Daytime eating prevents mood vulnerability in night work.

Shift workers have a 25 to 40% higher risk of depression and anxiety partly due to a misalignment between the central circadian clock and daily environmental/behavioral cycles that may negatively affect mood and emotional well-being. Hence, evidence-based circadian interventions are required to prevent mood vulnerability in shift work settings. We used a stringently controlled 14-d circadian paradigm to assess mood vulnerability during simulated night work with either daytime and nighttime or daytime-only eating as compared with simulated day work (baseline). Simulated night work with daytime and nighttime eating increased depression-like mood levels by 26.2% (p-value adjusted using False Discovery Rates, pFDR = 0.001; effect-size r = 0.78) and anxiety-like mood levels by 16.1% (pFDR = 0.001; effect-size r = 0.47) compared to baseline, whereas this did not occur with simulated night work in the daytime-only eating group. Importantly, a larger degree of internal circadian misalignment was robustly associated with more depression-like (r = 0.77; P = 0.001) and anxiety-like (r = 0.67; P = 0.002) mood levels during simulated night work. These findings offer a proof-of-concept demonstration of an evidence-based meal timing intervention that may prevent mood vulnerability in shift work settings. Future studies are required to establish if changes in meal timing can prevent mood vulnerability in night workers.

A theoretical explanation for how a nutrition counseling and medically tailored meal delivery program benefitted participants living with lung cancer.

PURPOSE: The purpose of this study was to assess participants' perceptions and experiences while participating in a Food is Medicine medically tailored meal plus intensive nutrition counseling intervention to create a theoretical explanation about how the intervention worked. METHODS: This interpretive qualitative study included the use of semi-structured interviews with active participants in a randomized controlled trial aimed at understanding how a medically tailored meal plus nutrition counseling intervention worked for vulnerable individuals with lung cancer treated at four cancer centers across the USA. During the 8-month long study, participants in the intervention arm were asked to be interviewed, which were recorded, transcribed verbatim, and analyzed using conventional content analysis with principles of grounded theory. RESULTS: Twenty individuals participated. Data analysis resulted in a theoretical explanation of the intervention's mechanism of action. The explanatory process includes three linked and propositional categories leading to patient resilience: engaging in treatment, adjusting to diagnosis, and active coping. The medically tailored meals plus nutrition counseling engaged participants throughout treatment, which helped participants adjust to their diagnosis, leading to active coping through intentional self-care, behavior change, and improved quality of life. CONCLUSIONS: These findings provide evidence that a Food is Medicine intervention may buffer some of the adversity related to the diagnosis of lung cancer and create a pathway for participants to experience post-traumatic growth, develop resilience, and change behaviors to actively cope with lung cancer. Medically tailored meals plus intensive nutrition counseling informed by motivational interviewing supported individuals' adjustment to their diagnosis and resulted in perceived positive behavior change.

Mothers' experiences of reducing family mealtime screen use in Australian households with young children.

OBJECTIVE: Screen use at mealtimes is associated with poor dietary and psychosocial outcomes in children and is disproportionately prevalent among families of low socio-economic position (SEP). This study aimed to explore experiences of reducing mealtime screen use in mothers of low SEP with young children. DESIGN: Motivational interviews, conducted via Zoom or telephone, addressed barriers and facilitators to reducing mealtime screen use. Following motivational interviews, participants co-designed mealtime screen use reduction strategies and trialled these for 3-4 weeks. Follow-up semi-structured interviews then explored maternal experiences of implementing strategies, including successes and difficulties. Transcripts were analysed thematically. SETTING: Australia. PARTICIPANTS: Fourteen mothers who had no university education and a child between six months and six years old. RESULTS: A range of strategies aimed to reduce mealtime screen use were co-designed. The most widely used strategies included changing mealtime location and parental modelling of expected behaviours. Experiences were influenced by mothers' levels of parenting self-efficacy and mealtime consistency, included changes to mealtime foods and an increased value of mealtimes. Experiences were reportedly easier, more beneficial and offered more opportunities for family communication, than anticipated. Change required considerable effort. However, effort decreased with consistency. CONCLUSIONS: The diverse strategies co-designed by mothers highlight the importance of understanding why families engage in mealtime screen use and providing tailored advice for reduction. Although promising themes were identified, in this motivated sample, changing established mealtime screen use habits still required substantial effort. Embedding screen-free mealtime messaging into nutrition promotion from the inception of eating will be important.

Efficacy of Mealtime Interventions for Malnutrition and Oral Intake in Persons With Dementia: A Systematic Review.

Malnutrition and weight loss are highly prevalent in persons with Alzheimer's disease and related dementias. Oral intake is an important interventional target for addressing these nutritional consequences. However, the efficacy of interventions remains poorly understood as prior syntheses have failed to examine the impact of intervention approaches on malnutrition and hypothesized mechanisms of action in persons with dementia. This review aimed to determine the efficacy of mealtime interventions to improve oral intake and nutritional outcomes in persons with dementia. Four databases yielded 1712 studies, resulting in 32 studies that met inclusion criteria. Studies included education, environmental modifications, feeding, oral supplementation, and other pharmacologic/ecopsychological interventions. While the majority of studies reported statistically significant improvements in at least 1 nutritional outcome, study design and outcome measures were heterogenous with many lacking adequate statistical power or blinding. Collectively, we found moderate evidence to suggest the efficacy of oral supplementation, and preliminary evidence to suggest that feeding interventions, education, and environmental modifications may confer improvements. Findings clarify the state of existing evidence regarding various interventional strategies for improving malnutrition in persons with dementia. While some approaches are promising, adequately powered and rigorously designed multidimensional intervention trials are needed to inform clinical decision-making in real-world contexts.

Understanding children's healthiness and hedonic perception of school meals via structured sorting.

Trends in the prevalence of childhood overweight and obesity in Europe and especially in Spain have continuously increased in the last three decades. The aim of this work was to study the healthiness understanding (healthy and unhealthy food) in children with different ages and to evaluate liking towards a set of school meals: first courses, second courses and fruit/dessert. Two hundred and seventy-seven children between the ages of six and twelve from three primary schools in northern Spain, Bizkaia, took part in this study. All the groups showed a good knowledge of the healthiness of the dishes offered in the school canteen. However, some dishes were difficult to assess for the 6-7- and 8-9-year old groups. Pasta and croquettes with chips were the most preferred dishes. Vegetables and fish dishes were the least preferred. Results suggest that children become increasingly aware of their preferences and critical in their choices with growing age. It was found in this study that there was a strongly inverse relationship between children's perceptions of the healthiness of foods and their preferences for them. The structured sorting task was a good tool for children to classify various dishes (complex food) considering healthiness and hedonic perception at the same time. In conclusion, these results contribute to a better understanding of children's nutritional perception (healthy/unhealthy food) and its relation to preferences of school meals, which is important for quality improvement and nutritional planning in school food services.

Interventions maintaining eating Independence in nursing home residents: a multicentre qualitative study.

BACKGROUND: Despite 32 years of research and 13 reviews published in the field, no intervention can be considered a gold standard for maintaining eating performance among residents with dementia. The study aim was to highlight the interventions derived from tacit knowledge and offered daily in assisting eating by healthcare professionals (HCPs) in nursing homes (NHs). METHOD: A multicentre descriptive qualitative study was performed in 2017. Thirteen NHs admitting residents with moderate/severe functional dependence in eating mainly due to dementia, were approached. A purposeful sample of 54 HCPs involved on a daily basis in assisting residents during mealtime were interviewed in 13 focus groups. Data analysis was conducted via qualitative content analysis. RESULTS: The promotion and maintenance of eating performance for as long as possible is ensured by a set of interventions targeting three levels: (a) environmental, by 'Ritualising the mealtime experience by creating a controlled stimulated environment'; (b) social, by 'Structuring effective mealtime social interactions'; and (c) individual, by 'Individualising eating care' for each resident. CONCLUSIONS: In NHs, the eating decline is juxtaposed with complex interventions regulated on a daily basis and targeting the environment, the social interactions, and the residents' needs. Several interventions that emerged as effective, according to the experience of participants, have never been documented before; while others are in contrast to the evidence documented. This suggests the need for further studies in the field; as no conclusions regarding the best interventions have been established to date.

A qualitative investigation of how mothers from low income households perceive their role during family meals.

BACKGROUND: Having regular family meals has been shown to be protective for child dietary intake (e.g., higher intake of fruit and vegetables). Mothers appear to be most responsible for preparing family meals. Therefore, understanding how mothers perceive their roles around family meals may help identify ways in which to help more families have regular family meals. METHODS: United States mothers (n = 83) from the Twin Cities, Minnesota were interviewed during an in-home visit. Researchers trained in qualitative interviewing used a semi-structured approach and asked questions regarding the mothers' overall perception of their role during family meals. Interviews were coded using a mixed deductive and inductive content analysis approach. The majority of mothers were from minority and low-income households. RESULTS: Mothers described their roles during family meals as the follows: 1) Helping children make healthy choices at family meals; 2) Making the meal happen; 3) Monitoring children's food intake; 4) Managing behavior at the family meal; 5) Making the family meal atmosphere enjoyable; and 6) Facilitating conversation/communication. Two secondary research questions also emerged about the specifics of the mothers' perception of her role at family meals (i.e., How do mothers deal with fighting or arguing if it occurs at family meals? and What do mothers talk about with children at family meals?) CONCLUSIONS: Results show that mothers have a large and varied role during family meals. Additionally, they are willing to put effort into family meals and want them to be enjoyable. Findings also suggest that mothers can be supported by encouraging fuller family participation in family meals and by offering mothers quality nutrition and parent feeding practice information.

"Meal realities" - An ethnographic exploration of hospital mealtime environment and practice.

AIM: To explore and understand patterns of mealtime culture, environment and social practice from the perspective of staff, volunteers and visitors on the hospital ward. BACKGROUND: Inadequate food intake is a common and complex problem in hospital and can lead to malnutrition. Mealtime interventions have been implemented to address this problem with limited success. A better understanding of mealtime environment and practice is needed to ascertain which interventions are more likely to be effective in addressing inadequate food intake in hospital. DESIGN: A qualitative, ethnographic approach was used to promote a comprehensive understanding of mealtime environment and practice. METHODS: Sixty-seven hours of fieldwork was conducted August-October 2015. More than 150 participants were observed and 61 unique participants were interviewed in 75 interviews. Data analysis followed an inductive, thematic approach, informed by systems and complexity theory. FINDINGS: Themes of "patient centredness" and "system" and their disharmonious interrelationship emerged. Staff, volunteers and visitors strive for patient centredness at mealtimes. The routine and structured nature of the meal and care systems was constantly in tension with providing patients the care they needed. CONCLUSION: The findings of this study expose the challenges associated with maintaining patient centredness at mealtimes in complex healthcare and foodservice systems. This facilitates a better understanding of why inadequate food intake is difficult to address in the hospital setting and highlights the need to support strategies that approach foodservice processes and nutritional care as complex and non-linear.

Increasing intention to cook from basic ingredients: A randomised controlled study.

The promotion of home cooking is a strategy used to improve diet quality and health. However, modern home cooking typically includes the use of processed food which can lead to negative outcomes including weight gain. In addition, interventions to improve cooking skills do not always explain how theory informed their design and implementation. The Behaviour Change Technique (BCT) taxonomy successfully employed in other areas has identified essential elements for interventions. This study investigated the effectiveness of different instructional modes for learning to cook a meal, designed using an accumulating number of BCTs, on participant's perceived difficulty, enjoyment, confidence and intention to cook from basic ingredients. 141 mothers aged between 20 and 39 years from the island of Ireland were randomised to one of four conditions based on BCTs (1) recipe card only [control condition]; (2) recipe card plus video modelling; (3) recipe card plus video prompting; (4) recipe card plus video elements. Participants rated their enjoyment, perceived difficulty, confidence and intention to cook again pre, mid and post experiment. Repeated one-way factorial ANOVAs, correlations and a hierarchical regression model were conducted. Despite no significant differences between the different conditions, there was a significant increase in enjoyment (P < 0.001), confidence (P < 0.001) and intention to cook from basics again (P < 0.001) and a decrease in perceived difficulty (P = 0.001) after the experiment in all conditions. Intention to cook from basics pre-experiment, and confidence and enjoyment (both pre and post experiment) significantly contributed to the final regression model explaining 42% of the variance in intention to cook from basics again. Cooking interventions should focus on practical cooking and increasing participants' enjoyment and confidence during cooking to increase intention to cook from basic ingredients at home.

Supporting existential care with protected mealtimes: patients' experiences of a mealtime intervention in a neurological ward.

AIM: The aim of this study was to explore the experiences of patients who were admitted to the neurological ward during an intervention - inspired by Protected Mealtime - that changed the traditional mealtime practice. BACKGROUND: Mealtimes are busy events in hospitals and patients are often interrupted by high-priority tasks (e.g. taking blood samples) while eating. Protected mealtimes is a British concept that changes the organizational structure of mealtimes and provides a focus on the mealtime by ceasing all non-acute activities while patients are eating. DESIGN: Influenced by protected mealtimes and based on the British Medical Research Council (MRC) guidelines, a clinical intervention called Quiet Please was developed, modified and tested in a department of neurology in November 2014. METHODS: To evaluate the Quiet Please intervention, 13 semi-structured interviews were conducted with patients who were admitted to the neurological ward. The interviews were recorded and transcribed. These data were thoroughly analysed and interpreted with inspiration from the French philosopher, Paul Ricouer. FINDINGS: Three themes were identified from the analysis and interpretation: (1) being powered by the bell; (2) being embraced by calmness and aesthetics and (3) being in a trust-bearing agreement. CONCLUSIONS: Patients experienced mealtimes as meaningful events that nourished them in an existential manner because the calming and aesthetically pleasing environment made them feel embraced and allowed them to reflect on the day for a while. The mealtime change, influenced by protected mealtimes, made the patients feel recognized as humans and established positive mealtime experiences that were considered professional and trust bearing.

Attitudes, perceptions and experiences of mealtimes among residents and staff in care homes for older adults: A systematic review of the qualitative literature.

Addressing problems associated with malnutrition in care home residents has been prioritized by researchers and decision-makers. This review aimed to better understand factors that may contribute to malnutrition by examining the attitudes, perceptions and experiences of mealtimes among care home residents and staff. Five databases were searched from inception to November 2015: Medline, Embase, PsychINFO, AMED, and the Cochrane Database. Forward and backward citation checking of included articles was conducted. Titles, abstracts, and full texts were screened independently by two reviewers and quality was assessed using the Wallace criteria. Thematic analysis of extracted data was undertaken. Fifteen studies were included in the review, encompassing the views and opinions of a total of 580 participants set in nine different countries. Four main themes were identified: (1) organizational and staff support, (2) resident agency, (3) mealtime culture, and (4) meal quality and enjoyment. Organizational and staff support was an over-arching theme, impacting all aspects of the mealtime experience. Mealtimes are a pivotal part of care home life, providing structure to the day and generating opportunities for conversation and companionship. Enhancing the mealtime experience for care home residents needs to take account of the complex needs of residents while also creating an environment in which individual care can be provided in a communal setting. PROSPERO Registration: CRD42015025890.

The importance of mealtime structure for reducing child food fussiness.

The aim of this study was to explore how the structure of mealtimes within the family setting is related to children's fussy eating behaviours. Seventy-five mothers of children aged between 2 and 4 years were observed during a typical mealtime at home. The mealtimes were coded to rate mealtime structure and environment as well as the child's eating behaviours (food refusal, difficulty to feed, eating speed, positive and negative vocalisations). Mealtime structure emerged as an important factor which significantly distinguished children with higher compared with lower levels of food fussiness. Children whose mothers ate with their child and ate the same food as their child were observed to refuse fewer foods and were easier to feed compared with children whose mothers did not. During mealtimes where no distractors were used (e.g. no TV, magazines or toys), or where children were allowed some input into food choice and portioning, children were also observed to demonstrate fewer fussy eating behaviours. Findings of this study suggest that it may be important for parents to strike a balance between structured mealtimes, where the family eats together and distractions are minimal, alongside allowing children some autonomy in terms of food choice and intake.

The role of family meals in the treatment of eating disorders: a scoping review of the literature and implications.

Family meal research is a fast growing field that has significant implications for the prevention and treatment of eating disorders (ED). Using a scoping review procedure, this article overviewed major historical and clinical trends that have guided the use of family meals or lunch sessions in adolescent ED family therapy over the past 40 years, and synthesized essential findings from current therapeutic family meal research. The relevant body of literature is reported within the framework of three models of family therapy (Maudsley model, family-based treatment, multi-family therapy), with a focus on their specific use of family lunch sessions and related empirical evidence. Although promising, current evidence remains contradictory, tentative and colored by therapists' convictions, resistance and fears. Future research priorities are discussed, including the need for a more direct examination of the impact of the family meal practice on therapeutic change, as well as a better understanding of its active ingredients and of the characteristics of patients/families that may benefit most from it. This review of the literature may help clinicians and family therapists (1) adhere more reliably and confidently to ED-focused treatment protocols that include a strong family meal component, and (2) make more informed decisions regarding the inclusion or exclusion of family meals in their practice. When feasibility or acceptability issues preclude their use, alternatives to family meals are also discussed, including family meal role-plays and drawings, coaching of home-based family meals and manual/DVD-based guidance.

"Dinner's ready!" A qualitative exploration of the food domain across the lifecourse.

The influence of the childhood food domain on adult food-related practices is only partially understood. Through an interpretive study using in-depth life-story interviewing and narrative analysis, we aimed to discover how preferences and perceptions relating to the food domain become embodied during childhood, and once embodied, how these influence practices in adulthood. We observed distinct 'food mood' pathways seemingly anchored in childhood memories about dinnertime. One pathway led to food philosophies participants perceived to be beneficial for their health and wellbeing, whilst another led to perceptions of food as a chore and bore they would rather ignore. Parental attitudes were very important to the food domain of childhood, as this is now recalled through life-story narratives. Our findings suggest a positive relationship with the food domain needs to be fostered during childhood for the long-term protection and promotion of health and wellbeing in adulthood.

Effect of combined naltrexone and bupropion therapy on the brain's reactivity to food cues.

OBJECTIVE: The significant weight loss observed with combination naltrexone-sustained release (SR) 32 mg and bupropion SR 360 mg (NB32) therapy is thought to be due, in part, to bupropion stimulation of hypothalamic pro-opiomelanocortin (POMC) neurons, and naltrexone blockade of opioid receptor-mediated POMC autoinhibition, but the neurobiological mechanisms are not fully understood. We assessed changes in brain reactivity to food cues before and after NB32 treatment. METHODS: Forty women (31.1±8.1 years; body mass index: 32.5±3.9) received 4 weeks of NB32 or placebo, and were instructed to maintain their dietary and exercise habits. Functional magnetic resonance imaging responses (analyzed using SPM2 and clusters (>100 pixels)) to a 5-min food video (preparation of the subject's favorite food) and a 5-min neutral video (manipulation of neutral objects) under conditions of mild food deprivation (∼14 h) were assessed before and after treatment. RESULTS: The food cues video induced positive brain activation in visual and prefrontal cortices, insula and subcortical brain regions. The group-by-treatment interaction on regional brain activation was significant and showed that whereas NB32 attenuated the activation in the hypothalamus in response to food cues (P<0.01), it enhanced activation in regions involved in inhibitory control (anterior cingulate), internal awareness (superior frontal, insula, superior parietal) and memory (hippocampal) regions (whole-brain analysis; P<0.05). CONCLUSIONS: Blunting the hypothalamic reactivity to food cues while enhancing the activation of regions involved with self-control and internal awareness by NB32 might underlie its therapeutic benefits in obesity.

A qualitative study to understand positive and negative child feeding behaviors of immigrant Asian Indian mothers in the US.

To understand current practice of child feeding behaviors, and underlying factors influencing these practices in Asian Indian mothers, qualitative in-depth interviews were conducted with 27 immigrant Asian Indian mothers of children ages 5-10 years. Using the theory of planned behavior as a guiding framework, child feeding behaviors employed, beliefs about the outcomes of feeding behaviors, perceived ease or difficultly in practicing feeding behaviors, and social norms were explored during the interviews. Thematic analysis was conducted using coding and display matrices. Mothers were motivated by nutrition outcomes when practicing positive and negative controlling feeding behaviors. Outcomes related to preservation of Indian culture and values also influenced feeding behaviors. Pressuring to eat was often practiced despite the perception of ineffectiveness. Use of food rewards was found, and use of TV to control children's food intake despite the clear understanding of undesirable nutrition outcomes was a unique finding. Asian Indian mothers need effective child feeding strategies that are culturally appropriate. Integrating cultural beliefs in nutrition education could help support existing motivation and behavior modification.

Supporting Mealtime Participation Among People Living With Dementia at Home: Challenges and Strategies for Caregivers.

BACKGROUND AND OBJECTIVES: Approximately 60% of people living with dementia at home are unable to routinely participate in mealtime activities (e.g., eating, safe food preparation), warranting assistance to ensure people with dementia meet their health and nutritional needs. The purpose of this study was to characterize these barriers to mealtime participation and identify potential caregiver-led strategies to enhance mealtime activities. RESEARCH DESIGN AND METHODS: We used a qualitative descriptive approach and obtained semistructured interview data from (a) allied health professionals and (b) community-based nutrition program providers who frequently serve people with dementia. Interview data were examined by means of directed content analysis and framework methodology until data saturation was reached. Codes from our analysis were categorized according to constructs drawn from the Socio-Ecological Model for Developing and Implementing Comprehensive Dementia Care. RESULTS: Data were obtained from 20 participants who attributed common mealtime participation barriers to: impairments in functional status, cognitive status deficits, a lack of caregiver knowledge and skills, and unsafe living conditions. Caregiver-led strategies to overcome these barriers included: reducing auditory and visual distractions, providing written cues to perform mealtime activities, eliminating clutter and fall risk hazards, and leveraging community-based nutrition program providers (e.g., home-delivered meal providers). DISCUSSION AND IMPLICATIONS: People with dementia face several eating and mealtime participation obstacles. Caregiver-led strategies implemented by family, friends, or community-based nutrition program providers may enhance mealtime activities at home. Findings point to opportunities to develop decision-making tools and resources for caregivers to optimize the health and nutrition of people with dementia.

If you can't eat what you like, like what you can: how children with coeliac disease and their families construct dietary restrictions as a matter of choice.

Although it is recognised that a gluten-free diet has many social implications for coeliac disease patients, not much is known about how such patients actually manage these implications in their everyday interactions. This article examines how dietary restrictions are treated by patients and their families. Data from recorded mealtime conversations of seven Dutch families with children suffering from coeliac disease were analysed using discursive psychology. We found two main discursive strategies by which patients and their families manage the diet during mealtime interactions. A reference to pleasure is used to manage the tension between the child's agency and parental responsibility in the face of health requirements and, by softening the denial of food, the diet is normalised and treated as a shared family practice. The analysis shows that the gluten-free diet is demedicalised and treated as a matter of choice rather than prescription. We conclude with the practical implications of these findings.

Hospital Services to Improve Nutritional Intake and Reduce Food Waste: A Systematic Review.

BACKGROUND AND AIMS: Patients' nutritional intake is a crucial issue in modern hospitals, where the high prevalence of disease-related malnutrition may worsen clinical outcomes. On the other hand, food waste raises concerns in terms of sustainability and environmental burden. We conducted a systematic review to ascertain which hospital services could overcome both issues. METHODS: A systematic literature search following PRISMA guidelines was conducted across MEDLINE, Web of Science, and Scopus for randomised controlled trials (RCTs) and observational studies comparing the effect of hospital strategies on energy intake, protein intake, and plate/food waste. The quality of included studies was assessed using the Newcastle-Ottawa Scale for cohort studies and the Cochrane Risk of Bias tool from the Cochrane Handbook for Systematic Reviews of Interventions for RCTs. RESULTS: Nineteen studies were included, assessing as many hospital strategies such as food service systems-including catering and room service-(n = 9), protected mealtimes and volunteer feeding assistance (n = 4), food presentation strategies (n = 3), nutritional counseling and education (n = 2), plant-based proteins meal (n = 1). Given the heterogeneity of the included studies, the results were narratively analysed. CONCLUSIONS: Although the results should be confirmed by prospective and large sample-size studies, the personalisation of the meal and efficient room service may improve nutritional intake while decreasing food waste. Clinical nutritionist staff-especially dietitians-may increase food intake reducing food waste through active monitoring of the patients' nutritional needs.

Strategies to Improve School Meal Consumption: A Systematic Review.

School meals can play an integral role in improving children's diets and addressing health disparities. Initiatives and policies to increase consumption have the potential to ensure students benefit from the healthy school foods available. This systematic review evaluates studies examining initiatives, interventions, and policies to increase school meal consumption. Following PRISMA guidelines, this review was conducted using four databases and resulted in a total of 96 studies. The research evidence supports the following strategies to increase school meal consumption: (1) offering students more menu choices; (2) adapting recipes to improve the palatability and/or cultural appropriateness of foods; (3) providing pre-sliced fruits; (4) rewarding students who try fruits and vegetables; (5) enabling students to have sufficient time to eat with longer (~30 min) lunch periods; (6) having recess before lunch; and (7) limiting students' access to competitive foods during the school day. Research findings were mixed when examining the impact of nutrition education and/or offering taste tests to students, although multiple benefits for nutrition education outside the cafeteria were documented. There is some evidence that choice architecture (i.e., "Smarter Lunchroom") techniques increase the proportion of students who select targeted meal components; however, there is not evidence that these techniques alone increase consumption. There were limited studies of the impact of increasing portion sizes; serving vegetables before other meal components; and strengthening local district and/or school wellness policies, suggesting that further research is necessary. Additionally, longer-term studies are needed to understand the impact of policies that limit students' access to flavored milk. Several studies found increases in students' meal consumption following the Healthy Hunger-Free Kids Act (HHFKA) and concerns regarding an increase in food waste following the HHFKA were not supported. Overall, there are a range of effective strategies to increase school meal consumption that can be implemented by schools, districts, and policymakers at the local, state, and federal levels (PROSPERO registration: CRD42021244688).