School-based interventions encouraging children to replace sugar-sweetened beverages with water show promise for reducing child overweight. However, students with child food insecurity (CFI) may not respond to nutrition interventions like children who are food-secure.

The Water First cluster-randomised trial found that school water access and promotion prevented child overweight and increased water intake. This secondary analysis used mixed-effects regression to evaluate the interaction between the Water First intervention and food insecurity, measured using the Child Food Security Assessment, on child weight status (anthropometric measurements) and dietary intake (student 24-h recalls, beverage intake surveys).

Eighteen elementary schools (serving ≥ 50 % children from low-income households), in which drinking water had not been previously promoted, in the San Francisco Bay Area.

Students in fourth-grade classes (n 1056).

Food insecurity interacted with the intervention. Among students with no CFI, the intervention group had a lower prevalence of obesity from baseline to 7 months (–0·04, CI –0·08, 0·01) compared with no CFI controls (0·01, CI –0·01, 0·04) (P = 0·04). Among students with high CFI, the intervention group had a pronounced increase in the volume of water consumed between baseline and 7 months (86·2 %, CI 21·7, 185·0 %) compared with high CFI controls (–13·6 %, CI –45·3, 36·6 %) (P = 0·02).

Addressing food insecurity in the design of water promotion interventions may enhance the benefit to children, reducing the prevalence of obesity.

Aspects of the school food environment can influence food purchasing and consumption among adolescents, particularly those without access to a school meal programme. Our objective was to describe and compare food vendors of junior high schools (JHS) in Ghana.

We conducted structured observations of food vendors within a 0·25-km radius of eight JHSs. We compared foods sold and hygiene practices by vendor and community characteristics, such as on- v. off-campus location, urban v. rural, and predominant income-generating activity of the community. We also assessed the relationship between adolescent diet quality (food group diversity, all-5, NCD-protect and NCD-risk scores) and procurement method for foods consumed during the school day.

Cape Coast and Elmina, Ghana.

200 randomly selected students.

Of 265 identified vendors, 25·3 % sold foods on-campus. On-campus vendors were less likely to sell branded snacks (19·4 % v. 33·8 %, P = 0·001) and beverages (17·9 % v. 35·4 %, P = 0·008) and more likely to sell prepared dishes (53·7 % v. 31·8 %, P = 0·001) than off-campus vendors. Vendors practised an average of 38·8 % of applicable food hygiene practices, which did not differ by on- or off-campus location. In the previous month, 59·4 % of students most often purchased food on campus. There were no significant relationships between method of food procurement and diet quality.

Many adolescents purchased food at school, and there were differences in foods sold by on- and off-campus vendors. School policies may be a promising avenue to alter food environments for adolescents.

Free school meals (FSM) are a crucial form of support for families. This study aimed to investigate whether the FSM allowance can provide what is perceived to be, healthy, sustainable and satisfying food.

A mixed methods study incorporating co-production, citizen science and participatory approaches was conducted. Citizen scientists were given a daily budget equivalent to the FSM allowance and asked to purchase a ‘tasty, healthy and sustainable’ school lunch for a week. Alongside keeping records of available and purchased foods, young people engaged in focus groups to capture information on perceptions of food offered and FSM allowance adequacy.

Secondary schools in Yorkshire, UK.

Citizen scientists (n 42) aged 11–15 years across seven schools.

Obstacles were faced in obtaining sustainable and healthful meals when restricted to an FSM allowance. Reasons included restrictions in what could be purchased due to costs, limitations in the use of allowances that restricted breaktime purchases leading to hunger, inadequate portion sizes, systemic barriers like hurried lunch breaks that encourage ‘grab and go’ options and broken water fountains that led students to purchase bottled drinks. Findings were reinforced by descriptive food record data.

Our findings suggest that schools would benefit from national policies to address the lack of funding, infrastructure issues and capacity to support optimal provision of food to those on FSM as well as provide greater flexibility in how pupils use their allowance. Young people verified these findings, which they presented to policymakers at a parliamentary event.

We examined whether point-of-sale warning posters, compared with control posters, reduced Guatemalan adolescents’ purchases of sugar-sweetened beverages (SSB) at school stores.

We used a difference-in-differences approach (4-week baseline and 4-week treatment). Our primary analysis compared two schools assigned to an intervention warning poster to one school that displayed a control poster. Based on purchase transaction data, the outcomes were volume of SSB, beverage kcal and sugar purchased per transaction.

Three private schools in Guatemala City, Guatemala.

Students between 12 and 18 years of age.

Our primary analysis found that the warning poster decreased the overall volume of SSB (in ounces) that adolescents purchased in the warning poster intervention schools (−2·27 oz. 95 % CI = (−2·70, −1·85)) compared with the control school. This reduction was driven by a decrease in SSB purchases (OR = 0·64, 95 % CI = (0·49, 0·86)). The warning posters were associated with a significant reduction in likelihood of purchasing a beverage with kilocalories (calories) (OR = 0·68, 95 % CI = (0·49, 0·92)). These changes were associated with a significant overall decrease in sugar purchased (−5·54 g 95 % CI = (−6·69, −4·39)). The posters were associated with a significant increase in non-SSB purchases in the intervention schools compared with the control school (OR = 1·53, 95 % CI = (1·16, 2·02)).

Our results suggest that messages that warn adolescents about the high-sugar content in SSB may be an effective, low-cost way to modestly reduce purchases of these drinks. These findings provide evidence to support national front-of-package labelling, currently being considered in Guatemala.

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

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

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

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

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

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

To examine the efficacy of a food-based intervention on preschool children’s (3–5 years) fruit and vegetable (FV) consumption, as measured by skin carotenoid status (SCS) using the Veggie Meter®.

Quasi-experimental intervention with baseline (T1), pre-intervention (T2) and post-intervention (T3) assessments of children’s SCS. Intervention classrooms (ICs) received the programme, which featured food-based learning (FBL) and gardening. Comparison classrooms (CC) received a standard curriculum. Child and Adult Care Food Program (CACFP) aligned menus were identical across all centres. Intervention teachers participated in semi-structured interviews to contextualise quantitative findings.

Head Start centres (n 7) across three counties in North Carolina.

183 Head Start children (n 88 IC; n 95 CC)

During the intervention period (T2–T3), significant SCS increases were observed in both groups: IC (T2 = 253·7, sd = 77·7; T3 = 299·0, sd = 77·4) and CC (T2 = 226·6, sd = 77·5; T3 = 255·9, sd = 79·9). The IC demonstrated a greater gain in SCS (17·8 % gain) than the CC (12·9 % gain). However, additional analyses revealed no significant difference in the SCS rate of change over time (P = 0·33). Teachers reported that the intervention improved children’s willingness to try fruits and vegetables and encouraged positive feeding practices beyond the mealtime setting.

The findings suggest that increased access to FVs through CACFP-supported meals and snacks may influence children’s overall improved FV consumption. However, improved food access paired with FBL may also support higher gains in FV consumption.

Food environments are a major determinant of children’s nutritional status. Scarce evidence on food environments exists in low- and middle-income countries (LMIC). This study aims to fill this gap by documenting the obesogenicity of food environments around schools in Greater Tunis, Tunisia – an LMIC of the Middle East and North Africa region with an ongoing nutrition transition and increasing rates of childhood obesity.

In this cross-sectional study, we assessed built food environments around fifty primary schools. Ground-truthing was performed to collect geographic coordinates and pictures of food retailers and food advertisement sets within an 800-m road network buffer of each school. Retailers and advertisement sets were categorised as healthy or unhealthy according to a NOVA-based classification. Associations between school characteristics and retailers or advertisement sets were explored using multinomial regression models.

Greater Tunis, Tunisia.

Random sample of fifty (thirty-five public and fifteen private) primary schools.

Overall, 3621 food retailers and 2098 advertisement sets were mapped. About two-thirds of retailers and advertisement sets were labelled as unhealthy. Most retailers were traditional corner stores (22 %) and only 6 % were fruit and vegetable markets. The prevailing food group promoted was carbonated and sugar-sweetened beverages (22 %). The proportion of unhealthy retailers was significantly higher in the richest v. poorest areas.

School neighbourhood food environments included predominantly unhealthy retailers and advertisements. Mapping of LMIC food environments is crucial to document the impact of the nutrition transition on children’s nutritional status. This will inform policies and interventions to curb the emergent childhood obesity epidemic.

To examine whether targeted determinants mediated the effects of the HEalth In Adolescents (HEIA) intervention on fruit and vegetable (FV) consumption and explore if these mediating effects were moderated by sex, parental education or weight status.

Cluster-randomised controlled trial.

The HEIA study (2007–2009) was a Norwegian 20-month multi-component school-based intervention to promote healthy weight development. FV consumption and targeted determinants were self-reported at baseline, mid-way (8 months) and post-intervention (20 months).

Adolescents (11–13-year-old) in twenty-five control schools (n 746) and twelve intervention schools (n 375).

At post-intervention, more adolescents in the intervention group compared with the control group had knowledge of the FV recommendations (OR: 1·4, 95 % CI 1·1, 1·9) and reported a decreased availability of vegetables at home (β: –0·1, 95 % CI –0·2, 0·0). Availability/accessibility of FV at home, availability of vegetables at dinner, taste preferences for different types of FV and knowledge of the FV recommendations were positively associated with the consumption of FV. However, none of the post-intervention determinants significantly mediated the intervention effects on FV consumption. Although no moderating influences by sex, parental education or weights status were observed on the mediating effects, exploratory analyses revealed significant moderations in the b-paths.

Since none of the targeted determinants could explain the increase in FV consumption, it remains unclear why the intervention was effective. Reporting on a wide range of mediators and moderators in school-based interventions is needed to reveal the pathways through which intervention effects are achieved.

To characterise children’s lunchbox contents for food, waste and packaging.

A cross-sectional study was conducted. Lunchboxes were photographed at two time points on the same day: before first morning break to capture food and packaging and post-lunch break to capture food waste. Contents were coded using an audit tool developed using REDCap.

Twenty-three sites across metropolitan Adelaide, South Australia including fourteen preschools and nine primary schools in low (n 8), medium (n 7) and high (n 8) socioeconomic areas.

Preschool (ages 3–5 years) to Grade 7 primary school (ages 6–13 years) students.

673 lunchboxes were analysed. Grain foods dominated (with at least half of them being discretionary varieties), with 92 % of lunchboxes having at least one item from that category, followed by fruits (78 %), snacks (62 %), dairy (32 %) and vegetables (26 %). Lunchboxes of preschool children contained more fruits (92 % v. 65 %; χ2(1) = 73·3, P < 0·01), vegetables (36 % v. 16 %; χ2(1) = 34·0, P < 0·01) and dairy items (45 % v. 19 %; χ2(1) = 53·6, P < 0·01), compared to lunchboxes of primary school children. Snack foods were more prevalent in primary school (68 %) than preschool (55 %; χ2(1) = 11·2, P < 0·01). Discretionary foods appeared more frequently, and single-use packaging accounted for half (53 %) of all packaging in lunchboxes, primarily from snacks and grain foods. Preschool children had less single-use packaging but more food waste. Vegetables were the most wasted food group.

Sandwiches, fruits and various snacks are typical lunchbox foods, often accompanied by single-use packaging. Considering both health and environmental factors in lunchbox choices could benefit children and sustainability efforts in schools.

To understand caregivers’ perceptions about their children’s mealtime social experiences at school and how they believe these social experiences impact their children’s consumption of meals at school (both meals brought from home and school meals).

Qualitative data were originally collected as part of a larger mixed methods study using an embedded-QUAN dominant research design.

Semi-structured interviews were conducted with United States (U.S.) caregivers over ZoomTM in English and Spanish during the 2021–2022 school year. The interview guide contained 14 questions on caregivers’ perceptions about their children’s experiences with school meals.

Caregivers of students in elementary, middle and high schools in rural, suburban and urban communities in California (n 46) and Maine (n 20) were interviewed. Most (60·6 %) were caregivers of children who were eligible for free or reduced-price meals.

Caregivers reported that an important benefit of eating meals at school is their child’s opportunity to socialise with their peers. Caregivers also stated that their child’s favourite aspect of school lunch is socialising with friends. However, some caregivers reported the cafeteria environment caused their children to feel anxious and not eat. Other caregivers reported that their children sometimes skipped lunch and chose to socialise with friends rather than wait in long lunch lines.

Socialising during school meals is important to both caregivers and students. Policies such as increasing lunch period lengths and holding recess before lunch have been found to promote school meal consumption and could reinforce the positive social aspects of mealtime for students.

The present study examined the association of screen and sleep time, physical fitness and eating behaviour with Mediterranean diet (MD) adherence in a sample of preschoolers from Granada, Spain.

A cross-sectional, non-randomised design was employed. A multilinear regression model with backward elimination was used for analysis.

Variables included age, screen time, hours of nightly sleep, physical fitness, food approach and food avoidance. The developed model met assumptions of multiple regression in terms of linearity, homoscedasticity, normality, independence and non-multicollinearity.

Data were collected from 653 of the 2250 three-to-six-year-old children attending the eighteen schools invited to take part in the present study. Data on children’s behaviours were parent-reported using validated questionnaires.

Better sleep time and lower screen time and food avoidance were found to be predictive of MD adherence. These variables explained 15 % of the variance in preschoolers’ MD adherence.

The present study suggests that sleep and screen time and food avoidance are important components to consider when targeting improvements in MD adherence in preschoolers. Future research should explore the way in which parental health behaviours influence their children’s health habits in order to better understand the outcomes.

Within the UK, dietary fibre intakes are well below recommended intakes and associated with increased risk of obesity. This study aimed to explore the views of parents and children on barriers and facilitators to increasing fibre intakes and improving diets, alongside investigating the appropriateness of intervention components to overcome modifiable barriers.

Qualitative study including semi-structured interviews and focus groups informed by the Theoretical Domains Framework (TDF) and the Capability-Opportunity-Motivation-Behaviour (COM-B) model.

Year 5 children (aged 9–10-years) and parents, recruited through London primary schools

A total of twenty-four participants (eleven parents and thirteen children) took part. Five key themes were identified as barriers and facilitators, namely lack of (and improving) knowledge, social factors (including parent–child conflicts, limited time for food preparation, influence of peer and family members), current eating habits, influence of the school, community and home environment in shaping eating behaviours, and the importance of choice and variety in finding foods that are healthy and tasty. Parents strongly supported school-based dietary interventions to enable consistent messaging at home and school and help support dietary behaviour change. Practical sessions (such as workshops to strengthen knowledge, taste tests and food swap ideas) were supported by parents and children.

By using a theory-driven approach to explore the barriers and facilitators to increasing fibre intake, this research identified important themes and modifiable barriers to behaviour change and identifies acceptable intervention components to overcome barriers and bring about sustained dietary behaviour change in primary school children.

To explore what Australian primary school parents want to learn about food and nutrition to improve their children’s eating behaviours, as well as the associations between parents’ personal and demographic characteristics and their views regarding their food and nutrition knowledge needs.

An online nationwide cross-sectional survey was conducted in 2021 using a mixed-methods approach. Logistic regression analysis was utilised to examine the relationship between parents’ demographics, personal values and their views. Content analysis was performed using Leximancer.

Australia.

Seven hundred and eighty-seven parents.

Fifty-one per cent wanted to learn more about food and nutrition to improve their children's healthy eating habits, and 77% of those preferred schools to provide that information. Online/printed newsletters and YouTube were the most preferred methods for receiving food and nutrition related information. Higher universalism-concern value (concern for the welfare of those in the larger society and world) scores were positively associated parents’ preference for schools to provide food and nutrition-related information. Parents with non-English-speaking backgrounds and younger parents were more likely to want to learn about food and nutrition. Parents wanted to learn more about encouraging healthy eating, ideas for the lunchbox, food labels and age-specific portion sizes and recommendations.

Findings can inform public health educators and assist them in designing future food and nutrition education programmes and resources targeting primary school parents.

Australian children fall short of national dietary guidelines with only 63 % consuming adequate fruit and 10 % enough vegetables. Before school care operates as part of Out of School Hours Care (OSHC) services and provides opportunities to address poor dietary habits in children. The aim of this study was to describe the food and beverages provided in before school care and to explore how service-level factors influence food provision.

A cross-sectional study was conducted in OSHC services. Services had their before school care visited twice between March and June 2021. Direct observation was used to capture food and beverage provision and child and staff behaviour during breakfast. Interviews with staff collected information on service characteristics. Foods were categorised using the Australian Dietary Guidelines, and frequencies were calculated. Fisher’s exact test was used to compare food provision with service characteristics.

The before school care of OSHC services in New South Wales, Australia.

Twenty-five OSHC services.

Fruit was provided on 22 % (n 11) of days and vegetables on 12 % (n 6). Services with nutrition policies containing specific language on food provision (i.e. measurable) were more likely to provide fruit compared with those with policies using non-specific language (P= 0·027). Services that reported receiving training in healthy eating provided more vegetables than those who had not received training (P= 0·037).

Before school care can be supported to improve food provision through staff professional development and advocating to regulatory bodies for increased specificity requirements in the nutrition policies of service providers.

To explore the information available in school food purchase data and ascertain the potential to assess pupils’ dietary intakes. The proportion of purchased food and drink items that were linked to (i) an Intake24 food group and (ii) a nutrient code from the UK National Diet and Nutrition Survey (NDNS) Databank was calculated.

Pupil-level food purchase data covering the whole school day were obtained. Each item purchased was linked to an Intake24 food group and an NDNS Nutrient Databank code. Depending on the level of detail provided, items may have been assigned both a food group and a nutrient code, a food group only or neither for items, which did not contain enough information about the type of food or drink purchased.

Five secondary schools in northeast England.

Secondary school pupils aged 11–16 years.

The data captured 119 125 purchases made by 3466 pupils. 92 % of item descriptions were assigned a food group, and this equated to 82 % of total purchases. 70 % were assigned an NDNS Databank nutrient code, which accounted for 60 % of total purchases. 8 % of items had insufficient information and did not have a food group or a nutrient code assigned.

The methodological challenges of collecting dietary data from pupils in the secondary school setting are significant. Purchase data offers an alternative, objective approach to collecting information on school food choices across the school day and for a large sample of pupils. With further development, the potential to use purchase data to assess intakes could be achieved.

We evaluated the impact of an established nutrition education intervention, ‘PhunkyFoods’ on food literacy, cooking skills and fruit and vegetable intake in primary school aged children.

A pre-registered cluster randomised controlled trial was used; the intervention group received the ‘PhunkyFoods’ programme and the wait-list control group received the usual school curriculum. Primary outcomes measured were differences in food literacy and cooking skills scores between the intervention and control arms after 12 months adjusted for baseline values.

The trial was undertaken in twenty-six primary schools in North Yorkshire, UK.

631 children aged 6–9 years participated (intervention n 307, control n 324) through assemblies, classroom activities and after-school clubs.

There were no significant effects of the intervention compared with control on food literacy, cooking skills, vegetable intake or fruit intake. Adjusting for baseline, the Food Literacy Total Score was 1·13 points lower in the intervention group than the control (95 % CI –2·87, 0·62, P = 0·2). The Cooking Skills Total Score was 0·86 lower in the intervention group compared with the control (95 % CI = –5·17, 3·45, P = 0·69). Girls scored 2·8 points higher than boys in cooking skills across the sample (95 % CI = 0·88, 4·82, P < 0·01).

The intervention did not result in improved food literacy or cooking skills, though sex effects on these outcomes were observed. More practical food preparation hours are needed in primary schools to improve the likelihood of an effect on outcomes.

To determine the reach, adoption, implementation and effectiveness of an intervention to increase children’s vegetable intake in long day care (LDC).

A 12-week pragmatic cluster randomised controlled trial, informed by the multiphase optimisation strategy (MOST), targeting the mealtime environment and curriculum. Children’s vegetable intake and variety was measured at follow-up using a modified Short Food Survey for early childhood education and care and analysed using a two-part mixed model for non-vegetable and vegetable consumers. Outcome measures were based on the RE-AIM framework.

Australian LDC centres.

Thirty-nine centres, 120 educators and 719 children at follow-up.

There was no difference between intervention and waitlist control groups in the likelihood of consuming any vegetables when compared with non-vegetable consumers for intake (OR = 0·70, (95 % CI 0·34–1·43), P = 0·32) or variety (OR = 0·73 (95 % CI 0·40–1·32), P = 0·29). Among vegetable consumers (n 652), there was no difference between groups in vegetable variety (exp(b): 1·07 (95 % CI:0·88–1·32, P = 0·49) or vegetable intake (exp(b): 1·06 (95 % CI: 0·78, 1·43)), P = 0·71) with an average of 1·51 (95 % CI 1·20–1·82) and 1·40 (95 % CI 1·08–1·72) serves of vegetables per day in the intervention and control group, respectively. Intervention educators reported higher skills for promoting vegetables at mealtimes, and knowledge and skills for teaching the curriculum, than control (all P < 0·001). Intervention fidelity was moderate (n 16/20 and n 15/16 centres used the Mealtime environment and Curriculum, respectively) with good acceptability among educators. The intervention reached 307/8556 centres nationally and was adopted by 22 % eligible centres.

The pragmatic self-delivered online intervention positively impacted educator’s knowledge and skills and was considered acceptable and feasible. Intervention adaptations, using the MOST cyclic approach, could improve intervention impact on children’ vegetable intake.