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      Effectiveness of a multicomponent intervention to enhance implementation of a healthy canteen policy in Australian primary schools: a randomised controlled trial


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          The implementation of school nutrition policies, which govern the provision of food in schools, is recommended as a public health strategy to support the development of healthy dietary behaviours in school-aged children. Despite this, research internationally and in Australia indicates that few schools implement such policies. This study aims to examine whether a theoretically designed, multi-strategy intervention was effective in increasing the implementation of a healthy canteen policy in Australian primary schools.


          A parallel group randomised controlled trial was conducted with all government and Catholic primary schools within one region in New South Wales, Australia who had an operational canteen that provided food to primary school aged children (5–12 years) and were not currently receiving an intervention to change their canteen practices. Schools randomised to the intervention arm received a 9-month multicomponent intervention including ongoing support, provision of resources, performance monitoring and feedback, executive support and recognition. The primary outcomes were the proportion of the schools with a canteen menu that: i) did not include ‘red’ or ‘banned’ items according to the healthy canteen policy; and ii) had more than 50 % ‘green’ items. The primary outcome was assessed via menu audit at baseline and follow up by dietitians blinded to group allocation.


          Fifty-three eligible schools were randomised to either the intervention or control group (28 intervention; 25 control). Analyses with 51 schools who returned school menus found that intervention schools were significantly more likely relative to control schools to have a menu without ‘red’ or ‘banned’ items ( RR = 5.78 (1.45–23.05); p = 0.002) and have at least 50 % of menu items classified as green ( RR = 2.03 (1.01–4.08); p = 0.03).


          This study found that a multi-component intervention was effective in improving primary schools’ compliance with a healthy canteen policy. Given the lack of evidence regarding how best to support schools with implementing evidence-based policies to improve child diet, this trial for the first time provides high quality evidence to practitioners and policy makers seeking to improve nutrition policy implementation in schools.

          Trial registration

          This trial was prospectively registered with the Australian New Zealand Clinical Trials Registry ( ACTRN12614001148662) 30th October 2014.

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          Most cited references27

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          Dissemination and implementation research on community-based cancer prevention: a systematic review.

          An extensive array of effective interventions for the prevention of cancer exists, suggesting that evidence is ready for widespread use. However, few of these approaches have been extensively utilized in real-world settings. Further, little is known on how to best disseminate and implement evidence-based interventions for the primary prevention of cancer in community settings. A systematic review of the dissemination and implementation literature was conducted between 2006 and 2008 in the topic areas of smoking, healthy diet, physical activity, and sun protection. English-language peer-reviewed articles published between 1980 and 2008 that met the inclusion criteria were classified by suitability of study design (i.e., greatest, moderate, least); quality of execution (i.e., good, fair, limited); and effectiveness (i.e., substantial, some, or little/no evidence of effectiveness) and were abstracted for dissemination- and implementation-related content. Twenty-five unique dissemination and implementation studies were identified. The majority of included studies were conducted in the U.S., in schools, and with children as the ultimate target population, had the least suitability of study design, had fair or limited execution, and used a theoretic framework, active dissemination and implementation approaches, and multimodal strategies. There was considerable heterogeneity across studies in reported mediators, moderators, and outcomes. Key implications from this review include the need for uniform language, studies targeting various populations and settings, valid and reliable measures, triangulation of and more practice-based evidence, standardized reporting criteria, and active and multimodal strategies. 2010 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.
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            Fruit, vegetables, and antioxidants in childhood and risk of adult cancer: the Boyd Orr cohort.

            To examine associations between food and nutrient intake, measured in childhood, and adult cancer in a cohort with over 60 years follow up. The study is based on the Boyd Orr cohort. Intake of fruit and vegetables, energy, vitamins C and E, carotene, and retinol was assessed from seven day household food inventories carried out during a study of family diet and health in 16 rural and urban areas of England and Scotland in 1937-39. 4999 men and women, from largely working class backgrounds, who had been children in the households participating in the pre-war survey. Analyses are based on 3878 traced subjects with full data on diet and social circumstances. Over the follow up period there were 483 incident malignant neoplasms. Increased childhood fruit intake was associated with reduced risk of incident cancer. In fully adjusted logistic regression models, odds ratios (95% confidence intervals) with increasing quartiles of fruit consumption were 1.0 (reference), 0.66 (0.48 to 0.90), 0.70 (0.51 to 0.97), 0.62 (0.43 to 0.90); p value for linear trend=0.02. The association was weaker for cancer mortality. There was no clear pattern of association between the other dietary factors and total cancer risk. Childhood fruit consumption may have a long term protective effect on cancer risk in adults. Further prospective studies, with individual measures of diet are required to further elucidate these relations.
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              What are the key food groups to target for preventing obesity and improving nutrition in schools?

              To determine differences in the contribution of foods and beverages to energy consumed in and out of school, and to compare consumption patterns between school canteen users and noncanteen users. Cross-sectional National Nutrition Survey, 1995. Australia. SUBJECTS ON SCHOOL DAYS: A total of 1656 children aged 5-15 y who had weekday 24-h dietary recall data. An average of 37% of total energy intake was consumed at school. Energy-dense foods and beverages such as fat spreads, packaged snacks, biscuits and fruit/cordial drinks made a greater contribution to energy intake at school compared to out of school (P< or =0.01). Fast foods and soft drinks contributed 11 and 3% of total energy intake; however, these food groups were mostly consumed out of school. Fruit intake was low and consumption was greater in school. In all, 14% of children purchased food from the canteen and they obtained more energy from fast food, packaged snacks, desserts, milk and confectionary (P< or =0.05) than noncanteen users. : Energy-dense foods and beverages are over-represented in the Australian school environment. To help prevent obesity and improve nutrition in schools, biscuits, snack bars and fruit/cordial drinks brought from home and fast food, packaged snacks, and confectionary sold at canteens should be replaced with fruit and water.

                Author and article information

                Int J Behav Nutr Phys Act
                Int J Behav Nutr Phys Act
                The International Journal of Behavioral Nutrition and Physical Activity
                BioMed Central (London )
                7 October 2016
                7 October 2016
                : 13
                [1 ]Hunter New England Population Health, Hunter New England Local Health District, Newcastle, New South Wales 2287 Australia
                [2 ]School of Medicine and Public Health, The University of Newcastle, Newcastle, New South Wales 2308 Australia
                [3 ]Hunter Medical Research Institute, Newcastle, New South Wales 2300 Australia
                © The Author(s). 2016

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                Custom metadata
                © The Author(s) 2016

                Nutrition & Dietetics
                Nutrition & Dietetics
                implementation, schools, nutrition, policy, canteen


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