Mixed Methods Study Investigating Adolescent Acceptance and Implementation Outcomes of Serving Spicy Vegetables in School Lunch.

Background: Only a few adolescents are meeting their daily vegetable requirement. At the same time, spicy food is increasingly popular and familiar across cultures. Objectives: To explore the implementation of spicy vegetables into school meals, the primary objective is to determine adolescents' preferred degree of hot spice on steamed broccoli. Secondary objectives include estimating the appropriateness and acceptability of spicy vegetables in the National School Lunch Program and identifying strategies to promote spicy vegetables within school meals. Methods: One hundred participants between the age 11 and 17 y sampled 4 steamed broccoli florets with varying levels of a ground red and cayenne pepper spice blend (0, 0.9, 2.0, and 4.0 g). Participants rated their likeability of each broccoli sample on a 9-point hedonic scale and answered a survey assessing chili liking, chili consumption patterns, appropriateness, and acceptability. An interview assessed perspectives on spicy vegetables within school lunch.Regression analyses assessed relationships between participant attributes and sample ratings and survey outcomes. Agglomerative hierarchical cluster analysis was conducted to cluster together participants with similar sample liking ratings. Results: Seventy-seven percent of participants reported that chili pepper makes food taste better, and 67% consumed spicy food weekly or daily. Chili likers (n = 41) were the dominant cluster group, compared with moderates (n = 31) and chili dislikers (n = 28). Thematic analysis results suggested that most participants support incorporating spicy vegetables into school lunch but mushy vegetable texture may undermine the impact of changing school vegetable spice levels. Conclusions: Spicy foods are commonly consumed by adolescents, and these findings support the inclusion of spicy vegetables in school lunch. Additional research is needed to identify policies and practices to improve the texture of vegetables in school meals and determine additional strategies to support cultural humility in child nutrition programs.

The need for stronger international support to integrate health and well-being and transform education: a perspective on developing countries.

The reciprocal relationship between education and health is well-established, emphasizing the need for integrating health, nutrition, and well-being components into educational sector planning. Despite widespread acknowledgment of this need, countries lack concrete measures to achieve this integration. We examine challenges that countries have faced and the progress they have made in integrating these components into education sector plans and review the extent to which existing educational planning guidelines and tools address health and well-being. The review reveals a significant underrepresentation of health, well-being, and related themes in existing educational planning frameworks. Recent tools and frameworks developed to support a more holistic approach to education have not yet been widely adopted in standard education sector planning processes. The implementation of such approaches remains inconsistent, with significant barriers including limited cross-sectoral collaboration, lack of capacity, and insufficient funding, among others. Addressing these gaps requires improved guidance, technical support, and a multisectoral approach to education planning that includes health, nutrition, and well-being as fundamental components of foundational learning, supported by political commitment, capacity, and adequate financing.

Exploring the Cross-Sectional Relationship Between Implementation Supports for Adopting Nutrition Standards and the Nutritional Quality of School Lunches Served.

BACKGROUND: The evidence-based nutrition standards of the Healthy, Hunger-Free Kids Act of 2010 significantly improved school meal nutrition, yet little is known about how school food authorities (SFAs) were supported to translate the standards into practice in schools. OBJECTIVE: This study tested whether or not 2 implementation supports, SFA receipt of training/technical assistance (TA) and purchase of new equipment, for implementing the nutrition standards were associated with the nutritional quality of school lunches. DESIGN: This study used a cross-sectional design. PARTICIPANTS/SETTING: The study sample included 365 SFAs derived from the US Department of Agriculture's School Nutrition and Meal Cost Study (2014 to 2015 school year), the only national data of school nutrition environments since the Healthy, Hunger-Free Kids Act of 2010. MAIN OUTCOME MEASURES: Implementation supports included reported participation in training/TA and the purchase of new equipment between the 2012 to 2013 (year of policy adoption) and 2014 to 2015 school years. The primary outcome, nutritional quality of school lunches served, was defined as low/high Healthy Eating Index 2010 scores during the 2014 to 2015 school year. Secondary implementation supports included the number of areas covered by training/TA, the adequacy of training/TA, and the degree of implementation challenges. STATISTICAL ANALYSES: Multivariable-adjusted logistic regression models assessed if receipt of implementation supports was associated with lunch Healthy Eating Index 2010 scores. RESULTS: The median lunch Healthy Eating Index 2010 score was 81.7 (95% CI 80.4 to 82.9). Most SFAs (78.4%, 95% CI 72.0% to 85.0%) reported having participated in training/TA and one-third (33.8%, 95% CI 24.4% to 43.2%) reported having purchased new equipment-neither were associated with the odds of having higher Healthy Eating Index 2010 scores for lunches served at the time of data collection. CONCLUSIONS: Many SFAs accessed implementation supports to adopt the nutrition standards. Information on dose, quality, and nutrition-related impact of implementation supports using measures of change are needed to determine how best to support SFAs with implementation of new nutrition standards.

Nutrition in Educational Institutions-The Perspective of School Principals and Parents on the Tasks of Local Governments (Poland).

BACKGROUND: The financing of nutrition in educational institutions is one of the cornerstones of the activities of local governments in Poland. Proper management of this area is crucial to ensuring that children and young people have access to wholesome meals, which directly affects their health, physical development, as well as educational effectiveness. OBJECTIVE: This study aimed to examine how school principals and parents perceive the role of local governments in managing school nutrition in Poland, given the growing importance of nutrition programs for children's health. METHODS: A survey was conducted with 200 school principals and 1000 parents, assessing satisfaction with the implementation, quality, and organization of nutrition programs overseen by local authorities. RESULTS: The results revealed significant differences between the two groups. While 75% of principals expressed satisfaction with the quality of meals provided in schools, only 55% of parents shared this view. Similarly, 80% of principals rated the organization of cooperation with food suppliers positively, compared to only 50% of parents. Regarding allergen information, 65% of principals felt adequately informed, while only 30% of parents agreed. These differences were statistically significant in several key areas, including adherence to nutrition standards (p = 0.009), frequency of health inspections (p = 0.009), and availability of allergen information (p = 0.013). CONCLUSIONS: The findings highlight a need for improved communication and collaboration between schools, parents, and local governments to enhance the effectiveness of nutrition programs. It is recommended that regular informational meetings be held and that the flow of information be improved to increase parental satisfaction and the overall effectiveness of school nutrition initiatives.

Assessment of preschool preparedness intervention package on adoption of nutrition friendly school initiative in rural Sindh, Pakistan: a pre-and post-intervention design.

Background: In 1995, the World Health Organization launched its Global School Health Initiative intending to expand this health promotion approach throughout schools globally. In this study, we aim to assess the preparedness of preschools in the adoption of intervention packages under the Nutrition Friendly School Initiative (NFSI) checklist. Methods: From three campuses of the Aga Khan School located in the Thatta and Sujawal districts of the Sindh province, Pakistan, all eligible preschool children were selected for this study. Using a pre-and post-intervention design, we assessed preschool preparedness using the NFSI checklist, knowledge of parents/caregivers regarding health and nutrition promoting behaviors, and anthropometric measurements (i.e., mid-upper arm circumference (MUAC), weight, and height) for preschool children. The NFSI checklist was analyzed with differential scores, while descriptive statistics were used for anthropometric and knowledge data. Continuous variables (i.e., height, weight, MUAC) were presented as means, while categorical variables (knowledge) were expressed as numbers and percentages. Paired t-tests for dependent samples were used to statistically assess mean differences in MUAC, height, weight, height-for-age Z-score, weight-for-age Z-score, weight-for-height Z-score, and changes in parental knowledge of preschool children. Results: Data from 164 preschool children (ages 24-84 months, mean age 56.7 months) were analyzed over 3 months. School preparedness scores improved from 10 to 22 points (out of 26). Parental knowledge on nutrition and health increased by 7.2 points (out of 25). Children showed mean increases in MUAC (0.27 cm), weight (0.36 kg), and height (0.62 cm) (p < 0.001). Stunting and overweight/obesity rates remained the same (7.3 and 4.3%), while underweight and wasting rates dropped from 10.4 to 7.3% and 7.9 to 6.1%, respectively. The initiative effectively reduced underweight and wasting but did not impact stunting and overweight. Conclusion: The NFSI has greatly enhanced preschool readiness for nutrition-friendly schools. Engaging the private sector in addressing nutritional challenges has paved the way for future public-private partnerships to tackle malnutrition. The nutrition policy formulated through this initiative could serve as a blueprint for a National School Nutrition Policy.

Promoting healthy school food environments and nutrition in Canada: a systematic review of interventions, policies, and programs.

CONTEXT: The school food environment is a critical interface for child and adolescent nutrition, and there is a need to understand existing literature on Canadian school food environments to identify equity gaps and opportunities, and empower decision-makers to plan for future action. OBJECTIVE: Literature on Canadian school food and nutrition interventions, policies, programs, and their effects on diets and nutritional status are synthesized and appraised in this systematic review. DATA SOURCES: A search strategy was developed for each database used (Medline, Embase, PsycINFO, ERIC, Cochrane Collaboration, Canadian Electronic Library, BiblioMap), with a combination of free text and controlled vocabulary, for articles published from 1990 to 2021. Unpublished data and grey literature were also searched. DATA EXTRACTION: Quantitative and qualitative studies with an observational or intervention study design, reviews, or program evaluations conducted in Canadian schools with participants aged 5-19.9 years were included. Key study characteristics and risk of bias were extracted independently by 2 investigators using a standardized tool. DATA ANALYSIS: A total of 298 articles were included (n = 192 peer reviewed and 106 from the grey literature), which were mostly conducted in Ontario (n = 52), British Columbia (n = 43), and Nova Scotia (n = 28). Twenty-four interventions, 5 nonevaluated programs, and 1 policy involved Indigenous populations. Overall, 86 articles measured and reported on effectiveness outcomes, including dietary intake; anthropometry; knowledge, attitudes, and practices; and physical activity. The literature remains largely heterogenous and primarily focused on nutrition education programs that use subjective assessments to infer changes in nutrition. A key facilitator to implementation and sustainability was community engagement, whereas key barriers were staff capacity, access to resources and funding, and consistent leadership. CONCLUSIONS: This review provides insight into Canadian school food and nutrition interventions, programs, and policies and uncovers important evidence gaps that require careful examination for future evaluations. Governments must create supportive environments that optimize nutrition for children and adolescents through equitable policies and programs. SYSTEMATIC REVIEW REGISTRATION: PROSPERO registration no. CRD42022303255.

School Nutrition Stakeholders Find Utility in MealSim: An Agent-Based Model.

OBJECTIVE: To obtain feedback from school nutrition stakeholders on an agent-based model simulating school lunch to inform model refinement and future applications. DESIGN: Qualitative study using online discussion groups. SETTING: School nutrition professional stakeholders across the US. PARTICIPANTS: Twenty-eight school nutrition stakeholders. PHENOMENON OF INTEREST: Perceptions and applicability of MealSim for school nutrition stakeholders to help reduce food waste. ANALYSIS: Deductive approach followed by inductive analysis of discussion group transcripts. RESULTS: Stakeholders appreciated the customizability of the cafeteria characteristics and suggested adding additional characteristics to best represent the school meal system, such as factors relating to school staff supervision of students during meals. The perceived utility of MealSim was high and included using it to train personnel and to advocate for policy and budgetary changes. However, they viewed MealSim as more representative of elementary than high schools. Stakeholders also provided suggestions for training school nutrition administrators on how to use MealSim and requested opportunities for technical assistance. CONCLUSIONS AND IMPLICATIONS: Although agent-based models were new to the school nutrition stakeholders, MealSim was viewed as a useful tool. Application of these findings will allow the model to meet the intended audience's needs and better estimate the system.

State Legislation Related to School Nutrition: Predictors of Bill Passage From 2010-2019.

OBJECTIVE: This study aimed to discover the prevalence of school nutrition state legislation and to identify the correlates of enactment. DESIGN, SETTING, AND PARTICIPANTS: An online legislative database, Legiscan, was used to collect bills related to school nutrition from the US from 2010 to 2019. Bills were coded and compiled into a study database with state-level dietary variables (obesity prevalence, fruit, and vegetable intake, sugar-sweetened beverage consumption), community variables (percent White, poverty), and bill-characteristic variables (party affiliation in legislature, strength of language, party of governor, school gardens, vegetable intake, and other salient variables). Multivariable models were built to examine predictors of bill enactment. RESULTS: Of the 462 bills introduced, 38.7% (n = 156) were enacted. In a multivariable model, the strength of bill language, political party affiliation, implementation of school gardens, and vegetable intake were the variables associated with bill passage. Bills with strong language were less likely to be enacted (P <0.001). Bills introduced by Democrats were more likely to be enacted (P = 0.01). CONCLUSION AND IMPLICATION: This study showed a better understanding of legislative support for child nutrition via policy surveillance of bills and their correlates of enactment. This information can be used to prioritize advocacy efforts and identify ways research can better inform policy.

Participation in the US Department of Agriculture's Summer Meal Programs: 2019-2021.

BACKGROUND: The US Department of Agriculture's (USDA) summer meal programs are designed to provide meals at no cost while school is out of session. In response to the COVID-19 pandemic, several regulatory waivers were enacted to facilitate meal distribution. The aim of this study was to assess the rates of meal distribution before and after these waivers were in effect. METHODS: Meal distribution patterns for 2019, 2020, and 2021 were examined through (1) a descriptive comparison of the number of participating districts, sponsors, meal sites, and meals distributed statewide, and (2) repeated measures ANOVAs to examine changes among districts in operation all years. RESULTS: The waivers were associated with an increase in the total number of participating districts, sponsors, and meal sites; an increase in the total number of meals distributed to children during the summer months; and an increase in meal distribution among sponsors that had been in place since 2019. CONCLUSION: Expanding the area eligibility criteria and enabling flexibility in meal distribution methods increased the number of meals provided. This study provides important preliminary evidence to suggest that the USDA should consider permanent regulatory changes to this program to maximize its reach.

Effects of policies or interventions that influence the school food environment on children's health and nonhealth outcomes: a systematic review.

CONTEXT: Globally, 1 in 3 children under 5 years is undernourished or overweight, and 1 in 2 suffers from hidden hunger due to nutrient deficiencies. As children spend a considerable time at school, school-based policies that aim to improve children's dietary intake may help address this double burden of malnutrition. OBJECTIVE: This systematic review aimed to assess the effects of implementing policies or interventions that influence the school food environment on children's health and nonhealth outcomes. DATA SOURCES, EXTRACTION, AND ANALYSIS: Eleven databases were searched up to April 2020 and the World Health Organization (WHO) released a call for data due in June 2020. Records were screened against the eligibility criteria, and data extraction and risk-of-bias assessment were conducted by 1 reviewer and checked by another. The synthesis was based on effect direction, and certainty of evidence was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. CONCLUSIONS: Seventy-four studies reporting 10 different comparisons were included. The body of evidence indicates that interventions addressing the school food environment may have modest beneficial effects on certain key outcomes. Nutrition standards for healthy foods and beverages at schools, interventions that change how food is presented and positioned, and fruit and vegetable provision may have a beneficial effect on the consumption of healthy foods and beverages. Regarding effects on the consumption of discretionary foods and beverages, nutrition standards may have beneficial effects. Nutrition standards for foods and beverages, changes to portion size served, and the implementation of multiple nudging strategies may have beneficial effects on energy intake. Regarding effects of purchasing or selecting healthier foods, changes to how food is presented and positioned may be beneficial. This review was commissioned and supported by the WHO (registration 2020/1001698-0). WHO reviewed and approved the protocol for the systematic review and reviewed the initial report of the completed systematic review. SYSTEMATIC REVIEW REGISTRATION: PROSPERO registration no: CRD42020186265.

Policy, Systems, and Environmental Changes in Child Nutrition Programs: A Systematic Literature Review.

The National School Lunch Program (NSLP) provides healthy food to millions of children annually. To promote increased lunch consumption, policy, systems, and environmental (PSE) change strategies are being implemented in child nutrition programs. An evaluation of the current evidence supporting PSE interventions in school nutrition programs is needed to facilitate evidence-based practices across the nation for programs. This systematic review aims to determine the quality and breadth of available evidence of the effectiveness of PSE strategies on the consumption and waste of fruits, vegetables, milk, and water in the NSLP. The inclusion criteria required studies to occur in a United States K-12 school setting, data collection after 2012, report consumption and waste findings for fruit, vegetable, milk, or water, and be an original research article. Articles included in the review are restricted to positive or neutral quality. Thirty studies are included, policy level (n = 4), systems level (n = 8), environmental level (n = 10), and multi-category (n = 8). Results from positively rated policy-level studies suggest that recess before lunch may increase milk consumption, whereas removing flavored milk may decrease consumption. System-level studies of offering vegetables first in isolation of other meal components and offering spiced vegetables compared with traditional preparations may increase vegetable consumption, and locally procuring produce may increase fruit and vegetable consumption. Environmental-level studies such as water promotion strategies such as placing cups near drinking fountains may increase water consumption. Improving the convenience, attractiveness, and palatability of fruits and vegetables may increase consumption. Future PSE research in child nutrition programs should incorporate implementation aides and metrics into their study designs to allow a better understanding of how to sustain interventions from the perspective of school nutrition professionals.

USDA's Summer Meals During the COVID-19 Pandemic: A Mixed-Methods Examination of Participants and Non-Participants in 2021.

BACKGROUND: The US Department of Agriculture's school meal programs have wide reach during the school year, but food insufficiency among households with children increases during summer months. The US Department of Agriculture summer meal programs are designed to fill this gap, yet participation has historically been low. OBJECTIVE: To examine the facilitators and barriers to participation in a 2021 summer meal program while the COVID-19 pandemic regulation waivers were in place. DESIGN: Cross-sectional mixed-methods survey research. PARTICIPANTS/SETTING: All parents/guardians of children enrolled in a school district in Connecticut were invited to participate in an online survey in December 2021. The respondents included summer meal participants (n = 622) and nonparticipants (n = 294). MAIN OUTCOME MEASURES: Survey respondents reported demographic variables, current food sufficiency, communication preferences, satisfaction with the program, reasons for using or not using the program, and whether they found the program helpful financially. The survey included three open-ended questions about barriers to participation. RESULTS: Respondents who used the summer meal program indicated that the pandemic-related regulatory waivers were key to their decision to participate. Reported barriers included lack of awareness of the program, inability to travel to sites during the times they were open, lack of transportation, concerns about dietary restrictions, and lack of variety in the menu, and concerns about wasting food. Parents/guardians expressed strong preferences for receiving communication about summer meals directly from their child's school and being able to access meals outside of typical work hours. CONCLUSIONS: The pandemic waivers allowed sponsors to test different models of distribution. Parents/guardians responded positively to the opportunity to access grab-and-go meals, multiple meals at once, and meals without a child present. These findings can be used to inform potential policy changes to reduce barriers and increase participation.

The Effects of Potato Presentation on Vegetable Intake in School-Aged Children: A Cross-Over Study.

Vegetables are an essential component of a healthy dietary pattern in children; however, their consumption is often insufficient due to lack of preference. To address this, the influence of combining vegetables (mixed peas and carrots-MPACs) with potatoes, a generally liked food, on overall vegetable consumption among children aged 7-13 years was explored. The research involved a cross-over study design with 65 participants who completed five lunchtime meal conditions, each with different combinations of MPACs and potatoes versus a control (MPACs with a wheat roll). The meals were provided in a cafeteria setting, and plate waste was used to measure vegetable consumption. Anthropometric data and other variables were also measured. Notably, self-reported hunger did not significantly differ between conditions. Meal condition was a significant predictor of MPACs (F = 5.20; p = 0.0005), with MPAC consumption highest when combined with shaped potato faces in the same bowl (+8.77 g compared to serving MPACs and shaped potato faces in separate bowls) and lowest when combined with diced potatoes in the same bowl (-2.85 g compared to serving MPACs and diced potatoes in separate bowls). The overall model for MPAC consumption was influenced by age, height z-score, body fat percentage z-score, and condition (likelihood ratio = 49.1; p < 0.0001). Age had the strongest correlation with vegetable consumption (r = 0.38), followed by male gender, height z-score (r = 0.30), and body fat z-score (r = -0.15). The results highlight the positive impact of combining potatoes with vegetables in school meals, particularly when using shaped potato faces. These findings emphasize the potential of potatoes as a valuable vegetable option in promoting healthier eating habits among children. Additionally, future research could explore the impact of different potato combinations and investigate other factors influencing meal consumption in school settings.

Predictors of Participation in the U.S. Department of Agriculture Summer Meal Programs: An Examination of Outreach Strategies and Meal Distribution Methods During COVID-19.

Introduction: Significantly fewer children participate in the U.S. Department of Agriculture-sponsored summer meal programs than in the federal school meal programs during the academic year. During the summer of 2021, several pandemic-related waivers supported more flexible operations for summer meal programs, such as allowing grab-and-go meals and the distribution of meals for multiple days at once. This study assessed how summer meal site characteristics and geographically targeted outreach methods were associated with summer meals served in 2021 in Connecticut. Methods: Weekly meal count data were requested from all sponsors of the Summer Food Service Program and the National School Lunch Program Seamless Summer Option. Data were received from 78 sponsors with 763 sites. Geographically targeted outreach (e.g., billboards, bus ads, and flyers) was tracked by location each week. Mixed methods ANOVA was used to examine the predictive value of outreach efforts, program characteristics, and meal distribution methods on meals served each week. The program characteristics examined included the hours open per week, the number of weeks serving meals, the maximum number of meals distributed at one time, and the number of open and closed sites in a school district. Results: Between June 21 and August 20, 2021, a total of 1,188,669 breakfasts and 1,389,347 lunches were served. Sites that were open more hours per week (mean=7.60 hours per week; range=0.17-35) and gave multiple meals to parents at each visit (mean=4.68 meals; range=1-15) reported greater rates of meal distribution. The outreach efforts assessed were not significantly associated with changes in meal distribution at nearby sites. Conclusions: The U.S. Department of Agriculture's waivers in response to COVID-19 permitted extended operating hours and multiple-meal distribution. These operational flexibilities should be considered for permanent regulation changes owing to their positive association with summer meal participation.

School Nutrition Environment and Services: Policies and Practices That Promote Healthy Eating Among K-12 Students.

BACKGROUND: Changes to policies at the federal, state, and local levels over the last decade have influenced the school nutrition environment and services. METHODS: This systematic review includes an analysis of individual research articles and government reports published from 2010 to 2021 that examine interventions to improve the school nutrition environment and services and increase the availability, selection, and consumption of healthier foods and beverages in K-12 schools in the United States. RESULTS: Nutrition standards for school meals and food outside of meals improved access to healthier options in school. Providing school nutrition professionals with professional development, improving the palatability of school meals, offering taste tests, pre-slicing fruit, providing recess before lunch, offering incentives for trying healthier options, and providing access to drinking water resulted in increased selection and consumption of healthier items. There were inconclusive or mixed findings for some intervention strategies including adequate seat time for meals. CONCLUSIONS: Despite demonstrated improvements to school meal programs and competitive foods, more work is needed to change the selection and consumption of healthier options among K-12 students. Schools can use multiple interventions to improve the school nutrition environment and services and help students adopt food and beverage choices that support health.

The School Environment and Physical and Social-Emotional Well-Being: Implications for Students and School Employees.

BACKGROUND: The school environment, consisting of the physical environment and social-emotional climate (SEC), plays a crucial role in both student and employee health; however, there is a lack of recent literature synthesizing school environment interventions in K-12 settings. We describe updated evidence about school environment interventions to support K-12 student and employee health in the United States. METHODS: A 2-phase search included a review of reviews (2010-2018), followed by a search for individual articles (2010-2020) that targeted school physical environment and/or SEC to address physical activity (PA) and/or nutrition. We also investigated how nutrition and PA interventions with an SEC component improves social-emotional and/or mental health outcomes. Because research on dietary and PA behaviors for school employees is limited; we included studies on other worksites (eg, hospitals and offices) to provide insight for school employees. FINDINGS: We identified 40 articles describing 40 unique studies and 45 interventions and grouped them by intervention type. Physical environment interventions demonstrated significant and positive nutrition and PA behavioral outcomes for students; outcomes among employees were mixed. Interventions with SEC components reported improvements in some mental health outcomes. IMPLICATIONS: The school environment can affect dietary and PA behaviors as well as mental health for students and employees. CONCLUSIONS: Establishing healthy school environments can support student and employee PA, dietary behaviors, and mental health.

The impact of a complex school nutrition intervention on double burden of malnutrition among Thai primary school children: a 2-year quasi-experiment.

OBJECTIVE: This study assessed the impacts of the Dekthai Kamsai programme on overweight/obesity, underweight and stunting among male and female primary school students. STUDY DESIGN: A quasi-experiment was conducted in 16 intervention and 19 control schools across Thailand in 2018 and 2019. In total, 896 treated and 1779 control students from grades 1 to 3 were recruited. In intervention schools, a set of multifaceted intervention components were added into school routine practices. Anthropometric outcomes were measured at baseline and at the beginning and end of every school term. METHODS: Propensity score matching with linear and Poisson difference-in-difference analyses were used to adjust for the non-randomisation and to analyse the intervention's effects over time. RESULTS: Compared with controls, the increases in mean BMI-for-age Z-score (BAZ) and the incidence rate of overweight/obesity were lower in the intervention schools at the 3rd, 4th and 8th measurements and the 3rd measurement, respectively. The decrease in mean height-for-age Z-score (HAZ) was lower at the 4th measurement. The decrease in the incidence rate of wasting was lower at the 5th, 7th and 8th measurements. The favourable impacts on BAZ and HAZ were found in both sexes, while the favourable impact on overweight/obesity and unfavourable impact on wasting were found in girls. CONCLUSIONS: This intervention might be effective in reducing BAZ, overweight/obesity, poor height gain, but not wasting. These findings highlight the benefits of a multifaceted school nutrition intervention and a need to incorporate tailor-made interventions for wasting to comprehensively address the double burden of malnutrition.

Perceptions of Existing School Fruit and Vegetable Marketing Materials Targeted to School Students by School Nutrition Professionals and Youth.

Little published research explores the perceptions of school nutrition professionals and youth regarding existing school nutrition marketing materials. A two-phased approach was taken to address this gap. In Phase 1, a national convenience sample of US school nutrition professionals (n = 1546; 89% female; 83.3% white; mean age 50 ± 10.2 years) evaluated a sample of marketing materials via a web-based survey. Phase 2 involved a sample of youth (n = 61; 51% female, 52.5% Hispanic; 98% participation in free/reduced price lunch) living in the Phoenix, Arizona metro area who completed interviews on the top-rated materials from the school nutrition professionals (Phase 1). Main outcome measures included perceived attractiveness/appeal, comprehension, relevance, motivation/persuasion, and uniqueness of marketing materials. In Phase 1, means/standard deviations of school nutrition professionals' perceptions across materials are provided. For Phase 2, a thematic/subtheme analysis of the youth interviews is provided. School nutrition professionals found the materials easy to understand (82%); however, they rated the materials low in motivational appeal (48%) and low in their ability to influence the selection or consumption of fruits/vegetables (95%). Youth participants discussed their likes, dislikes, comprehension, social aspects, and health aspects of the materials. Results indicate that existing marketing materials were not highly rated by professionals or youth. Greater investment and research are needed to test and develop nutrition marketing materials for schools, with a focus on enhancing their appeal and impact on fruit/vegetable consumption.

Design, Methods, and Select Baseline Results from a School Nutrition Project for Adolescents in Bangladesh.

Background: The School Nutrition for Adolescents Project (SNAP) provided weekly iron and folic acid (WIFA) supplementation and menstrual hygiene management (MHM) support for girls; actions to improve water, sanitation, and hygiene (WASH) practices; and behavior change interventions to adolescents aged 10-19 y in 65 intervention schools in 2 districts of Bangladesh. Objectives: We aimed to describe the project design and select baseline results of students and school project implementers. Methods: Girls (n = 2244) and boys (n = 773) in 74 schools (clusters) and project implementers [headteachers (n = 74), teachers (n = 96), and student leaders (n = 91)] participated in a survey assessing nutrition, MHM, and WASH knowledge and experience. Hemoglobin, inflammation-adjusted ferritin, retinol-binding protein, and serum and RBC folate (RBCF) levels in girls were measured. School WASH infrastructure was observed and drinking water was tested for E. coli. Results: IFA and deworming tablet intake in the last 1 and 6 mo were 4% and 81% for girls and 1% and 86%, respectively. Applying the Minimum Dietary Diversity for Women (MDD-W) tool, most (63%-68%) girls and boys achieved minimum dietary diversity. Fewer adolescents (14%-52%) had ever heard of anemia, IFA tablets, or worm infestation than project implementers (47%-100%). Girls (35%) missed school during menstruation; 39% reported of ever leaving school due to unexpected menstruation. The micronutrient status and deficiency severity varied: anemia (25%), RBCF insufficiency (76%), risk of serum folate deficiency (10%), deficiencies of iron (9%), and vitamin A (3%). WASH in school sustainable development goal (SDG) indicators achievement varied: basic drinking water service (70%), basic sanitation service (42%), and basic hygiene service (3%); 59% of sampled drinking water access points complied with WHO E. coli standards. Conclusions: There is room for improvement of nutrition and health awareness, practices, micronutrient status, SDG basic WASH in-school services, and E coli contamination in school drinking water.This trial was registered in clinicaltrials.gov as NCT05455073.

Participatory prioritisation of interventions to improve primary school food environments in Gauteng, South Africa.

BACKGROUND: In South Africa, overweight and obesity affect 17% of children aged 15-18. School food environments play a vital role in children's health, influencing dietary behaviours and resulting in high obesity rates. Interventions targeting schools can contribute to obesity prevention if evidence-based and context-specific. Evidence suggests that current government strategies are inadequate to ensure healthy school food environments. The aim of this study was to identify priority interventions to improve school food environments in urban South Africa using the Behaviour Change Wheel model. METHODS: A three-phased iterative study design was implemented. First, we identified contextual drivers of unhealthy school food environments through a secondary framework analysis of 26 interviews with primary school staff. Transcripts were deductively coded in MAXQDA software using the Behaviour Change Wheel and the Theoretical Domains Framework. Second, to identify evidence-based interventions, we utilised the NOURISHING framework and matched interventions to identified drivers. Third, interventions were prioritised using a Delphi survey administered to stakeholders (n = 38). Consensus for priority interventions was defined as an intervention identified as being 'somewhat' or 'very' important and feasible with a high level of agreement (quartile deviation ≤ 0.5). RESULTS: We identified 31 unique contextual drivers that school staff perceived to limit or facilitate a healthy school food environment. Intervention mapping yielded 21 interventions to improve school food environments; seven were considered important and feasible. Of these, the top priority interventions were to: 1) "regulate what kinds of foods can be sold at schools", 2) "train school staff through workshops and discussions to improve school food environment", and affix 3) "compulsory, child-friendly warning labels on unhealthy foods". CONCLUSION: Prioritising evidence-based, feasible and important interventions underpinned by behaviour change theories is an important step towards enhanced policy making and resource allocation to tackle South Africa's childhood obesity epidemic effectively.