Long-Term Effectiveness of a Multi-Strategy Choice Architecture Intervention in Increasing Healthy Food Choices of High-School Students From Online Canteens (Click & Crunch High Schools): Cluster Randomized Controlled Trial.

BACKGROUND: School canteens are a recommended setting to influence adolescent nutrition due to their scope to improve student food choices. Online lunch ordering systems ("online canteens") are increasingly used and represent attractive infrastructure to implement choice architecture interventions that nudge users toward healthier food choices. A recent cluster randomized controlled trial demonstrated the short-term effectiveness (2-month follow-up) of a choice architecture intervention to increase the healthiness of foods purchased by high school students from online canteens. However, there is little evidence regarding the long-term effectiveness of choice architecture interventions targeting adolescent food purchases, particularly those delivered online. OBJECTIVE: This study aimed to determine the long-term effectiveness of a multi-strategy choice architecture intervention embedded within online canteen infrastructure in high schools at a 15-month follow-up. METHODS: A cluster randomized controlled trial was undertaken with 1331 students (from 9 high schools) in New South Wales, Australia. Schools were randomized to receive the automated choice architecture intervention (including menu labeling, positioning, feedback, and prompting strategies) or the control (standard online ordering). The foods purchased were classified according to the New South Wales Healthy Canteen strategy as either "everyday," "occasional," or "should not be sold." Primary outcomes were the average proportion of "everyday," "occasional," and "should not be sold" items purchased per student. Secondary outcomes were the mean energy, saturated fat, sugar, and sodium content of purchases. Outcomes were assessed using routine data collected by the online canteen. RESULTS: From baseline to 15-month follow-up, on average, students in the intervention group ordered significantly more "everyday" items (+11.5%, 95% CI 7.3% to 15.6%; P<.001), and significantly fewer "occasional" (-5.4%, 95% CI -9.4% to -1.5%; P=.007) and "should not be sold" items (-6%, 95% CI -9.1% to -2.9%; P<.001), relative to controls. There were no between-group differences over time in the mean energy, saturated fat, sugar, or sodium content of lunch orders. CONCLUSIONS: Given their longer-term effectiveness, choice architecture interventions delivered via online canteens may represent a promising option for policy makers to support healthy eating among high school students. TRIAL REGISTRATION: Australian Clinical Trials ACTRN12620001338954, https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380546 ; Open Science Framework osf.io/h8zfr, https://osf.io/h8zfr/.

Exploratory analysis of a cluster randomized controlled trial of a multi-strategy intervention delivered via online canteens on improving the nutritional quality of primary school students' pre-ordered foods & drinks at recess.

School canteens are a recommended setting to deliver public health nutrition strategies given their wide reach, and frequent use by children. Online canteens, where users (i.e. students or their carers) pre-order and pay for food and drinks online, represent attractive systems to deliver strategies that encourage healthier food choices. There have been few studies exploring the efficacy of public health nutrition interventions in online food ordering environments. Therefore, this study aims to assess the efficacy of a multi-strategy intervention implemented in an online school canteen ordering system in reducing the energy, saturated fat, sugar, and sodium content of students' online recess orders (i.e. foods ordered during the mid-morning or afternoon snack period). This was an exploratory analysis of recess purchases for a cluster randomized controlled trial that initially sought to examine the efficacy of the intervention on lunch orders. A total of 314 students from 5 schools received the multi-strategy intervention (involving menu labelling, placement, prompting and availability) that was integrated into the online ordering system, and 171 students from 3 schools received the control (usual online ordering). Analysis of main outcomes found that the mean energy (difference: -269.3 kJ; P = 0.006), saturated fat (difference: -1.1 g; P = 0.011) and sodium (difference: -128.6 mg; P = 0.014) content per student recess order was significantly lower in the intervention group than the control group at 2-month follow-up. Findings suggest that embedding strategies to encourage healthier choices within online canteen ordering systems can improve the nutrient composition of student recess purchases. These results add to the current evidence base suggesting that interventions delivered via online food ordering systems represent an effective strategy for improving child public health nutrition in schools.

The Effectiveness of Strategies to Improve User Engagement With Digital Health Interventions Targeting Nutrition, Physical Activity, and Overweight and Obesity: Systematic Review and Meta-Analysis.

BACKGROUND: Digital health interventions (DHIs) are effective in improving poor nutrition, physical inactivity, overweight and obesity. There is evidence suggesting that the impact of DHIs may be enhanced by improving user engagement. However, little is known about the overall effectiveness of strategies on engagement with DHIs. OBJECTIVE: This study aims to assess the overall effectiveness of strategies to improve engagement with DHIs targeting nutrition, physical activity, and overweight or obesity and explore associations between strategies and engagement outcomes. The secondary aim was to explore the impact of these strategies on health risk outcomes. METHODS: The MEDLINE, Embase, PsycINFO, CINAHL, CENTRAL, Scopus, and Academic Source Complete databases were searched up to July 24, 2023. Eligible studies were randomized controlled trials that evaluated strategies to improve engagement with DHIs and reported on outcomes related to DHI engagement (use or user experience). Strategies were classified according to behavior change techniques (BCTs) and design features (eg, supplementary emails). Multiple-variable meta-analyses of the primary outcomes (usage and user experience) were undertaken to assess the overall effectiveness of strategies. Meta-regressions were conducted to assess associations between strategies and use and user experience outcomes. Synthesis of secondary outcomes followed the "Synthesis Without Meta-Analysis" guidelines. The methodological quality and evidence was assessed using the Cochrane risk-of-bias tool, and the Grading of Recommendations Assessment, Development, and Evaluation tool respectively. RESULTS: Overall, 54 studies (across 62 publications) were included. Pooled analysis found very low-certainty evidence of a small-to-moderate positive effect of the use of strategies to improve DHI use (standardized mean difference=0.33, 95% CI 0.20-0.46; P<.001) and very low-certainty evidence of a small-to-moderate positive effect on user experience (standardized mean difference=0.29, 95% CI 0.07-0.52; P=.01). A significant positive association was found between the BCTs social support (effect size [ES]=0.40, 95% CI 0.14-0.66; P<.001) and shaping knowledge (ES=0.39, 95% CI 0.03-0.74; P=.03) and DHI use. A significant positive association was found among the BCTs social support (ES=0.70, 95% CI 0.18-1.22; P=.01), repetition and substitution (ES=0.29, 95% CI 0.05-0.53; P=.03), and natural consequences (ES=0.29, 95% CI 0.05-0.53; P=.02); the design features email (ES=0.29, 95% CI 0.05-0.53; P=.02) and SMS text messages (ES=0.34, 95% CI 0.11-0.57; P=.01); and DHI user experience. For secondary outcomes, 47% (7/15) of nutrition-related, 73% (24/33) of physical activity-related, and 41% (14/34) of overweight- and obesity-related outcomes reported an improvement in health outcomes. CONCLUSIONS: Although findings suggest that the use of strategies may improve engagement with DHIs targeting such health outcomes, the true effect is unknown because of the low quality of evidence. Future research exploring whether specific forms of social support, repetition and substitution, natural consequences, emails, and SMS text messages have a greater impact on DHI engagement is warranted. TRIAL REGISTRATION: PROSPERO CRD42018077333; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=77333.

The efficacy of a multi-strategy choice architecture intervention on improving the nutritional quality of high school students' lunch purchases from online canteens (Click & Crunch High Schools): a cluster randomized controlled trial.

BACKGROUND: High school canteens are an ideal setting for public health nutrition intervention, and choice architecture strategies that facilitate the purchase of healthier foods and beverages from school canteens are recommended by the World Health Organization. The rapid uptake of online lunch ordering within school canteens provides a unique opportunity to implement choice architecture strategies that support healthier food choices with high fidelity. Despite this, no trial has tested the efficacy of choice architecture strategies within an online lunch ordering system on improving the nutritional quality of high school student lunch purchases. The objective of this study was to assess the impact of embedding choice architecture strategies into an online lunch ordering system on the nutritional quality of the school canteen lunch purchases of high school students (aged 12-19 years). METHODS: A cluster randomized controlled trial was conducted with nine high schools in one Australian state. Schools were randomized to receive either a 2-month choice architecture intervention (involving menu labelling, prompts, item positioning, and feedback), or usual online ordering. Nutrient quality of online canteen lunch purchases was assessed using routine data collected by the online ordering system. Primary outcomes were the proportion of 'Everyday', 'Occasional', and 'Should not be sold' items purchased, categorized using the state healthy canteen policy. Secondary outcomes were the mean energy, saturated fat, sugar, and sodium content of purchases and the mean weekly revenue from online lunch orders. Linear mixed models were analyzed to assess outcomes. RESULTS: Analysis of the student cohort (Intervention: 4 schools, 656 students; Control: 5 schools, 675 students) showed significant between group differences over time for the intervention group for the mean percentage of online lunch items per student that were 'Everyday' (+ 5.5%; P < 0.001) and 'Should not be sold' (- 4.4%; P < 0.001). There were no between group differences over time in the mean percentage of online lunch items that were 'Occasional'; the average energy, saturated fat, sugar, or sodium content of lunch orders. There was also no difference in mean weekly revenue from high school student online lunch orders (P = 0.23). CONCLUSIONS: These findings suggest that a low intensity, choice architecture intervention embedded within an online ordering system can increase the purchase of healthier food items for high school students in one Australian state without any adverse impact on canteen revenue. TRIAL REGISTRATION: This trial was prospectively registered on Open Science Framework on 23rd October 2020 as osf.io/h8zfr.

Barriers and facilitators to the implementation of healthy eating, physical activity and obesity prevention policies, practices or programs in family day care: A mixed method systematic review.

Family day care (FDC) services provide care to young children typically within the carer's own home and represents a unique setting to deliver public health programs to improve child health. To support the implementation of programs targeting healthy eating, physical activity and obesity prevention in the FDC setting, an understanding of the factors influencing their implementation is required. This mixed methods systematic review aimed to describe the barriers and facilitators to the implementation of healthy eating, physical activity or obesity prevention policies, practices and programs (hereafter referred to as programs) in the FDC setting, and synthesise these according to the Theoretical Domains Framework (TDF). Electronic searches were conducted in 7 databases up to July 2020 to identify studies reporting the barriers and/or facilitators to program implementation in the FDC setting. Methodological quality assessments of included studies were conducted using the Mixed Methods Appraisal Tool (MMAT). Twenty studies met the review inclusion criteria (12 qualitative, 6 quantitative, 2 mixed methods). Of the 20 included studies, 16 reported barriers and facilitators mapped to the 'environmental contexts and resources' TDF domain; 10 reported barriers mapped to the 'social influences' TDF domain. Ten of the 12 qualitative studies and none of the quantitative or mixed method studies met all relevant MMAT criteria. This review comprehensively describes barriers and facilitators that need to be addressed to improve the implementation of healthy eating, physical activity and obesity prevention programs in FDC to ensure the expected health benefits of such programs reach children attending FDC.

The effectiveness of canteen manager audit and feedback reports and online menu-labels in encouraging healthier food choices within students' online lunch orders: A pilot cluster randomised controlled trial in primary school canteens in New South Wales, Australia.

Online school canteen lunch ordering systems may offer a unique opportunity to support the implementation of school canteen nutrition polices, while delivering behavioural interventions directly to consumers to influence healthy student purchasing. This cluster randomised controlled trial aimed to test the effectiveness of a menu audit and feedback strategy alone, and in combination with online menu labels in encouraging healthier purchasing from an online school canteen ordering system. Five intervention schools received a menu audit and feedback strategy, plus online menu labels; and five control schools received a delayed menu audit and feedback strategy. Data from 19,799 student lunch orders, containing over 40,000 items were included in the evaluation. Outcomes were assessed at baseline (pre-intervention), follow-up 1 (menu audit and feedback vs control), and follow-up 2 (menu audit and feedback plus online menu labels vs menu audit and feedback alone). From baseline to follow-up 1, the menu audit and feedback strategy alone had no significant effect on the proportion of healthy ('Everyday') and less healthy ('Occasional' or 'Should not be sold') items purchased. From baseline to follow-up 2, schools that received menu audit and feedback plus online menu labels had significantly higher odds of students purchasing 'Everyday' items (OR: 1.19; p = 0.019), and significantly lower odds of students purchasing 'Occasional' (OR: 0.86; p = 0.048) and 'Should not be sold' (OR: 0.52; p < 0.001) items. Menu audit and feedback with the addition of online menu labels was effective in increasing the proportion of healthy items purchased relative to menu audit and feedback in isolation. There may be a greater role for online menu labelling as part of a suite of strategies to improve public health nutrition in schools.

Investigating differences between traditional (paper bag) ordering and online ordering from primary school canteens: a cross-sectional study comparing menu, usage and lunch order characteristics.

OBJECTIVE: To assess differences between traditional paper bag ordering and online ordering from primary school canteens in terms of menu, usage and lunch order characteristics. DESIGN: A cross-sectional study. SETTING: New South Wales (NSW) primary schools that offered both paper bag and online canteen ordering. PARTICIPANTS: Students (aged 5-12 years) with a lunch order on the day of the observation. RESULTS: Across the six school canteens, 59-90 % of all available items were listed on both the online and paper menus, with no significant differences in the nutritional quality ('Everyday'/'Occasional') or nutritional content (kJ/saturated fat/sugar/sodium) of menu items. In total, 387 student lunch orders were placed, containing 776 menu items. Most orders (68 %) were placed online. There were no significant differences between order modality in the quantity of items ordered or the cost of orders, or the nutritional quality of orders based on the classification system of the NSW Healthy School Canteen Strategy ('Everyday'/'Occasional'). However, nutritional analysis revealed that paper bag orders contained 222 fewer kJ than online orders (P = 0·001), 0·65 g less saturated fat (P = 0·04) and 4·7 g less sugar (P < 0·001). CONCLUSIONS: Online canteens are commonly used to order canteen lunches for primary school children. This is the first study to investigate differences between traditional paper bag ordering and online ordering in this setting. Given the rapid increase in the use of online ordering systems in schools and other food settings and their potential to deliver public health nutrition interventions, additional research is warranted to further investigate differences in ordering modalities.

Associations Between Digital Health Intervention Engagement, Physical Activity, and Sedentary Behavior: Systematic Review and Meta-analysis.

BACKGROUND: The effectiveness of digital health interventions is commonly assumed to be related to the level of user engagement with the digital health intervention, including measures of both digital health intervention use and users' subjective experience. However, little is known about the relationships between the measures of digital health intervention engagement and physical activity or sedentary behavior. OBJECTIVE: This study aims to describe the direction and strength of the association between engagement with digital health interventions and physical activity or sedentary behavior in adults and explore whether the direction of association of digital health intervention engagement with physical activity or sedentary behavior varies with the type of engagement with the digital health intervention (ie, subjective experience, activities completed, time, and logins). METHODS: Four databases were searched from inception to December 2019. Grey literature and reference lists of key systematic reviews and journals were also searched. Studies were eligible for inclusion if they examined a quantitative association between a measure of engagement with a digital health intervention targeting physical activity and a measure of physical activity or sedentary behavior in adults (aged ≥18 years). Studies that purposely sampled or recruited individuals on the basis of pre-existing health-related conditions were excluded. In addition, studies were excluded if the individual engaging with the digital health intervention was not the target of the physical activity intervention, the study had a non-digital health intervention component, or the digital health interventions targeted multiple health behaviors. A random effects meta-analysis and direction of association vote counting (for studies not included in meta-analysis) were used to address objective 1. Objective 2 used vote counting on the direction of the association. RESULTS: Overall, 10,653 unique citations were identified and 375 full texts were reviewed. Of these, 19 studies (26 associations) were included in the review, with no studies reporting a measure of sedentary behavior. A meta-analysis of 11 studies indicated a small statistically significant positive association between digital health engagement (based on all usage measures) and physical activity (0.08, 95% CI 0.01-0.14, SD 0.11). Heterogeneity was high, with 77% of the variation in the point estimates explained by the between-study heterogeneity. Vote counting indicated that the relationship between physical activity and digital health intervention engagement was consistently positive for three measures: subjective experience measures (2 of 3 associations), activities completed (5 of 8 associations), and logins (6 of 10 associations). However, the direction of associations between physical activity and time-based measures of usage (time spent using the intervention) were mixed (2 of 5 associations supported the hypothesis, 2 were inconclusive, and 1 rejected the hypothesis). CONCLUSIONS: The findings indicate a weak but consistent positive association between engagement with a physical activity digital health intervention and physical activity outcomes. No studies have targeted sedentary behavior outcomes. The findings were consistent across most constructs of engagement; however, the associations were weak.

Correction: Associations Between Digital Health Intervention Engagement, Physical Activity, and Sedentary Behavior: Systematic Review and Meta-analysis.

[This corrects the article DOI: 10.2196/23180.].

Long-term Effectiveness of a Multistrategy Behavioral Intervention to Increase the Nutritional Quality of Primary School Students' Online Lunch Orders: 18-Month Follow-up of the Click & Crunch Cluster Randomized Controlled Trial.

BACKGROUND: School food services, including cafeterias and canteens, are an ideal setting in which to improve child nutrition. Online canteen ordering systems are increasingly common and provide unique opportunities to deliver choice architecture strategies to nudge users to select healthier items. Despite evidence of short-term effectiveness, there is little evidence regarding the long-term effectiveness of choice architecture interventions, particularly those delivered online. OBJECTIVE: This study determined the long-term effectiveness of a multistrategy behavioral intervention (Click & Crunch) embedded within an existing online school lunch-ordering system on the energy, saturated fat, sugar, and sodium content of primary school students' lunch orders 18 months after baseline. METHODS: This cluster randomized controlled trial (RCT) involved a cohort of 2207 students (aged 5-12 years) from 17 schools in New South Wales, Australia. Schools were randomized to receive either a multistrategy behavioral intervention or the control (usual online ordering only). The intervention strategies ran continuously for 14-16.5 months until the end of follow-up data collection. Trial primary outcomes (ie, mean total energy, saturated fat, sugar and sodium content of student online lunch orders) and secondary outcomes (ie, the proportion of online lunch order items that were categorized as everyday, occasional, and caution) were assessed over an 8-week period at baseline and 18-month follow-up. RESULTS: In all, 16 schools (94%) participated in the 18-month follow-up. Over time, from baseline to follow-up, relative to control orders, intervention orders had significantly lower energy (-74.1 kJ; 95% CI [-124.7, -23.4]; P=.006) and saturated fat (-0.4 g; 95% CI [-0.7, -0.1]; P=.003) but no significant differences in sugar or sodium content. Relative to control schools, the odds of purchasing everyday items increased significantly (odds ratio [OR] 1.2; 95% CI [1.1, 1.4]; P=.009, corresponding to a +3.8% change) and the odds of purchasing caution items significantly decreased among intervention schools (OR 0.7, 95% CI [0.6, 0.9]; P=.002, corresponding to a -2.6% change). There was no between-group difference over time in canteen revenue. CONCLUSIONS: This is the first study to investigate the sustained effect of a choice architecture intervention delivered via an online canteen ordering systems in schools. The findings suggest that there are intervention effects up to 18-months postbaseline in terms of decreased energy and saturated fat content and changes in the relative proportions of healthy and unhealthy food purchased for student lunches. As such, this intervention approach may hold promise as a population health behavior change strategy within schools and may have implications for the use of online food-ordering systems more generally; however, more research is required. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12618000855224; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375075.

Effectiveness of a Multistrategy Behavioral Intervention to Increase the Nutritional Quality of Primary School Students' Web-Based Canteen Lunch Orders (Click & Crunch): Cluster Randomized Controlled Trial.

BACKGROUND: School food outlets represent a key setting for public health nutrition intervention. The recent proliferation of web-based food ordering systems provides a unique opportunity to support healthy purchasing from schools. Embedding evidence-based choice architecture strategies within these routinely used systems provides the opportunity to impact the purchasing decisions of many users simultaneously and warrants investigation. OBJECTIVE: This study aims to assess the effectiveness of a multistrategy behavioral intervention implemented via a web-based school canteen lunch ordering system in reducing the energy, saturated fat, sugar, and sodium content of primary students' web-based lunch orders. METHODS: The study used a parallel-group, cohort, cluster randomized controlled trial design with 2207 students from 17 Australian primary schools. Schools with a web-based canteen lunch ordering system were randomly assigned to receive either a multistrategy behavioral intervention that included choice architecture strategies embedded in the web-based system (n=9 schools) or the standard web-based ordering system only (n=8 control schools). Automatically collected student purchasing data at baseline (term 2, 2018) and 12 months later (term 2, 2019) were used to assess trial outcomes. Primary trial outcomes included the mean energy (kJ), saturated fat (g), sugar (g), and sodium (mg) content of student lunch orders. Secondary outcomes included the proportion of all web-based lunch order items classified as everyday, occasional, and caution (based on the New South Wales Healthy School Canteen Strategy) and canteen revenue. RESULTS: From baseline to follow-up, the intervention lunch orders had significantly lower energy content (-69.4 kJ, 95% CI -119.6 to -19.1; P=.01) and saturated fat content (-0.6 g, 95% CI -0.9 to -0.4; P<.001) than the control lunch orders, but they did not have significantly lower sugar or sodium content. There was also a small significant between-group difference in the percentage of energy from saturated fat (-0.9%, 95% CI -1.4% to -0.5%; P<.001) but not in the percentage of energy from sugar (+1.1%, 95% CI 0.2% to 1.9%; P=.02). Relative to control schools, intervention schools had significantly greater odds of having everyday items purchased (odds ratio [OR] 1.7, 95% CI 1.5-2.0; P<.001), corresponding to a 9.8% increase in everyday items, and lower odds of having occasional items purchased (OR 0.7, 95% CI 0.6-0.8; P<.001), corresponding to a 7.7% decrease in occasional items); however, there was no change in the odds of having caution (least healthy) items purchased (OR 0.8, 95% CI 0.7-1.0; P=.05). Furthermore, there was no change in schools' revenue between groups. CONCLUSIONS: Given the evidence of small statistically significant improvements in the energy and saturated fat content, acceptability, and wide reach, this intervention has the potential to influence dietary choices at a population level, and further research is warranted to determine its impact when implemented at scale. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12618000855224; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375075. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1136/bmjopen-2019-030538.

Secondary school implementation of a healthy eating policy.

ISSUE ADDRESSED: Healthy canteen policies regulating the sales of food and beverages are available across all the states and territories in Australia. The aim of this study was to assess the compliance with a newly updated healthy school canteen policy in New South Wales (NSW) among a sample of secondary schools. METHODS: A cross-sectional study of secondary school canteen menus was undertaken in selected regions across NSW (September 2017-November 2017). Government and Catholic secondary schools with a canteen menu publicly available on school websites were eligible for inclusion. Menus were classified according to the NSW Healthy School Canteen Strategy using a Quick Menu Audit tool, previously validated in primary schools. RESULTS: Of 62 Catholic and 128 Government secondary schools located in the study region, 53 secondary schools (25 Catholic and 28 Government) were eligible to participate. The average percentage of "everyday" (healthy) items on secondary school menus was 54% (strategy criteria is >75%). Twenty-eight per cent of menus had no "sugary drinks" (should not be sold). None of the 53 menus assessed met all strategy criteria regarding the availability of foods and beverages. There was no statistically significant difference in meeting; (a) 75% minimum "everyday" items and (b) no "sugary drinks," by socio-economic region, remoteness, school enrolments or school type. CONCLUSIONS: If public health benefits of healthy eating policies are to be realised, secondary schools need to be supported to implement such policies. SO WHAT?: Future research assessing the impact of intervention strategies to support policy implementation in secondary schools is recommended.

A systematic review of interventions to improve the dietary intake, physical activity and weight status of children attending family day care services.

OBJECTIVE: To (i) identify and synthesise findings from interventions to improve the dietary intake, physical activity and weight status of children aged 0-6 years attending family day care services; and (ii) assess the impact of interventions on family day care environments, intervention cost and adverse outcomes. DESIGN: Medline in Process, PsycINFO, ERIC, Embase, CINAHL, CENTRAL and Scopus databases were searched in March 2019. Studies were included if they (i) evaluated an intervention to improve the diet, physical activity and/or weight of children aged 0-6 years; (ii) were delivered in family day care services; (iii) targeted child diet, physical activity and/or weight; and (iv) used a parallel control group design. Screening was undertaken by two reviewers with disagreements resolved by a third reviewer. SETTING: Family day care services, also known as family childcare homes. PARTICIPANTS: Children aged 0-6 years attending family day care services. RESULTS: In total, 8977 titles were retrieved, and 199 full-texts reviewed. No studies met the inclusion criteria for the primary outcome; however, two studies reporting on the secondary outcome of family day care environments were included. The 4-year community-wide obesity prevention programme and the 12-month train-the-trainer programme both reported statistically significant improvements in the healthy eating and physical activity environments of family day care, compared to cross-sectional state-average control groups. CONCLUSIONS: Findings highlight few existing interventions in family day care services and a need for high-quality controlled trials to identify effective interventions to improve children's diet, activity and weight in this setting.

A cross-sectional study of the nutritional quality of student canteen purchases from New South Wales primary-school canteens.

OBJECTIVE: To assess the nutritional quality of student canteen purchases at recess and lunch, including: (i) the mean energy (kilojoules), saturated fat (grams), total sugar (grams) and Na (milligrams) and percentage of energy from saturated fat and total sugar; and (ii) the proportion and types of foods purchased that are healthier (green) and less healthy (amber/red) according to a state school canteen policy. DESIGN: A cross-sectional study of student canteen food and beverage recess and lunch purchases. SETTING: Twenty-six randomly selected government primary schools that were non-compliant with a state school canteen policy from a region of New South Wales, Australia, were approached to participate. PARTICIPANTS: Students (aged 5-12 years) of participating schools. RESULTS: Eighteen schools (69 %) consented to participate. On average students' recess purchases contained 571·2 kJ energy, 1·6 g saturated fat, 11·6 g total sugar and 132·4 mg Na with 10·0 % of energy from saturated fat and 37·8 % of energy from total sugar. Students' lunch purchases contained 685·4 kJ energy, 1·8 g saturated fat, 12·7 g total sugar and 151·4 mg Na with 9·5 % of energy from saturated fat and 31·8 % of energy from total sugar. Less healthy items represented 72 and 76 % of all items purchased at recess and lunch, respectively, with 'savoury snacks' and 'sugar-sweetened ice blocks and slushies' being the most common recess and lunch purchases, respectively. CONCLUSIONS: There is considerable scope to improve the nutritional quality of student purchases from primary-school canteens, with a high percentage of energy from total sugar. Future research is required to identify effective strategies to enhance compliance with canteen policies and support the purchase of healthier foods from school canteens.

Two-year follow-up of a randomised controlled trial to assess the sustainability of a school intervention to improve the implementation of a school-based nutrition policy.

ISSUE ADDRESSED: School-based nutrition policies can have a positive effect on the school food environment. The primary aim of this study was to assess the primary school adherence to a mandatory state-wide healthy canteen policy 12 months after an effective multi-strategic implementation intervention concluded. METHODS: Primary schools were randomised to (a) a 12-14 months multi-strategic intervention or (b) no-intervention (control). The intervention aimed to improve implementation of a state-wide canteen policy by encouraging schools to remove unhealthy food and beverages (classified as ''red'' or ''banned'') from canteen menus and replace with healthy items (classified as ''green''). No implementation support was provided to either group by the research team between the 12 and 24 months data collection period. RESULTS: Seventy schools participated, of which 56 schools were assessed at 24-month follow-up. Intervention schools were less likely to have a menu which contained ''red/banned'' items at 24-month follow-up (RR = 2.28; 95% CI: 1.18-4.40; P = 0.01). Intervention schools, however, were not more likely than controls to have a menu which contained >50% ''green'' items at 24-month follow-up (RR = 1.29; 95% CI: 0.98-1.70; P = 0.10). Intervention schools were more likely to adhere to both policy components (no red/banned items and >50% green items on the menu) than control schools (RR = 2.61; 95% CI: 1.29-5.29; P = 0.006). Among intervention schools that were fully adherent to the policy following implementation support (12-month post baseline), all were also adherent at the 24-month follow-up. CONCLUSION: The intervention was effective in achieving long-term school adherence to a state-wide canteen policy at 24-month follow-up. SO WHAT?: The findings suggest that sustained improvements in implementation of school nutrition policies is possible following a period (12 months) of comprehensive implementation support.

Availability of food and beverage items on school canteen menus and association with items purchased by children of primary-school age.

OBJECTIVE: To (i) describe the proportion of foods and beverages available on school canteen menus classified as having high ('green'), moderate ('amber') or low ('red') nutritional value; (ii) describe the proportion of these items purchased by students; and (iii) examine the association between food and beverage availability on school canteen menus and food and beverage purchasing by students. DESIGN: A cross-sectional study was conducted as part of a larger randomised controlled trial (RCT). SETTING: A nested sample of fifty randomly selected government schools from the Hunter New England region of New South Wales, Australia, who had participated in an RCT of an intervention to improve the availability of healthy foods sold from school canteens, was approached to participate. SUBJECTS: School principals, canteen managers and students. RESULTS: The average proportion of green, amber and red items available on menus was 47·9, 47·4 and 4·7 %, respectively. The average proportion of green, amber and red items purchased by students was 30·1, 61·8 and 8·1 %, respectively. There was a significant positive relationship between the availability and purchasing of green (R 2=0·66), amber (R 2=0·57) and red menu items (R 2=0·61). In each case, a 1 % increase in the availability of items in these categories was associated with a 1·21, 1·35 and 1·67 % increase in purchasing of items of high, moderate and low nutritional value, respectively. CONCLUSIONS: The findings provide support for school-based policies to improve the relative availability of healthy foods for sale in these settings.

Assessing the potential impact of a front-of-pack nutritional rating system on food availability in school canteens: A randomised controlled trial.

BACKGROUND: Front-of-pack graphical nutritional rating of products is becoming an important strategy in many countries to improve healthy food purchases by consumers. Evidence of the effectiveness of such on facilitating healthy food choices by school food service providers has not been reported. The primary aim of the study was to assess the impact of providing front-of-pack nutritional rating information on school canteen managers' likely food selections. Secondary outcomes were canteen manager awareness, attitudes and reported barriers to using the front-of-pack information. METHODS: A randomised controlled trial involving primary school canteen managers was conducted in a single region in New South Wales, Australia. Eligible participants were randomised to an intervention or control group and asked in a telephone interview which of 12 common food products sold in school canteens they would sell. Both groups received product name and brand information. The intervention group also received information regarding the nutritional rating of products. RESULTS: Canteen managers in the intervention group were significantly more likely than those in the control group to indicate they would sell three of the six 'healthier' products (p = 0.036, 0.005, 0.009). There was no difference between groups in the likelihood of making available for sale any of the six 'less healthy' products. The majority of canteen managers who had heard of a product nutritional rating system agreed that it was helpful in identifying 'healthier' foods (88%, n = 31). CONCLUSIONS: The inclusion of product nutritional rating information has the potential to improve the availability of some 'healthier' items on canteen menus and contribute to improving child dietary intake. Further research is required to determine whether the use of product nutritional rating information actually makes a difference to canteen manager choices.

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

BACKGROUND: A number of school-based policies or practices have been found to be effective in improving child diet and physical activity, and preventing excessive weight gain, tobacco or harmful alcohol use. Schools, however, frequently fail to implement such evidence-based interventions. OBJECTIVES: The primary aims of the review are to examine the effectiveness of strategies aiming to improve the implementation of school-based policies, programs or practices to address child diet, physical activity, obesity, tobacco or alcohol use.Secondary objectives of the review are to: Examine the effectiveness of implementation strategies on health behaviour (e.g. fruit and vegetable consumption) and anthropometric outcomes (e.g. BMI, weight); describe the impact of such strategies on the knowledge, skills or attitudes of school staff involved in implementing health-promoting policies, programs or practices; describe the cost or cost-effectiveness of such strategies; and describe any unintended adverse effects of strategies on schools, school staff or children. SEARCH METHODS: All electronic databases were searched on 16 July 2017 for studies published up to 31 August 2016. We searched the following electronic databases: Cochrane Library including the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; MEDLINE In-Process & Other Non-Indexed Citations; Embase Classic and Embase; PsycINFO; Education Resource Information Center (ERIC); Cumulative Index to Nursing and Allied Health Literature (CINAHL); Dissertations and Theses; and SCOPUS. We screened reference lists of all included trials for citations of other potentially relevant trials. We handsearched all publications between 2011 and 2016 in two specialty journals (Implementation Science and Journal of Translational Behavioral Medicine) and conducted searches of the WHO International Clinical Trials Registry Platform (ICTRP) (http://apps.who.int/trialsearch/) as well as the US National Institutes of Health registry (https://clinicaltrials.gov). We consulted with experts in the field to identify other relevant research. SELECTION CRITERIA: 'Implementation' was defined as the use of strategies to adopt and integrate evidence-based health interventions and to change practice patterns within specific settings. We included any trial (randomised or non-randomised) conducted at any scale, with a parallel control group that compared a strategy to implement policies or practices to address diet, physical activity, overweight or obesity, tobacco or alcohol use by school staff to 'no intervention', 'usual' practice or a different implementation strategy. DATA COLLECTION AND ANALYSIS: Citation screening, data extraction and assessment of risk of bias was performed by review authors in pairs. Disagreements between review authors were resolved via consensus, or if required, by a third author. Considerable trial heterogeneity precluded meta-analysis. We narratively synthesised trial findings by describing the effect size of the primary outcome measure for policy or practice implementation (or the median of such measures where a single primary outcome was not stated). MAIN RESULTS: We included 27 trials, 18 of which were conducted in the USA. Nineteen studies employed randomised controlled trial (RCT) designs. Fifteen trials tested strategies to implement healthy eating policies, practice or programs; six trials tested strategies targeting physical activity policies or practices; and three trials targeted tobacco policies or practices. Three trials targeted a combination of risk factors. None of the included trials sought to increase the implementation of interventions to delay initiation or reduce the consumption of alcohol. All trials examined multi-strategic implementation strategies and no two trials examined the same combinations of implementation strategies. The most common implementation strategies included educational materials, educational outreach and educational meetings. For all outcomes, the overall quality of evidence was very low and the risk of bias was high for the majority of trials for detection and performance bias.Among 13 trials reporting dichotomous implementation outcomes-the proportion of schools or school staff (e.g. classes) implementing a targeted policy or practice-the median unadjusted (improvement) effect sizes ranged from 8.5% to 66.6%. Of seven trials reporting the percentage of a practice, program or policy that had been implemented, the median unadjusted effect (improvement), relative to the control ranged from -8% to 43%. The effect, relative to control, reported in two trials assessing the impact of implementation strategies on the time per week teachers spent delivering targeted policies or practices ranged from 26.6 to 54.9 minutes per week. Among trials reporting other continuous implementation outcomes, findings were mixed. Four trials were conducted of strategies that sought to achieve implementation 'at scale', that is, across samples of at least 50 schools, of which improvements in implementation were reported in three trials.The impact of interventions on student health behaviour or weight status were mixed. Three of the eight trials with physical activity outcomes reported no significant improvements. Two trials reported reductions in tobacco use among intervention relative to control. Seven of nine trials reported no between-group differences on student overweight, obesity or adiposity. Positive improvements in child dietary intake were generally reported among trials reporting these outcomes. Three trials assessed the impact of implementation strategies on the attitudes of school staff and found mixed effects. Two trials specified in the study methods an assessment of potential unintended adverse effects, of which, they reported none. One trial reported implementation support did not significantly increase school revenue or expenses and another, conducted a formal economic evaluation, reporting the intervention to be cost-effective. Trial heterogeneity, and the lack of consistent terminology describing implementation strategies, were important limitations of the review. AUTHORS' CONCLUSIONS: Given the very low quality of the available evidence, it is uncertain whether the strategies tested improve implementation of the targeted school-based policies or practices, student health behaviours, or the knowledge or attitudes of school staff. It is also uncertain if strategies to improve implementation are cost-effective or if they result in unintended adverse consequences. Further research is required to guide efforts to facilitate the translation of evidence into practice in this setting.

Online canteens: awareness, use, barriers to use, and the acceptability of potential online strategies to improve public health nutrition in primary schools.

Issue addressed This study of primary school principals assessed the awareness, use, barriers to use and acceptability of online canteens. Methods A telephone survey of 123 primary school principals within the Hunter New England Region of New South Wales, Australia was conducted from September 2014 to November 2014. Results Fifty-six percent of principals were aware of the existence of online canteens, with 8% having implemented such a system, and 38% likely to do so in the future. Medium/large schools were more likely to be aware of or to use online canteens, however there were no differences in awareness or use in relation to school rurality or socioeconomic advantage. Principals cited parent internet access as the most commonly identified perceived barrier to online canteen use, and the majority of principals (71-93%) agreed that it would be acceptable to implement a range of consumer behaviour strategies via an online canteen. Conclusions Study findings suggest that despite relatively low levels of current use, online canteens have the potential to reach a large proportion of school communities in the future, across geographical and socioeconomic divides, and that the nutrition interventions which they have the capacity to deliver are considered acceptable to school principals. So what? Online canteens may represent an opportunity to deliver nutrition interventions to school communities. Future research should examine the feasibility and potential effectiveness of interventions delivered via this modality.