The impact of school-based cooking classes on vegetable intake, cooking skills and food literacy of children aged 4-12 years: A systematic review of the evidence 2001-2021.

BACKGROUND: Many children consume a poor quality diet with only a third of children aged 6-9 years eating vegetables daily. A high quality diet is important for good health in childhood; however, the prevalence of children living with obesity has doubled from 10% to 23% during primary school in the UK. Cooking lessons have the potential to improve diet quality and reduce obesity prevalence in childhood, both of which are associated with improved cardiometabolic outcomes in adulthood. The aim of this systematic review is to investigate the impact of school-based cooking classes on cooking skills, food literacy and vegetable intake of children aged 4-12 years. METHODS: We conducted a systematic review of OVID Medline, OVID Embase, EBSCO CINHAL and EBSCO ERIC for comparative studies that evaluated outcomes of children receiving cooking classes compared to a control group. Interventions included contained food preparation or a cooking activities and took place on school premises. Risk of bias was assessed using ROB2 and Robins-I. Outcomes were pooled in a meta-analysis using a random-effects model using standardised mean differences or reviewed using narrative synthesis. Certainty of evidence was assessed using GRADE. RESULTS: We included 21 studies, (6 randomised). Meta-analysis showed a small positive effect on cooking self-efficacy of 0.39 units (95% CI 0.05 to 0.54), and a small positive effect on vegetable intake of 0.25 units (95% CI 0.05 to 0.45). Programmes with more than 6 h of cooking showed the greatest effects. CONCLUSIONS: Children's cooking programmes result in small improvements in cooking efficacy and vegetable intake, particularly those with more than 6 h of classes. It is recommended that future interventions use consistent measurement for children's food literacy and cooking confidence.

Understanding school food systems to support the development and implementation of food based policies and interventions.

BACKGROUND: Schools provide opportunities to improve the quality of children's diet, whilst reducing inequalities in childhood diet and health. Evidence supports whole school approaches, including consistency in food quality, eating culture and food education. However, such approaches are often poorly implemented due to the highly complex environments in which schools operate. We aimed to develop a school food systems map using a systems thinking approach to help identify the key factors influencing primary school children's dietary choice. METHODS: Eight workshops were conducted with 80 children (from schools from varying locations (region of England/UK; urban/rural), deprivation levels and prioritisation of school food policies)) and 11 workshops were held with 82 adult stakeholders across the UK (principals, teachers, caterers, school governors, parents, and local and voluntary sector organisations) to identify factors that influence food choice in children across a school day and their inter-relationships. Initial exploratory workshops started with a 'blank canvas' using a group model building approach. Later workshops consolidated findings and supported a wider discussion of factors, relationships and influences within the systems map. Strengths of the relationship between factors/nodes were agreed by stakeholders and individually depicted on the map. We facilitated an additional eight interactive, in-person workshops with children to map their activities across a whole school day to enable the production of a journey map which was shared with stakeholders in workshops to facilitate discussion. RESULTS: The final 'CONNECTS-Food' systems map included 202 factors that were grouped into 27 nodes. Thematic analysis identified four key themes: leadership and curriculum; child food preference; home environment; and school food environment. Network analysis highlighted key factors that influence child diet across a school day, which were largely in keeping with the thematic analysis; including: 'available funds/resources', 'awareness of initiatives and resources', 'child food preference and intake', 'eligibility of free school meals', 'family circumstances and eating behaviours', 'peer/social norms', 'priorities of head teachers and senior leaders'. CONCLUSIONS: Our systems map demonstrates the need to consider factors external to schools and their food environments. The map supports the identification of potential actions, interventions and policies to facilitate a systems-wide positive impact on children's diets.

Validation of the Oxford WebQ Online 24-Hour Dietary Questionnaire Using Biomarkers.

The Oxford WebQ is an online 24-hour dietary questionnaire that is appropriate for repeated administration in large-scale prospective studies, including the UK Biobank study and the Million Women Study. We compared the performance of the Oxford WebQ and a traditional interviewer-administered multiple-pass 24-hour dietary recall against biomarkers for protein, potassium, and total sugar intake and total energy expenditure estimated by accelerometry. We recruited 160 participants in London, United Kingdom, between 2014 and 2016 and measured their biomarker levels at 3 nonconsecutive time points. The measurement error model simultaneously compared all 3 methods. Attenuation factors for protein, potassium, total sugar, and total energy intakes estimated as the mean of 2 applications of the Oxford WebQ were 0.37, 0.42, 0.45, and 0.31, respectively, with performance improving incrementally for the mean of more measures. Correlation between the mean value from 2 Oxford WebQs and estimated true intakes, reflecting attenuation when intake is categorized or ranked, was 0.47, 0.39, 0.40, and 0.38, respectively, also improving with repeated administration. These correlations were similar to those of the more administratively burdensome interviewer-based recall. Using objective biomarkers as the standard, the Oxford WebQ performs well across key nutrients in comparison with more administratively burdensome interviewer-based 24-hour recalls. Attenuation improves when the average value is taken over repeated administrations, reducing measurement error bias in assessment of diet-disease associations.

The effectiveness of lunchbox interventions on improving the foods and beverages packed and consumed by children at centre-based care or school: a systematic review and meta-analysis.

OBJECTIVE: To assess the effectiveness of lunchbox interventions aiming to improve the foods and beverages packed and consumed by children at centre-based care or school; and subsequent impact on children's adiposity. METHODS: Systematic search of nine databases for controlled trials published in English between 1995-January 2017. Where appropriate, data were pooled in a random effects meta-analysis. RESULTS: Of the 1601 articles identified, ten studies (centre-based care n = 4, school n = 6) were included of which eight were RCTs. The impact of interventions on the packing of discretionary foods, sugar-sweetened drinks and other core foods was inconsistent. Meta-analysis of four RCTs trials found a moderate increase in provision of vegetables (SMD = 0.40 95% CI 0.16 to 0.64, p = 0.001, I2 = 82%; equivalent to a mean difference of 0.28 serves) but not fruit. Four studies reported impact on children's dietary intake, one reported no significant effect on consumption of discretionary foods, one reported improvements in the consumption of sugar-sweetened drinks and water, and two reported improvements in consumption of vegetables and fruit. Two studies, that were broader obesity prevention interventions, reported no significant impact on adiposity. CONCLUSIONS: There is some evidence that lunchbox interventions are effective in improving the packing of vegetables in children's lunchboxes, however more robust research is required to determine the impact on children's dietary intake and adiposity. TRIAL REGISTRATION: PROSPERO 2016: CRD42016035646 .

The impact of HENRY on parenting and family lifestyle: Exploratory analysis of the mechanisms for change.

BACKGROUND: Childhood obesity is a major public health concern. In the United Kingdom, a quarter of children are overweight or obese at age 5 years. Overweight and obese children are more likely to develop serious health issues such as diabetes later in life. Consequently, there is an urgent need for effective, early obesity prevention and intervention. This study investigated the impact of an 8-week child obesity intervention-HENRY (Health Exercise Nutrition for the Really Young)-designed to help parents with preschool children develop the skills and knowledge needed to improve family lifestyle and well-being. We were particularly interested in exploring the potential mechanisms by which HENRY may have a positive impact. METHOD: Focus groups (n = 7, total participants = 39) were completed with mothers attending the HENRY programme at one of seven locations across England. They took place within 2 weeks of programme completion. Follow-up telephone interviews were completed with a subsample of participants (n = 10) between 17 and 21 weeks later. RESULTS: Parents consistently reported enhanced self-efficacy in terms of improved confidence in their ability to encourage healthier behaviours such as eating fruit and vegetables and increasing physical activity, and improvements to family health behaviours. Many changes were reportedly sustained at follow-up. Data provided insights into the potential mechanisms that created the conditions for the positive changes. Participants described the importance of mutual support, being listened to by facilitators, and encouragement to identify their own ideas. Their comments indicated the success of a solution-focused, strength-based, partnership approach to supporting family lifestyle change. CONCLUSION: The results of this study contribute to the body of evidence suggesting that HENRY may have a positive impact on parenting and family lifestyle behaviour. Although data were collected in 2011, the findings contribute to an understanding of the components of effective obesity prevention in young children.

Common dietary patterns and risk of cancers of the colon and rectum: Analysis from the United Kingdom Women's Cohort Study (UKWCS).

Few prospective cohort studies in the UK have specifically focused on the associations between commonly consumed dietary patterns and colorectal cancer (CRC). The aim of our study was to assess whether red meat, poultry, fish and vegetarian dietary patterns are associated with differences in the incidence of cancers of colon and rectum in the UKWCS. Four common dietary patterns were defined based on a hierarchy of consumption of red meat, poultry and fish for each cohort participant, using a 217-item food frequency questionnaire. Cox proportional hazards regression was used to provide adjusted hazard ratios (HR) and 95% confidence intervals (CI) for CRC. A total of 32,147 women recruited and surveyed between 1995 and 1998 were followed up for a mean of 17.2 years (426,798 person-years). A total of 462 incident CRC cases were documented; 335 colon cancers (172 proximal and 119 distal) and 152 in the rectum. In multivariable-adjusted models, there was no evidence of a reduction in risk of overall CRC (HR = 0.86, 95% CI: 0.66-1.12), colon cancer (HR = 0.77, 95% CI: 0.56-1.05) or rectal cancer (HR = 1.04, 95% CI: 0.66-1.63) when comparing grouped red meat free diets with diets containing red meat. Exploratory analysis suggested a reduced risk of distal colon cancer in grouped red meat free diets (HR = 0.56, 95% CI: 0.34-0.95), though numbers with this outcome were small. These results indicate that a protective association of red meat free diets specifically on distal colon cancer merits confirmation in a larger study.

Does adherence to the World Cancer Research Fund/American Institute of Cancer Research cancer prevention guidelines reduce risk of colorectal cancer in the UK Women's Cohort Study?

Evidence on adherence to diet-related cancer prevention guidelines and associations with colorectal cancer (CRC) risk is limited and conflicting. The aim of this cohort analysis is to evaluate associations between adherence to the World Cancer Research Fund/American Institute of Cancer Research (WCRF/AICR) 2007 recommendations and incident CRC. The UK Women's Cohort Study comprises over 35 372 women who filled in a FFQ at baseline in 1995. They were followed up for CRC incidence for a median of 17·4 years, an individual score linking adherence to eight of the WCRF/AICR recommendations was constructed. Cox proportional hazards regression provided hazard ratios (HR) and 95 % CI for the estimation of CRC risk, adjusting for confounders. Following exclusions, 444 CRC cases were identified. In the multivariate-adjusted model, women within the second and third (highest) categories of the WRCF/AICR score had HR of 0·79 (95 % CI 0·62, 1·00) and 0·73 (95 % CI 0·48, 1·10), respectively, for CRC compared with those in the lowest, reference category. The overall linear trend across the categories was not significant (P=0·17). No significant associations were observed between the WCRF/AICR score and proximal colon, distal colon and rectal cancers separately. Of the individual score components, a BMI within the normal weight range was borderline significantly protective only for rectal cancer in the fully adjusted model. In view of the likely different causes of CRC subtypes, further research is needed to identify the optimal dietary patterns associated with reducing colon and rectal cancer risk, respectively.

Agreement between an online dietary assessment tool (myfood24) and an interviewer-administered 24-h dietary recall in British adolescents aged 11-18 years.

myfood24 Is an online 24-h dietary assessment tool developed for use among British adolescents and adults. Limited information is available regarding the validity of using new technology in assessing nutritional intake among adolescents. Thus, a relative validation of myfood24 against a face-to-face interviewer-administered 24-h multiple-pass recall (MPR) was conducted among seventy-five British adolescents aged 11-18 years. Participants were asked to complete myfood24 and an interviewer-administered MPR on the same day for 2 non-consecutive days at school. Total energy intake (EI) and nutrients recorded by the two methods were compared using intraclass correlation coefficients (ICC), Bland-Altman plots (using between and within-individual information) and weighted κ to assess the agreement. Energy, macronutrients and other reported nutrients from myfood24 demonstrated strong agreement with the interview MPR data, and ICC ranged from 0·46 for Na to 0·88 for EI. There was no significant bias between the two methods for EI, macronutrients and most reported nutrients. The mean difference between myfood24 and the interviewer-administered MPR for EI was -230 kJ (-55 kcal) (95 % CI -490, 30 kJ (-117, 7 kcal); P=0·4) with limits of agreement ranging between 39 % (3336 kJ (-797 kcal)) lower and 34 % (2874 kJ (687 kcal)) higher than the interviewer-administered MPR. There was good agreement in terms of classifying adolescents into tertiles of EI (κ w =0·64). The agreement between day 1 and day 2 was as good for myfood24 as for the interviewer-administered MPR, reflecting the reliability of myfood24. myfood24 Has the potential to collect dietary data of comparable quality with that of an interviewer-administered MPR.

Impact of school lunch type on nutritional quality of English children's diets.

OBJECTIVE: Nutrient and food standards exist for school lunches in English primary schools although packed lunches brought from home are not regulated. The aim of the present study was to determine nutritional and dietary differences by lunch type. DESIGN: A cross-sectional survey was carried out in 2007 assessing diet using the Child and Diet Evaluation Tool (CADET), a validated 24 h estimated food diary. The data were analysed to determine nutritional and dietary intakes over the whole day by school meal type: school meals and packed lunches. SETTING: Fifty-four primary schools across England. SUBJECTS: Children (n 2709) aged 6-8 years. RESULTS: Children having a packed lunch consumed on average 11·0 g more total sugars (95 % CI 6·6, 15·3 g) and 101 mg more Na (95 % CI 29, 173 mg) over the whole day. Conversely, children having a school meal consumed, on average, 4·0 g more protein (95 % CI 2·3, 5·7 g), 0·9 g more fibre (NSP; 95 % CI 0·5, 1·3 g) and 0·4 mg more Zn (95 % CI 0·1, 0·6 mg). There was no difference in daily energy intake by lunch type. Children having a packed lunch were more likely to consume snacks and sweetened drinks; while children having a school meal were more likely to consume different types of vegetables and drink water over the whole day. CONCLUSIONS: Compared with children having a school meal, children taking a packed lunch to school consumed a lower-quality diet over the whole day, including higher levels of sugar and Na and fewer vegetables. These findings support the introduction of policies that increase school meal uptake.

Is there an association between food portion size and BMI among British adolescents?

The prevalence of obesity has increased simultaneously with the increase in the consumption of large food portion sizes (FPS). Studies investigating this association among adolescents are limited; fewer have addressed energy-dense foods as a potential risk factor. In the present study, the association between the portion size of the most energy-dense foods and BMI was investigated. A representative sample of 636 British adolescents (11-18 years) was used from the 2008-2011 UK National Diet and Nutrition Survey. FPS were estimated for the most energy-dense foods (those containing above 10·5 kJ/g (2·5 kcal/g)). Regression models with BMI as the outcome variable were adjusted for age, sex and misreporting energy intake (EI). A positive association was observed between total EI and BMI. For each 418 kJ (100 kcal) increase in EI, BMI increased by 0·19 kg/m2 (95 % CI 0·10, 0·28; P< 0·001) for the whole sample. This association remained significant after stratifying the sample by misreporting. The portion sizes of a limited number of high-energy-dense foods (high-fibre breakfast cereals, cream and high-energy soft drinks (carbonated)) were found to be positively associated with a higher BMI among all adolescents after adjusting for misreporting. When eliminating the effect of under-reporting, larger portion sizes of a number of high-energy-dense foods (biscuits, cheese, cream and cakes) were found to be positively associated with BMI among normal reporters. The portion sizes of only high-fibre breakfast cereals and high-energy soft drinks (carbonated) were found to be positively associated with BMI among under-reporters. These findings emphasise the importance of considering under-reporting when analysing adolescents' dietary intake data. Also, there is a need to address adolescents' awareness of portion sizes of energy-dense foods to improve their food choice and future health outcomes.