Effectively implementing healthy and sustainable food practices in out-of-home food service locations: The perspective of the catering staff members.

Restaurants, canteens, residential care, hospitals and other out-of-home food service locations can play an important role in improving people's diet quality by offering healthier and more sustainable food choices. However, the effectiveness of implementing sustainable and healthy food practices at these locations is, at least partly, dependent on the extent to which they are accepted and implemented by the staff members. This study aims to assess staff members' motivation, perceived capability, perceived opportunity and their readiness to change their behaviour (i.e., stages of change) in offering more healthy and sustainable food options to their customers or patients. Eleven out-of-home locations that wanted to adjust their assortment towards more healthy and sustainable product offerings participated in this study and were able to distribute a comparable questionnaire among their staff members to assess their perceived readiness to change. Results among 268 participants show that staff members find both a healthy and sustainable food assortment important and also seem to be motivated to improve their food assortment regarding health and sustainability. Perceived opportunity seems to be the largest barrier for staff members, although there is also room for improvement regarding their perceived capability. In addition, personal motivation seems to play the dominant role in staff members' readiness to change the health of the assortment, whereas perceived capability seems to play the dominant role in their perceived readiness to change the sustainability of the assortment. This study shows that taking into account the perspective of the catering staff members may help to effectively implement healthy and sustainable food practices in out-of-home food service locations.

The perceptions of food service staff in a nursing home on an upcoming transition towards a healthy and sustainable food environment: a qualitative study.

BACKGROUND: Healthy and sustainable food environments are urgently needed, also in nursing and residential care homes. Malnutrition in care homes is becoming an increasing problem as populations worldwide are ageing and many older people do not consume sufficient protein, fibre, fruit, and vegetables. Nursing homes also often experience a lot of food waste. A transition in the food environment like a nursing home, involves the participation of facility management and food service staff members. This study aims to map out their perceived barriers and facilitators for this transition. METHODS: A qualitative study using semi-structured interviews was conducted with food service staff members (n = 16), comprising of kitchen staff (n = 4), wait staff (n = 10), and facility management (n = 2) of two nursing homes in the Netherlands. Thematic analysis was used to derive content and meaning from transcribed interviews. RESULTS: Four main themes were identified. Theme 1: 'Communication, transparency and accountability in the chain', highlighting the lack of effective communication flows and a fragmented overview of the food service chain as a whole. Theme 2: 'Understanding, knowledge and ability of the concepts healthy and sustainable', revealing the gap in staff's understanding of these abstract concepts, despite perceiving themselves as having sufficient knowledge and ability. Theme 3: 'The pampering service mind-set', highlighting the contradiction in the staff's shared goal of proving the highest quality of life for residents while also pampering them in ways that may not align with promoting healthy and sustainable food choices. Theme 4: 'Transition is important but hard to realize', describing the barriers such as existing routines and a lack of resources as challenges to implementing changes in the food service. CONCLUSIONS: Facilitators to transitioning nursing homes towards a healthy and sustainable food environment as perceived by staff members included transparent communication, accountability in the food supply chain, staff's perceived ability and shared goal, while barriers included lack of understanding of the concepts healthy and sustainable, the current pampering mindset, and top-down decision-making. These findings provide valuable insights for nursing homes seeking to transition towards a healthier and more sustainable food environment.

Implementation of four strategies in Dutch day-care centres to stimulate young children's fruit and vegetable consumption.

The day-care setting is an ideal place to encourage children's fruit and vegetable (=F&V) eating. Whereas many studies have focused on the effectiveness to increase F&V consumption, little is known about how to successfully implement effective strategies in daily practice. This study aimed to investigate how day-care professionals evaluated the implementation of a self-chosen strategy to support children's F&V eating. Thirteen day-care locations chose one out of five promising strategies and implemented this strategy for 10-12 weeks. Before (N = 98) and after the study (N = 49), day-care professionals completed a questionnaire to assess their implementation experiences, the impact on children's F&V eating as well as their future intention to use the strategy (on a 5-point scale). Parents (N = 152) completed a short questionnaire at the end of the study to capture their experiences and potential transfer effects to the home situation. Results showed that acceptability, appropriateness, feasibility and sustainability of the strategies were generally satisfactory (scores ≥3.5 on a 5-point scale), but the strategy of cooking scored less favourable on appropriateness and sustained implementation. Children's willingness to taste F&V varieties (3.4 ± 0.7 vs. 2.8 ± 0.8; p < 0.001) and eating pleasure for vegetables (3.4 ± 0.6 vs. 3.1 ± 0.8; p = 0.01) increased, whereas children's F&V consumption did not change (p > 0.14). Parents valued the day-cares' efforts to encourage children's F&V consumption and a small group (∼20%) experienced positive effects at home. This study shows that implementing a self-chosen F&V strategy at the day-care is acceptable, appropriate and feasible for day-care professionals and has potential to positively impact children's F&V eating behaviour. Future research should investigate the effects of long-term implementation on children's eating behaviour and examine how structural implementation can be further supported.

Observational study on dietary changes of participants following a multicomponent lifestyle program (Reverse Diabetes2 Now).

BACKGROUND: Lifestyle intervention studies to treat type 2 diabetes (T2D) are on the rise. However, in-depth research is lacking into the dietary changes that participants make. METHODS: The present study aimed to observe the dietary intake of participants following the group program 'Reverse Diabetes2 Now' (RD2N) over 12 months. The web-based 24-h dietary recall-tool Compl-eat was used to collect dietary intake data. RESULTS: In total, 147 T2D patients were included in a cross-sectional study (n = 37 at baseline, n = 58 at 6 months, n = 52 at 12 months). A lower intake of total energy, carbohydrates and iodine was found for the groups at 6 and 12 months compared to the baseline group. The absolute consumption of total fat and saturated fat did not differ between the groups; only the percentage as total calorie consumption decreased. Consumption of vegetables and full-fat yoghurt was higher in groups at 6 and 12 months compared to the group at baseline. Consumption of bread, cakes and sweet biscuits, pasta/rice/tortillas, artificially sweetened soft drinks, and crisps were lower in the groups at 6 and 12 months compared to the group at baseline. Similar results were observed in a separate prospective study in 22 participants over 12 months following the same lifestyle-intervention. CONCLUSIONS: Overall, participants shifted their dietary intake somewhat towards a healthier dietary pattern with overall lower energy and carbohydrates and more vegetables. Moreover, participants largely maintained this healthier pattern over 12 months. There were some concerns regarding iodine intake. These promising results need to be confirmed in a fully-scaled study, as well in a comparison with controls.

Fingerfoods: a feasibility study to enhance fruit and vegetable consumption in Dutch patients with dementia in a nursing home.

BACKGROUND: Eating problems are highly prevalent in older patients with dementia and as a consequence, these patients are at greater risk of becoming malnourished. Fingerfoods, snacks that can be picked with thumb and forefinger, could be used to counteract malnutrition in patients with dementia. The aim of this feasibility study was to evaluate whether providing fruit and vegetable rich fingerfoods in the form of recognizable and familiar snacks on top of the normal intake was feasible for both patients with dementia and caregivers as a means to increase patients' nutritional status. METHODS: Institutionalised patients with dementia (N = 15, 93% female, mean age = 85 years) were included in this feasibility study in the Netherlands. The residents received their regular diet supplemented with fingerfoods, comprising quiches and cakes rich in fruit or vegetables, for 6 weeks. Daily fingerfood consumption together with compensation behaviour at dinner of residents was administered with a checklist and food diaries at the start and end of the intervention as dose delivered. Furthermore, caregivers were asked to fill out a feedback form at the end of the intervention to measure fidelity and appreciation of the intervention. RESULTS: Patients consumed on average 1.4 pieces (70 g) of fingerfoods daily, containing 41 g of fruit and/or vegetables. Fruit and vegetable consumption increased during the provision of the fingerfoods and the residents seemed not to compensate this intake during the rest of the day. The intervention was generally positively received by the majority of caregivers, depending on the type of fingerfood and state of the resident. CONCLUSION: This feasibility study showed that providing recognizable fruit and vegetable rich fingerfoods to patients with dementia seems feasible for both patients and caregivers and could provide a pragmatic approach to enhance fruit and vegetable consumption and total food intake in institutionalized elderly. In an up-scaled study, effects of fingerfoods on nutritional status and quality of life should be investigated.

Towards the measurement of food literacy with respect to healthy eating: the development and validation of the self perceived food literacy scale among an adult sample in the Netherlands.

BACKGROUND: Food literacy refers to the capability to make healthy food choices in different contexts, settings and situations. The aim of this study is to develop and validate the self-perceived food literacy (SPFL) scale, to assess individuals' level of food literacy, including a knowledge, skills and behavior to plan, manage, select, prepare and eat food healthfully. METHODS: An initial set of 50 items for the SPFL scale were generated based on expert insights and literature. A cross-sectional online survey was conducted among a sample of Dutch adults (n = 755) in order to determine convergent, divergent and criterion validation against psychosocial variables that were expected to correlate with food literacy (self-control, impulsiveness) and against the expected outcome of high food literacy, namely healthy food consumption. Principal Component Analyses (PCA), Pearson correlation tests and linear regression analyses were conducted. The capacity to distinguish of the SPFL scale was determined by comparing SPFL scores of the general population with that of a sample of dieticians (n = 207). RESULTS: The participants in the general sample had an average age of 44.8 (SD:16.1), the majority were women (90.7%), they had a healthy weight (61.4%) and were highly educated (59.1%). Of the initial 50 items, 29 items remained after PCA and reflected eight domains of food literacy. SPFL was positively correlated with self-control (r = 0.51, p = <.001) and negatively with impulsiveness (r = - 0.31, p = <.01). Participants with higher levels of food literacy reported a significantly higher frequency of fruit consumption (≥5 times/week), vegetable consumption (≥5times/week) and fish consumption (≥1times/week) and consumed larger portions of fruit (≥2pieces/day) and vegetables ≥200 g/day) in comparison with participants who had lower levels of food literacy. Dieticians had slightly higher scores on SPFL than general adults (B = 0.08, SE = 0.03, t = 2.83, 95%-CI = 0.03 to 0.14). CONCLUSIONS: The 29 item SPFL scale is a validated, expert-based and theory-driven tool for measuring self-perceived food literacy with respect to healthy eating among adults. Higher levels of food literacy were associated with more self-control, less impulsiveness and healthier food consumption. Additional research is needed to validate the SPFL scale in different populations (different age groups, socioeconomic groups, male populations) and in different contexts.

Effectiveness of Taste Lessons with and without additional experiential learning activities on children's willingness to taste vegetables.

This study assessed the effectiveness of the Dutch school programme Taste Lessons with and without additional experiential learning activities on children's willingness to taste unfamiliar vegetables. Thirty-three primary schools (877 children in grades 6-7 with a mean age of 10.3 years) participated in Taste Lessons Vegetable Menu (TLVM, lessons and extra activities), Taste Lessons (TL, lessons), or a control group. A baseline and follow-up measurement was used to assess for each child: number of four familiar and four unfamiliar vegetables tasted, quantity tasted, choice of vegetable of which to eat more, and number of vegetables willing to taste again later. Furthermore, children filled out a questionnaire on daily vegetable intake and food neophobia. Multilevel and Cox regression analyses were conducted to compare changes in the outcome measures between the three study groups. No significant intervention effects were found on willingness to taste unfamiliar vegetables. Neither were effects found on familiar vegetables, except for number of familiar vegetables tasted (p < 0.05). Furthermore, no significant intervention effects were found on daily vegetable consumption and food neophobia. These results indicate that more intensive school-based nutrition education activities are needed to increase children's willingness to taste unfamiliar vegetables and increase their vegetable intake.

Unravelling the effect of the Dutch school-based nutrition programme Taste Lessons: the role of dose, appreciation and interpersonal communication.

BACKGROUND: To unravel the effect of school-based nutrition education, insight into the implementation process is needed. In this study, process indicators of Taste Lessons (a nutrition education programme for Dutch elementary schools) and their association with changes in behavioural determinants relevant to healthy eating behaviour are studied. METHODS: The study sample consisted of 392 Dutch primary school children from 12 schools. Data were collected using teacher and child questionnaires at baseline, and at one and six months after the intervention. Multilevel regression analyses were conducted to study the association between dose, appreciation and children's engagement in interpersonal communication (talking about Taste Lessons with others after the lessons), and change in knowledge, awareness, skills, attitude, emotion, subjective norm and intention towards two target behaviours. RESULTS: With an average implementation of a third of the programme activities, dose positively predicted change in children's subjective norm of the teacher after one month. Teachers and children highly appreciated Taste Lessons. Whereas teacher appreciation was inversely associated, child appreciation was positively associated with children's change in awareness, emotion and subjective norm of teachers after one month and in attitude and subjective norm of parents after six months. Interpersonal communication was positively associated with children's change in five determinants after one month and in attitude and intention after six months. CONCLUSIONS: The implementation process is related to the programme outcomes of Taste Lessons. Process data provide valuable insights into factors that contribute to the effect of interventions in real-life settings.

Effectiveness of Taste Lessons with and without additional experiential learning activities on children's psychosocial determinants of vegetables consumption.

Experiential learning methods seem to be promising to enhance healthy eating behaviour in children. Therefore, this study compared the effectiveness of the Dutch programme Taste Lessons with and without additional experiential learning activities on children's psychosocial determinants of vegetable consumption. In a quasi-experimental design, 800 children aged 8-11 years old from 34 elementary schools participated in a Taste Lessons (TL: 5 lessons) group, a Taste Lessons Vegetable Menu (TLVM: TL with 3 added experiential learning activities) group, and a control group. During a baseline and follow-up measurement, children completed a questionnaire on psychosocial determinants towards vegetables consumption. Multilevel regression analyses were conducted to compare changes in the determinants between the TLVM group and the TL group, and between the two intervention groups and the control group. The TLVM group showed a significantly higher increase in knowledge (p < 0.001), attitude and subjective norm of the teacher (both p < 0.05), whereas the TL group only showed a significantly higher increase in knowledge (p < 0.001) compared to the control group. Increases in knowledge (p < 0.10), subjective norm (p < 0.10) and cooking self-efficacy (p < 0.05) were higher in the TLVM group than in the TL group. Therefore, more and stronger effects were found in children who participated in the additional hands-on activities.

Effect of the Dutch school-based education programme 'Taste Lessons' on behavioural determinants of taste acceptance and healthy eating: a quasi-experimental study.

OBJECTIVE: To assess the effect of the Dutch school-based education programme 'Taste Lessons' on children's behavioural determinants towards tasting unfamiliar foods and eating healthy and a variety of foods. DESIGN: In a quasi-experimental study design, data on behavioural determinants were collected at baseline, four weeks and six months after the intervention in both the intervention and control group. Children completed consecutively three questionnaires in which knowledge, awareness, skills, attitude, emotion, subjective norm and intention towards the two target behaviours were assessed. Teachers implemented on average a third of the programme activities. Multilevel regression analyses were conducted to compare individual changes in the determinants in the intervention group with those in the control group, corrected for children's gender and age. Effect sizes were expressed as Cohen's d. SETTING: Dutch elementary schools. SUBJECTS: Forty-nine classes (1183 children, 9-12 years old) in grades 5-8 of twenty-one elementary schools. RESULTS: The intervention group showed a higher increase in knowledge (d=0·26, P<0·01), which persisted after six months (d=0·23, P<0·05). After four weeks, the intervention group showed a higher increase in number of foods known (d=0·22, P<0·05) and tasted (d=0·21, P<0·05), subjective norm of the teacher (d=0·17, P<0·05) and intention (d=0·16, P<0·05) towards the target behaviours. CONCLUSIONS: Partial implementation of Taste Lessons during one school year showed small short-term effects on increasing behavioural determinants in relation to tasting unfamiliar foods and eating healthy and a variety of foods. Full and repeated implementation of Taste Lessons in subsequent years might result in larger effects.

Barriers and Facilitators of Fruit and Vegetable Consumption in Renal Transplant Recipients, Family Members and Healthcare Professionals-A Focus Group Study.

Low fruit and vegetable consumption is associated with poor outcomes after renal transplantation. Insufficient fruit and vegetable consumption is reported in the majority of renal transplant recipients (RTR). The aim of this study was to identify barriers and facilitators of fruit and vegetable consumption after renal transplantation and explore if certain barriers and facilitators were transplant-related. After purposive sampling, RTR (n = 19), their family members (n = 15) and healthcare professionals (n = 5) from a Dutch transplant center participated in seven focus group discussions (three each for RTR and family members, one with healthcare professionals). Transcripts were analyzed using social cognitive theory as conceptual framework and content analysis was used for identification of themes. Transplant-related barriers and facilitators were described separately. In categorizing barriers and facilitators, four transplant-related themes were identified: transition in diet (accompanied by, e.g., fear or difficulties with new routine), physical health (e.g., recovery of uremic symptoms), medication (e.g., cravings by prednisolone) and competing priorities after transplantation (e.g., social participation activities). Among the generic personal and environmental barriers and facilitators, food literacy and social support were most relevant. In conclusion, transplant-related and generic barriers and facilitators were identified for fruit and vegetable consumption in RTR. The barriers that accompany the dietary transition after renal transplantation may contribute to the generally poorer fruit and vegetable consumption of RTR. These findings can be used for the development of additional nutritional counseling strategies in renal transplant care.