SAGE curriculum topics with home and community activities. Parents rated frequency of receipt, helpfulness, satisfaction, and use of content. Most participants were Hispanic (>78%) and women (>95%). Most reported receiving newsletters; nearly all reported that they were helpful. Favorite newsletter components included recipes, pictures of their children and seasonal produce spotlights. Most reported doing physical activities from the newsletters (51.9%). Few reported doing featured physical activity (8.9%) and fruit and vegetable (12.7%) community activities. Newsletter outreach methods are a simple strategy to add value to preschool-based interventions promoting healthy families.

Socioeconomic inequalities in the consumption of minimally processed and ultra-processed foods in Brazilian adolescents

In this study, we evaluated socioeconomic inequalities in the consumption of in natura/minimally processed and ultra-processed foods among adolescents. We used data from the Brazilian National Survey of School Health (PeNSE), 2015. According to the self-reported consumption of beans, vegetables and fruits, a score of in natura/minimally processed foods was generated (0-21 points). Sodas, sweets, instant noodles, and ultra-processed meat were used for the score of ultra-processed foods (0-21 points). Equality indicators were gender, maternal education, and socioeconomic level. Absolute difference, ratios, concentration index and slope index of inequality were calculated. Adolescents (n=101,689, 51% girls, 14.2 years) reported a mean score of 9.97 and 11.46 for ultra-processed foods and in natura/minimally processed foods, respectively. Absolute and relative differences between adolescents with the highest and lowest socioeconomic level, there were differences of 2.64 points and 33% for consumption of in natura/minimally processed foods; and 1.48 points and 15% for ultra-processed foods. Adolescents from higher socioeconomic level ate more in natura/minimally processed foods and ultra-processed foods.

The Effect of the "Colorful Eating Is Healthy Eating" Long-Term Nutrition Education Program for 3- to 6-Year-Olds on Eating Habits in the Family and Parental Nutrition Knowledge

Background: Effective strategies for improving eating habits and dietary intake in preschoolers are essential for reducing the risk of chronic non-infectious diseases in later life. The aim of this study was to evaluate the effect of long-term nutrition education for 3- to 6-year-olds on parental nutrition knowledge. Methods: The study was conducted as part of the “Colorful Eating is Healthy Eating” nutrition education program that has been implemented in kindergartens in Lublin since 2016. A total of 11 kindergartens were involved in this stage of the program, and 733 parents consented to participate in the project. The study was divided into three stages. In the first stage all parents completed a questionnaire containing 54 items. In the next stage, 211 children from four randomly selected kindergartens participated in the “Colorful Eating Is Healthy Eating” educational program that lasted 7 months. In the third stage of the study, the parents of children who had completed the 7-month educational program and the parents of control group children once again completed the questionnaire. Results: A positive outcome of the educational program was that it contributed to a decrease in the consumption of sweetened hot beverages (p = 0.005) and an increase in water intake (p = 0.001). The nutrition education program was also successful in reducing the consumption of sweets. Children’s education improved the parents’ knowledge about dietary sources of fiber and the recommended fiber intake, and it contributed to the awareness that breakfast is the most important meal of the day. The program did not enhance the parents’ knowledge about snacking between meals or the role of sweetened beverages in dental caries, overweight and obesity. Conclusions: Long-term multi-stage nutrition education for children aged 3 to 6 years can be helpful in shaping families’ eating habits and improving parental nutrition knowledge. However, the program was less effective in eliminating the respondents’ preference for sweet-tasting foods.

What Works to Improve Nutrition and Food Sustainability across the First 2000 Days of Life: A Rapid Review

Informed by the Innocenti framework, this rapid review of systematic reviews (n = 60) and sentinel grey literature (n = 27) synthesises the evidence of what works to improve nutrition and food sustainability across the first 2000 days. Most systematic reviews focused on interventions targeting the behaviour of parents and caregivers (n = 49), with fewer reviews focusing on the personal (n = 7) and external (n = 4) food environments. No reviews focused on food supply-chain activities. Most reviews were rated as critically low (n = 28, 47%) or low (n = 21, 35%) quality using AMSTAR 2. Evidence supports the effectiveness of multi-component breastfeeding interventions, interventions delivered in home and child-care settings, particularly when involving parents, interactive skill building and repeated exposure to vegetables. Food vouchers and access to local farmers markets and community gardens have potential for improving access and availability to healthier foods, while evidence supports interventions improving the external food environment, including fiscal strategies such as the SSB tax, restrictions on marketing and advertising of discretionary products and improved food labelling. Overall, this review highlights the importance of action across a range of settings and sectors at the international, national and local levels to improve young children’s diets.

Spillover Effects of a Family-Based Childhood Weight-Management Intervention on Parental Nutrient Biomarkers and Cardiometabolic Risk Factors

BACKGROUND

Parental involvement has been shown to favorably affect childhood weight-management interventions, but whether these interventions influence parental diet and cardiometabolic health outcomes is unclear.

OBJECTIVES

The aim was to evaluate whether a 1-y family-based childhood weight-management intervention altered parental nutrient biomarker concentrations and cardiometabolic risk factors (CMRFs).

METHODS

Secondary analysis from a randomized-controlled, parallel-arm clinical trial (NCT00851201). Families were recruited from a largely Hispanic population and assigned to either standard care (SC; American Academy of Pediatrics overweight/obesity recommendations) or SC + enhanced program (SC+EP; targeted diet/physical activity strategies, skill building, and monthly support sessions). Nutrient biomarkers (plasma carotenoids and fat-soluble vitamins, RBC fatty acid profiles) and CMRFs (BMI, blood pressure, glucose, insulin, lipid profile, inflammatory and endothelial dysfunction markers, adipokines) were measured in archived samples collected from parents of participating children at baseline and end of the 1-y intervention.

RESULTS

Parents in both groups (SC = 106 and SC+EP = 99) had significant reductions in trans fatty acid (-14%) and increases in MUFA (2%), PUFA n-6 (ɷ-6) (2%), PUFA n-3 (7%), and β-carotene (20%) concentrations, indicative of lower partially hydrogenated fat and higher vegetable oil, fish, and fruit/vegetable intake, respectively. Significant reductions in high-sensitivity C-reactive protein (hsCRP; -21%) TNF-α (-19%), IL-6 (-19%), and triglycerides (-6%) were also observed in both groups. An additional significant improvement in serum insulin concentrations (-6%) was observed in the SC+EP parents. However, no major reductions in BMI or blood pressure and significant unfavorable trajectories in LDL-cholesterol and endothelial dysfunction markers [P-selectin, soluble intercellular adhesion molecule (sICAM), thrombomodulin] were observed. Higher carotenoid, MUFA, and PUFA (n-6 and n-3) and lower SFA and trans fatty acid concentrations were associated with improvements in circulating glucose and lipid measures, inflammatory markers, and adipokines.

CONCLUSIONS

The benefits of a family-based childhood weight-management intervention can spill over to parents, resulting in apparent healthier dietary shifts that are associated with modest improvements in some CMRFs.

Effectiveness of Nutritional Strategies on Improving the Quality of Diet of Children from 6 to 12 Years Old: A Systematic Review

Dietary habits, that are formed during childhood and consolidated in adulthood, are known to influence the development of future chronic diseases such as metabolic syndrome or type 2 diabetes. The aim of this review was to evaluate the effectiveness of nutritional interventions carried out in recent years focused on improving the quality of the diet of the child population. A systematic search of the PubMed and Scopus databases was performed from January 2011 until September 2021. A total of 910 articles were identified and screened based on their title, abstract and full text. Finally, 12 articles were included in the current systematic review. Of those, in six studies the intervention was based on the provision of healthy meals and in the other six studies the intervention focused on modifying the school environment. Six of the studies selected included other components in their intervention such as nutritional education sessions, physical activity and/or families. A wide variety of methods were used for diet assessments, from direct method to questionnaires. The results suggest that interventions that modify the school environment or provide different meals or snacks may be effective in improving children’s dietary patterns, both in the short and long term. Further research is necessary to evaluate the real effectiveness of strategies with multidisciplinary approach (nutritional sessions, physical activity and family’s involvement).

Digital Interventions to Promote Healthy Eating in Children: Umbrella Review

BACKGROUND

eHealth and web-based service delivery have become increasingly common during the COVID-19 pandemic. Digital interventions may be highly appealing to young people; however, their effectiveness compared with that of the usual face-to-face interventions is unknown. As nutrition interventions merge with the digital world, there is a need to determine the best practices for digital interventions for children.

OBJECTIVE

The aim of this study is to examine the effectiveness of digital nutrition interventions for children on dietary outcomes compared with status quo interventions (eg, conventional face-to-face programming or nondigital support).

METHODS

We conducted an umbrella review of systematic reviews of studies assessing primary research on digital interventions aimed at improving food and nutrition outcomes for children aged <18 years compared with conventional nutrition education were eligible for inclusion.

RESULTS

In total, 11 systematic reviews published since 2015 were included (7/11, 64%, were of moderate quality). Digital interventions ranged from internet, computer, or mobile interventions to websites, programs, apps, email, videos, CD-ROMs, games, telehealth, SMS text messages, and social media, or a combination thereof. The dose and duration of the interventions varied widely (single to multiple exposures; 1-60 minutes). Many studies have been informed by theory or used behavior change techniques (eg, feedback, goal-setting, and tailoring). The effect of digital nutrition interventions for children on dietary outcomes is small and inconsistent. Digital interventions seemed to be the most promising for improving fruit and vegetable intake compared with other nutrition outcomes; however, reviews have found mixed results.

CONCLUSIONS

Owing to the heterogeneity and duration of digital interventions, follow-up evaluations, comparison groups, and outcomes measured, the effectiveness of these interventions remains unclear. High-quality evidence with common definitions for digital intervention types evaluated with validated measures is needed to improve the state of evidence, to inform policy and program decisions for health promotion in children. Now is the time for critical, robust evaluation of the adopted digital interventions during and after the COVID-19 pandemic to establish best practices for nutrition interventions for children.

Nutrition Supports Deconstructed and Disrupted: An Evaluation of a Multilevel School-Based Intervention during the Time of COVID

The Best Food Forward (BFF) project aims to provide multiple nutrition supports and interventions to improve family food security (FS) and health outcomes associated with FS within two metropolitan school districts. A quasi-experimental time-series design guided a multilevel evaluation for BFF through surveys, biometric screenings, focus groups, and observations among a random sample of caregiver-child dyads. FS, utilization of school meal programs, and nutrition behaviors were observed and analyzed at three time points: preintervention, postintervention pre-COVID-19, and postintervention post-COVID-19. Participants included 122 parents and 162 youth. Families reported (1) an income less than $35,000 annually (48.8%) and (2) a COVID-19-related job loss (36.9%). Parents used Supplemental Nutrition Assistance Programs or Women, Infants, Children benefits prior to (51.1%) and following COVID-19 (50.0%). No significant differences in FS were found. RM-ANOVA indicated an increase in breakfast consumption at home and a decrease in use of the school breakfast program (F(1.78, 74) = 19.64, p < 0.001, partial η² = 0.21) and school lunch program (F(1.51, 74) = 23.30, p < 0.001, partial η² = 0.24). Rates of FS and eating behaviors did not change significantly over time. Correlations of program usage and eating behaviors demonstrate the importance of promoting participation in school meal programs. BFF may have prevented significant decreases in FS during COVID-19.

Dietary Outcomes of the 'Healthy Youngsters, Healthy Dads' Randomised Controlled Trial

(1) Background: The effect of fathers on dietary intake in preschool-aged children is under-explored. The aims were to: (i) evaluate the efficacy of a family-based lifestyle intervention, Healthy Youngsters, Healthy Dads, on change in dietary intake in fathers and their preschool-aged children post-intervention (10 weeks) and at 9 months follow-up compared to a waitlist control group and (ii) investigate associations in father-child dietary intakes. (2) Methods: Linear mixed models estimated group-by-time effects for all dietary outcomes, measured by food frequency questionnaires. Cohen's d determined effect sizes, while correlation tests determined associations in father-child dietary intakes. (3) Results: For children, medium group-by-time effects sizes were identified at 10 weeks for sodium intake (d = 0.38) and percentage energy from core foods (d = 0.43), energy-dense, nutrient-poor (EDNP) foods (d = 0.43) and prepacked snacks (d = 0.45). These findings were sustained at 9 months follow-up. For fathers, medium to large, group-by-time effect sizes were identified at 10 weeks for energy intake (d = 0.55), sodium intake (d = 0.64) and percentage energy from core foods (d = 0.49), EDNP foods (d = 0.49), and confectionary (d = 0.36). For all of these dietary variables, except sodium, effects were sustained at 9 months. Moderate to strong associations existed in father-child dietary intakes for some of the dietary variables. (4) Conclusions: Although further research is required, this study provides preliminary support for targeting fathers as agents of change to improve dietary intakes in their preschool-aged children.

Prioritization of Features for Mobile Apps for Families in a Federal Nutrition Program for Low-Income Women, Infants, and Children: User-Centered Design Approach

Background

The Special Supplemental Nutrition Assistance Program for Women, Infants, and Children (WIC) is a federal nutrition program that provides nutritious food, education, and health care referrals to low-income women, infants, and children up to the age of 5 years. Although WIC is associated with positive health outcomes for each participant category, modernization and efficiency are needed at the clinic and shopping levels to increase program satisfaction and participation rates. New technologies, such as electronic benefits transfer (EBT), online nutrition education, and mobile apps, can provide opportunities to improve the WIC experience for participants.

Objective

This formative study applies user-centered design principles to inform the layout and prioritization of features in mobile apps for low-income families participating in the WIC program.

Methods

To identify and prioritize desirable app features, caregivers (N=22) of the children enrolled in WIC participated in individual semistructured interviews with a card sorting activity. Interviews were transcribed verbatim and analyzed using constant comparative analysis for themes. App features were ranked and placed into natural groupings by each participant. The sum and average of the rankings were calculated to understand which features were prioritized by the users. Natural groupings of features were labeled according to participant descriptions.

Results

Natural groupings focused on the following categories: clinics/appointments, shopping/stores, education/assessments, location, and recipes/food. Themes from the interviews triangulated the results from the ranking activity. The priority app features were balance checking, an item scanner, and appointment scheduling. Other app features discussed and ranked included appointment reminders, nutrition training and quizzes, shopping lists, clinic and store locators, recipe gallery, produce calculator, and dietary preferences/allergies.

Conclusions

This study demonstrates how a user-centered design process can aid the development of an app for low-income families participating in WIC to inform the effective design of the app features and user interface.

Effectiveness of an Innovative Sensory Approach to Improve Children's Nutritional Choices

A case-control study was conducted to investigate the effectiveness of the Edueat^® Method, through experiential workshops focused on the use of all 5 senses. In two different primary schools in the same city, questionnaires were administered in two months with a follow-up one year later. Participants: 119 children (age 8.2–9.0) chosen randomly; control group 66 (55.5%). Seven lessons of 2 h each were held in the schools by experts of the Edueat^® method and seven extra lessons by the teachers. The main outcome measures were the children’s changes in their approach and attitude towards their eating habits. The answers were grouped with factor analysis and summarized through scores. Repeated-measures analysis of variance was conducted in order to identify the relationships between scores and treatment over time. At the end of treatment, the intervention group showed a significant appreciation towards healthy foods (+4.15 vs. −0.05, p = 0.02) and a greater capacity in identifying foods which are very good for the health (+15.6 vs. +14.4, p = 0.02). In conclusion, the Edueat^® method was found to be particularly promising in transmitting knowledge of those foods which are healthy. Greater involvement of teachers and parents is crucial.

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.

Perspectives of Black/African American and Hispanic Parents and Children Living in Under-Resourced Communities Regarding Factors That Influence Food Choices and Decisions: A Qualitative Investigation

Families living in under-resourced communities are at risk of obesity and obesity-related chronic diseases. To develop effective interventions, it is important to identify parent and child perspectives of factors that influence food-related choices and decisions. This paper reports qualitative findings from a larger mixed method study investigating this topic. Hybrid thematic analysis was used to code and analyze the interviews. Family-generated photographs of factors influencing food choices were discussed during the interviews. Qualitative findings were organized by the socio-ecological model. Verbatim quotes and photographs were used to support themes. Thirty-six interviews were conducted (18 parents, 18 children). Findings from parents revealed personal (e.g., culture, beliefs, time), family (e.g., mother, child, father, health, finances, cohesiveness), environmental (e.g., availability, convenience, cost), and other (e.g., school food) factors influenced food choices. Similarly, child-reported influences were personal (e.g., preferences, beliefs, taste), family (e.g., mother, family encouragement, father, family time), social (e.g., school, friends), environmental (e.g., availability), and other (e.g., media, sports). The socio-ecological model provided a useful framework for identifying factors that influence food choices and decisions of families living in under-resourced communities. A deeper understanding of these factors could enhance both responsiveness and effectiveness of interventions to enhance diet and reduce obesity risk in families living in under-resourced communities.

Current Systems-Level Evidence on Nutrition Interventions to Prevent and Treat Cardiometabolic Risk in the Pediatric Population: An Evidence Analysis Center Scoping Review

Improving and maintaining cardiometabolic health remains a major focus of health efforts for the pediatric population. Recent research contributes understanding of the systems-level nutrition factors influencing cardiometabolic health in pediatric individuals. This scoping review examines current evidence on interventions and exposures influencing pediatric cardiometabolic health to inform registered dietitian nutritionists working at each systems level, ranging from individual counseling to public policy. A literature search of MEDLINE, CINAHL, Cochrane Databases of Systematic Reviews, and other databases was conducted to identify evidence-based practice guidelines, systematic reviews, and position statements published in English from January 2017 until April 2020. Included studies addressed nutrition interventions or longitudinal exposures for participants 2 to 17 years of age who were healthy or had cardiometabolic risk factors. Studies were categorized according level of the social-ecological framework addressed. The databases and hand searches identified 2614 individual articles, and 169 articles were included in this scoping review, including 6 evidence-based practice guidelines, 141 systematic reviews, and 22 organization position statements. The highest density of systematic reviews focused on the effects of dietary intake (n = 58) and interventions with an individual child or family through counseling or education (n = 54). The least frequently examined levels of interventions or exposures were at the policy level (n = 12). Registered dietitian nutritionists can leverage this considerable body of recent systematic reviews to inform a systems-level, collaborative approach to prevention and treatment of pediatric cardiometabolic risk factors.

A belief-based parenting behavior model for promoting family's ability to care for children with avoidant restrictive food intake disorder (ARFID) in Indonesia

Background: Family's ability to care for children with avoidant restrictive food intake disorder (ARFID) is a central indicator in preventing the children from worse nutritional disorders. Environmental factor, child factor, caregiving behavioral systems, and beliefs can improve the family's ability to care for children. The aim of this research was to analyze the effect of environmental factor, child factor, caregiving behavioral systems, and beliefs on the family's ability to care for children with ARFID. Design and Methods: This cross-sectional research was carried out on 245 families with children suffering from ARFID in Malang Regency, in the working area of the Health Office of Malang Regency. The population of this research was families with children suffering from ARFID within the working area of the Health Office of Malang Regency. The research sample size was computed using the rule of thumb in structural equation modeling (SEM), the sample size used was 245. Results: Results showed that the family's ability to care for children with ARFID was highly influenced by the caregiver's belief (t = 21.796; β = 0.713). Caregiver's belief became a dominant factor in the promotion of the family's ability to care for children with ARFID. A caregiver's belief was influenced by his/her behavior. Conclusions: It was concluded that the caregiver's belief serves as a primary factor in the promotion of the family's ability to care for children with ARFID. A caregiver's behavior holds a prominent role in influencing his/her belief in providing care for children suffering from ARFID.

Effects of a Community-Based Pilot Intervention on Home Food Availability among U.S. Households

The purpose of this study was to assess the effects of a pilot community-based behavioral intervention on the home food environment in U.S. households. Parents (21 females, 2 males; age = 36 ± 5.5 years; 78% Hispanic) of elementary school-aged children attended a 10-week dietary improvement behavioral intervention targeting an increase in fruit and vegetable consumption and a reduction in sugar intake. Home food availability of fruit, vegetables, and sugar-laden foods and beverages were assessed before and after the intervention using a modified version of the Home Food Inventory. Relative to baseline, the intervention resulted in significant increases in fruit availability (7.7 ± 3.2 items vs. 9.4 ± 3.1 items; p = 0.004) and low sugar cereal (2.3 ± 1.4 types vs. 2.7 ± 1.4 types; p = 0.033). There was a significant reduction in sugar-sweetened beverage availability (3.2 ± 1.9 types vs. 1.7 ± 1.3 types; p = 0.004). There was a significant increase in the number of households with accessible ready-to-eat vegetables and fruit, and a significant reduction in available prepared desserts, and candy (p < 0.01). There were no significant changes in the availability of vegetables and sugar-laden cereals. The current intervention resulted in positive changes in the home food environment. Further research to confirm these results in a randomized controlled trial is warranted.

Facilitators and barriers to healthy food selection at children's sports arenas in Norway: a qualitative study among club managers and parents

Objective:

To investigate club managers’ and parents’ experiences with food selection at handball halls in order to identify facilitators and barriers to the availability of healthy food.

Design:

Individual interviews with club managers (n 6) and focus groups (n 5) with parents (n 21) were conducted. Interviews were recorded and transcribed verbatim, transcripts were coded in NVivo and the analysis was guided by thematic analysis.

Setting:

Interviews were conducted at five handball clubs with varying socio-economic user populations and sizes in the area of Oslo, Norway.

Participants:

The club managers were responsible for food selection at the handball clubs. The participating parents had one or two active children between the ages of 6 and 12 years who took part in the clubs.

Results:

The club managers and parents generally described food selection at the handball halls as unhealthy and wanted a healthier selection of food. The club managers’ primary barriers to providing a healthier food selection included the potential to lose profits, limited facilities and time to prepare these foods. The parents often valued unhealthy food, as they believed that it supported the social environment and served as a reward for the children. Trainers were perceived as important role models for the promotion of healthy eating. The participants thought that national guidelines could facilitate healthy food environments in sports arenas.

Conclusion:

Healthier food options in sports settings could be facilitated through national guidelines that describe healthy foods and establish who is responsible for providing healthy food selections.

Development of a Family-Based Nutrition Program Rooted in Food Parenting Literature

Family-based nutrition programs have been used to support healthy eating; however, few programs emphasize parental roles in regard to food. The purpose of this study was to develop and test a family-based curriculum with a parenting focus aimed at influencing child obesity risk. Qualitative data in the pilot implementation (cohort 1, n = 6 families with elementary-aged children) suggested parent value for: positive messages, hands-on learning, and group sharing. However, Family Nutrition and Physical Activity (FNPA) scores for cohorts 2-6 (n = 18 families) did not change significantly from pre- to post-program. Future implementations will consider more robust ways of assessing change and recruiting participants at various stages of change.

Effects of the Preschool-Based Family-Involving DAGIS Intervention Program on Children's Energy Balance-Related Behaviors and Self-Regulation Skills: A Clustered Randomized Controlled Trial

The study examines the effects of a preschool-based family-involving multicomponent intervention on children’s energy balance-related behaviors (EBRBs) such as food consumption, screen time and physical activity (PA), and self-regulation (SR) skills, and whether the intervention effects differed among children with low or high parental educational level (PEL) backgrounds. The Increased Health and Wellbeing in Preschools (DAGIS) intervention was conducted as a clustered randomized controlled trial, clustered at preschool level, over five months in 2017–2018. Altogether, 802 children aged 3–6 years in age participated. Parents reported children’s consumption of sugary everyday foods and beverages, sugary treats, fruits, and vegetables by a food frequency questionnaire, and screen time by a 7-day diary. Physical activity was assessed by a hip-worn accelerometer. Cognitive and emotional SR was reported in a questionnaire by parents. General linear mixed models with and without repeated measures were used as statistical methods. At follow-up, no differences were detected in EBRBs or SR skills between the intervention and control group, nor did differences emerge in children’s EBRBs between the intervention and the control groups when stratified by PEL. The improvement in cognitive SR skills among low PEL intervention children differed from low PEL control children, the significance being borderline. The DAGIS multicomponent intervention did not significantly affect children’s EBRBs or SR. Further sub-analyses and a comprehensive process evaluation may shed light on the non-significant findings.

Exploring Knowledge and Perspectives of South Asian Children and Their Parents Regarding Healthy Cardiovascular Behaviors: A Qualitative Analysis

South Asian children and parents have been shown to have a higher risk for cardiovascular disease (CVD) relative to white individuals. To design interventions aimed at addressing the comparatively higher burden in South Asians, a better understanding of attitudes and perspectives regarding CVD-associated behaviors is needed. As a result, we sought to understand knowledge about CVD risk in both children and parents, and attitudes toward physical activity and diet in both the children and parents, including potential cultural influences. In-depth interviews were conducted with 13 South Asian child-and-parent dyads representing a range of child body mass index (BMI) levels, ages, and with both sexes. South Asian children and parents demonstrated good knowledge about CVD prevention; however, knowledge did not always translate into behavior. The influence of social and cultural dynamics on behavior was also highlighted. To ensure that interventions aimed at this population are effective, an understanding of the unique social dynamics that influence diet and physical activity-related behaviors is needed.

"GENOGRAM Physician Involvement Model" New Approach for Indonesian Physician Involvement with Family

Background

The family, as the smallest social institution, has responsibilities across many functions, including maintaining family health. Increases in chronic diseases and life expectancy require more family support to prevent disease and implement treatment for family members with chronic diseases. Therefore, physician involvement in not only the treatment of diseases but also their prevention and rehabilitation is required In Indonesia. Hence, a new approach for physician involvement with families is required, especially with regard to comprehensiveness. This study aimed to develop a physician involvement program with the family model for primary healthcare in Indonesia.

Methods

A two-round Delphi method with family medicine experts from 17 of the highest accredited medical faculties in Indonesia as participants was conducted, and factor analysis performed thereafter. The items were considered relevant at ≤0.8 validity content ratio. The second step of this research is survey using e-questionnaire involving 101 primary care physician from all over Indonesia. They live scattered in several provinces in the main islands of Indonesia such Sumatra, Java, Kalimantan, Sulawesi dan Bali.

Results

Results showed an adequately measured sample and correlation for all items (Kaiser-Meyer-Olkin of sampling=0.821; Bartlett’s test <0.001). Seven dimensions were derived from results with eigenvalue of >1, and 25 items were filtered after determining the loading factor of >0.5. The Cronbach’s α for each factor varied from 0.602 to 0.829, and that for the total 25 items was 0.913, with a total variation documented as high as 66%.

Conclusion

A new physician involvement model with the family approach model, known as the “GENOGRAM model,” was developed, which consisted of seven dimensions and 25 items.

Involving Parents to Help Improve Children's Energy Balance-Related Behaviours Through a School-Based Intervention

The Challenge Me intervention aimed to indirectly involve parents in a school-based intervention, by challenging primary school children to perform physical activity (PA) and nutrition-related activities with their parents. The aim of this study is to gain insight in whether this was a feasible strategy to engage children and parents, especially those of vulnerable populations. An exploratory cross-sectional study design was applied. Four primary schools implemented the intervention. Data consisted of challenges completed (intervention posters) and child and family characteristics (questionnaires and anthropometric measurements). Associations between challenges performed and child and family characteristics were assessed using linear regression analysis. Of the 226 study participants, 100% performed at least one challenge, and 93% performed at least one challenge involving parents. Children who performed more PA challenges were often younger, a sports club member, lived in higher socioeconomic status neighbourhoods, of Western ethnicity and from larger families. Regarding nutrition challenges involving parents, younger children performed more challenges. There was no difference in intervention engagement regarding gender, weight status, PA preference, healthy nutrition preference, or the Family PA and Family Nutrition Climate. Challenge Me has potential in involving parents in a school-based intervention. However, certain characteristics were associated with higher involvement.

Influence of pre-schooler and parent nutrition education on carotenoid levels of Mexican-heritage children

OBJECTIVE

To determine the mediating effect of direct preschool and parent nutrition education on changes in skin carotenoids scores over 2 years in children of Mexican heritage.

DESIGN

In a quasi-experimental, community-based study, two school districts were randomly assigned to either a comparison group (parent workshops unrelated to nutrition) or a childhood obesity prevention intervention group which included nutrition education at family nights for parents and at school for children. Changes in skin carotenoid intensity scores (diffCAROT, year 2015 minus 2013) were measured in children as a proxy for fruit and vegetable consumption using Resonance Raman Spectroscopy.

SETTING

Two rural, low-income, school districts from a county in California's Central Valley.

PARTICIPANTS

316 Mexican heritage families with children aged 3-8 years.

RESULTS

Intervention group children improved over 2 years in skin carotenoid scores relative to comparison group children (diffCAROT mean +1419 (sd 9540) v. -3473 (sd 9272), P = 0·0001). Parent attendance at nutrition education classes partially mediated the intervention effect on diffCAROT (P = 0·02). Controlling for child's age and other covariates, participation in preschool during the study had a significant positive effect on diffCAROT among intervention children compared with controls (P < 0·03), whereas no significant difference by group was observed among those not enrolled in preschool or already enrolled in elementary school.

CONCLUSIONS

Programmes that combine direct parent and preschool nutrition education may be effective in low-income Mexican heritage families to improve children's intake of fruit and vegetables.

Promotion of Healthy Eating in Spanish High Schools

Obesity and overweight are both public health problems, affecting increasingly younger populations. Promoting healthy eating should be a must in schools. Therefore, getting to know the eating habits of a population group as sensitive as adolescents and whether their schools apply an appropriate policy for their nutrition should be a priority. Therefore, the objective of this study was to discover whether the Secondary Education High Schools of Huelva and its province could be considered as centres that promote a healthy diet. A cross-sectional descriptive study was developed using a questionnaire comprising 39 indicators that were evaluated on 5 previously piloted subcategories of validated information. Data were obtained through a questionnaire presented to 200 key informants with four different profiles. The highest score for promoting healthy eating in the centres was related to the subcategory "School Curriculum", whereas the lowest means were those related to the Community category. No practical activities such as outings or cooking workshops were carried out. The low participation in activities promoting healthy eating habits, research and health training must be highlighted. Little attention was paid to compliance and monitoring of school cafeterias. Most of the studied Secondary Education High Schools did not meet the requisites to be considered promoters of healthy eating habits. Only three of the studied centres can be considered healthy-eating promoters. Institutional commitment is needed to favour the intersectorality of the different agents implied and to provide teaching units and other teaching profiles with the necessary resources, training, and tools to achieve integral and protective teaching activities aimed at promoting students' healthy eating habits.

Effectiveness of Interventions to Promote Healthy Eating Habits in Children and Adolescents at Risk of Poverty: Systematic Review and Meta-Analysis

The objective of this review was to provide an up-to-date review of trials that include behavioral intervention on the eating habits of children and adolescents at risk of poverty, applying meta-analysis to estimate the size of the intervention effect. A systematic literature search was performed in the following databases: MEDLINE via Pubmed and via EBSCOhost, LILACS and IBECS via VHL. The MeSH terms were used: "social class", "poverty", "diet", "health promotion" (PROSPERO ID: 183900). A total of 14 articles were finally included in this systematic review. The primary results of the included studies were meta-analyzed with the RevMan 5.3 program, assuming a random effects model. Analysis of the overall effect showed combined standardized mean differences (SMD) of 0.16 (CI 95%: [0.03, 0.30], I² = 76%). The p-value for the Z statistic was 0.02, which reflects accuracy in the effect estimation. When establishing subgroups based on the intervention tracking time points, studies that provided longer-term follow-up data showed a combined SMD of 0.15 (CI 95%: [-0.02, 0.32], I² = 81%]). Small effects of behavioral interventions were found to promote healthy eating habits, but better effects were shown in cases where the invention was followed up in the long term.

Child-level evaluation of a web-based intervention to improve dietary guideline implementation in childcare centers: a cluster-randomized controlled trial

BACKGROUND

Although it is recommended that childcare centers provide foods consistent with dietary guidelines, the impact of implementing sector-specific guidelines on child outcomes is largely unknown.

OBJECTIVES

This study aims to examine the impact of a web-based program and support to implement dietary guidelines in childcare centers on children's 1) diet; 2) BMI z scores; and 3) child health-related quality of life (HRQoL).

METHODS

This study was a cluster-randomized controlled trial utilizing a Type-3 Hybrid implementation-effectiveness design conducted between October 2016 and March 2018. This study reports on child outcomes. Fifty-four childcare centers in New South Wales, Australia were randomly assigned to the intervention (a web-based menu-planning tool and support) or control group (usual care). The intervention was designed to address barriers and enablers to dietary guideline implementation according to the Theoretical Domains Framework. A quota of 35 consenting childcare centers undertook child-level evaluation of dietary intake where 522 parents consented to completing ≥1 component of data collection for their child. Child consumption of core and discretionary (unhealthy) foods while in care was assessed via dietary observations by blinded research assistants, childcare diet quality was assessed via educator-completed questionnaires, BMI z scores were assessed via measured weight and height, and child HRQoL was assessed via parent report at baseline and 12-mo follow-up.

RESULTS

There was a significant increase in mean child consumption of fruit (0.39 servings; 95% CI: 0.12, 0.65 servings) and dairy foods (0.38 servings; 95% CI: 0.19, 0.57 servings) and a significant reduction in consumption of discretionary foods (-0.40 servings; 95% CI: -0.64, -0.16 servings) in care in the intervention group, relative to control at 12-mo follow-up. No significant differences were observed in diet quality, BMI z scores, or HRQoL.

CONCLUSIONS

A web-based intervention to support planning of childcare menus consistent with dietary guidelines can improve child consumption of healthier foods in daycare. This trial was registered at www.anzctr.org.au as ACTRN12616000974404.

Diet quality of children in the United States by body mass index and sociodemographic characteristics

OBJECTIVE

The primary objective was to use the Healthy Eating Index-2015 (HEI-2015) to describe diet quality by categories of body mass index (BMI) and by sociodemographic characteristics within categories of BMI using a nationally representative sample of US children.

METHODS

Dietary datasets from three cycles of the National Health and Nutrition Examination Survey (2009-2014) were analysed for children 2 to 18 years of age (N = 8894). Using the population ratio method, mean and 95% confidence intervals for HEI-2015 total and component scores were computed by BMI (underweight, normal weight, overweight, and obese) and by age (2-5, 6-11, and 12-18 y), gender, race/ethnicity (non-Hispanic black, non-Hispanic white, Mexican American, other Hispanic, and other race), and family poverty to income ratio (below and at/above poverty threshold).

RESULTS

HEI-2015 mean total scores were 50.4, 55.2, 55.1, and 54.0 out of 100 points for children with underweight, normal weight, overweight, and obesity, respectively, and were not significantly different. Within BMI categories, significant differences in total and mean component scores were present for age and race/ethnicity groups.

CONCLUSIONS

Total and most components of diet quality did not significantly differ among child populations classified by BMI status. Within BMI categories, significant diet quality differences were found for age and race/ethnicity groups, although scores were low for all child groups. Researchers may need to address or target specific dietary components with low quality in various child populations to have the greatest effect on improving nutrition nationwide.

Study Protocol for the Evaluation of "SuperFIT", a Multicomponent Nutrition and Physical Activity Intervention Approach for Preschools and Families

The promotion of healthy energy balance-related behaviours (EBRB) is already important for children at a young age. Different settings, for example childcare and home, play an important role in the EBRB of young children. Further, factors in different types of environment (e.g., physical, sociocultural and political) influence their behaviours. SuperFIT (Systems of Underprivileged Preschoolers in their home and preschool EnviRonment: Family Intervention Trial) is a comprehensive, integrated intervention approach for 2-4 year old children. This paper describes the development and design of the evaluation of SuperFIT. The SuperFIT intervention approach consists of preschool-based, family-based, and community-based components. Intervention activities aimed at changing the physical, sociocultural and political environments in each setting and establishing an increased alignment between the settings. A quasi-experimental design was adopted with twelve intervention and nine control preschools to evaluate effectiveness. The primary outcomes were Body Mass Index (BMI) z-scores (objectively assessed height and weight), dietary intake (24 h recall), and physical activity (accelerometer) of the children. Further, the effects on the nutrition- and physical activity-related practices of preschool teachers and parents were evaluated (questionnaires). Intervention effectiveness was evaluated using linear mixed models. Process evaluation was performed using mixed methods; both quantitative (questionnaires) and qualitative (observations and in-depth interviews) measures were used. The comprehensive, integrated approach of SuperFIT is expected to support healthy EBRB in young children.

Parent-child cooking meal together may relate to parental concerns about the diets of their toddlers and preschoolers: a cross-sectional analysis in Japan

BACKGROUND

Parents often have concerns about the food habits of their young children. Cooking is a frequent behavior related to dietary activities at home. We hypothesized that "a parent cooking meals together with young children might alleviate dietary concerns." The aim of this study was to identify the relationship between parental cooking practices (e.g., cooking meals together with the child) and diet-related concerns.

METHODS

Data were extracted from the "National nutrition survey on preschool children" conducted among nation-wide households with toddlers and preschoolers in 2015 by the Ministry of Health, Labour and Welfare of Japan. Parents were classified into two groups comprising those who cooked meals together with their children and those who did not. The following variables were compared: taking too much time to eat (slow eaters), "picky" eating (eating only certain foods), inconsistent food intake (eating too much or too little), playing with food/utensils while eating, preferring sweetened beverages and snacks over meals, eating too fast to chew well, not swallowing food, disinterested in eating, and spitting out food. The associations between parent-child cooking meals together and the concerns pertaining to the child's dietary habits and food intake were analyzed and compared between the two groups.

RESULTS

The concerns of "picky eating" and "playing with food/utensils while eating" were lower, while "eating too much" was higher in the parent-cooking together group. The intake frequency of fish, soybeans/soy products, vegetables, and milk among children were higher in the "cooking together" group than among those in the "not cooking together" group. Children in the "cooking together" group consumed a significantly greater variety of foods than those in the "not cooking together" group.

CONCLUSIONS

Cooking a meal together with a child may be related to the parent's lower concerns about the dietary habits of the child, including "picky eating" and "playing with food/utensils while eating," but may also be related to the higher concerns of "eating too much."

Factors that contribute to effective nutrition education interventions in children: a systematic review

Context

Establishing healthy dietary practices at an early age is crucial, as dietary behaviors in childhood track to adulthood.

Objective

The purpose of this systematic review was to identify factors associated with successful nutrition education interventions conducted in children and published between 2009 and 2016.

Data Sources

Using the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) guidelines, relevant studies were identified through the PubMed, Web of Science, ScienceDirect, and ERIC (Educational Resources Information Center) databases.

Study Selection

Studies published in English between 2009 and 2016 that included a nutrition education intervention among children aged 2 to 19 years were included. Review articles, abstracts, qualitative or cross-sectional studies, and studies targeting children with special nutritional needs were excluded.

Data Extraction

Four authors screened and determined the quality of the studies using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) system and extracted the data from the articles.

Data Analysis

Forty-one studies were included: 7 targeted preschool children, 26 targeted elementary school children, and 8 targeted secondary school children. A total of 46% met their primary objectives of nutrition education intervention, while the rest either partially achieved or did not achieve their stated objectives.

Results

Successful interventions targeting school children engaged parents by means of face-to-face sessions, identified specific behaviors to be modified, and assured fidelity by training teachers or recruiting trained experts to deliver the intervention. In addition, they allowed adequate dosage, with an intervention duration of at least 6 months, and used age-appropriate activities.

Conclusions

Interventions with a multicomponent approach that were age appropriate and of adequate duration (≥ 6 months), that engaged parents, and that ensured fidelity and proper alignment between the stated objectives, the intervention, and the desired outcomes were more likely to succeed.