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      Effectiveness of school food environment policies on children’s dietary behaviors: A systematic review and meta-analysis

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          Abstract

          Background

          School food environment policies may be a critical tool to promote healthy diets in children, yet their effectiveness remains unclear.

          Objective

          To systematically review and quantify the impact of school food environment policies on dietary habits, adiposity, and metabolic risk in children.

          Methods

          We systematically searched online databases for randomized or quasi-experimental interventions assessing effects of school food environment policies on children’s dietary habits, adiposity, or metabolic risk factors. Data were extracted independently and in duplicate, and pooled using inverse-variance random-effects meta-analysis. Habitual (within+outside school) dietary intakes were the primary outcome. Heterogeneity was explored using meta-regression and subgroup analysis. Funnel plots, Begg’s and Egger’s test evaluated potential publication bias.

          Results

          From 6,636 abstracts, 91 interventions (55 in US/Canada, 36 in Europe/New Zealand) were included, on direct provision of healthful foods/beverages (N = 39 studies), competitive food/beverage standards (N = 29), and school meal standards (N = 39) (some interventions assessed multiple policies). Direct provision policies, which largely targeted fruits and vegetables, increased consumption of fruits by 0.27 servings/d (n = 15 estimates (95%CI: 0.17, 0.36)) and combined fruits and vegetables by 0.28 servings/d (n = 16 (0.17, 0.40)); with a slight impact on vegetables (n = 11; 0.04 (0.01, 0.08)), and no effects on total calories (n = 6; -56 kcal/d (-174, 62)). In interventions targeting water, habitual intake was unchanged (n = 3; 0.33 glasses/d (-0.27, 0.93)). Competitive food/beverage standards reduced sugar-sweetened beverage intake by 0.18 servings/d (n = 3 (-0.31, -0.05)); and unhealthy snacks by 0.17 servings/d (n = 2 (-0.22, -0.13)), without effects on total calories (n = 5; -79 kcal/d (-179, 21)). School meal standards (mainly lunch) increased fruit intake (n = 2; 0.76 servings/d (0.37, 1.16)) and reduced total fat (-1.49%energy; n = 6 (-2.42, -0.57)), saturated fat (n = 4; -0.93%energy (-1.15, -0.70)) and sodium (n = 4; -170 mg/d (-242, -98)); but not total calories (n = 8; -38 kcal/d (-137, 62)). In 17 studies evaluating adiposity, significant decreases were generally not identified; few studies assessed metabolic factors (blood lipids/glucose/pressure), with mixed findings. Significant sources of heterogeneity or publication bias were not identified.

          Conclusions

          Specific school food environment policies can improve targeted dietary behaviors; effects on adiposity and metabolic risk require further investigation. These findings inform ongoing policy discussions and debates on best practices to improve childhood dietary habits and health.

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          Most cited references93

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          Interventions for preventing obesity in children.

          Prevention of childhood obesity is an international public health priority given the significant impact of obesity on acute and chronic diseases, general health, development and well-being. The international evidence base for strategies that governments, communities and families can implement to prevent obesity, and promote health, has been accumulating but remains unclear. This review primarily aims to update the previous Cochrane review of childhood obesity prevention research and determine the effectiveness of evaluated interventions intended to prevent obesity in children, assessed by change in Body Mass Index (BMI). Secondary aims were to examine the characteristics of the programs and strategies to answer the questions "What works for whom, why and for what cost?" The searches were re-run in CENTRAL, MEDLINE, EMBASE, PsychINFO and CINAHL in March 2010 and searched relevant websites. Non-English language papers were included and experts were contacted. The review includes data from childhood obesity prevention studies that used a controlled study design (with or without randomisation). Studies were included if they evaluated interventions, policies or programs in place for twelve weeks or more. If studies were randomised at a cluster level, 6 clusters were required. Two review authors independently extracted data and assessed the risk of bias of included studies.  Data was extracted on intervention implementation, cost, equity and outcomes. Outcome measures were grouped according to whether they measured adiposity, physical activity (PA)-related behaviours or diet-related behaviours.  Adverse outcomes were recorded. A meta-analysis was conducted using available BMI or standardised BMI (zBMI) score data with subgroup analysis by age group (0-5, 6-12, 13-18 years, corresponding to stages of developmental and childhood settings). This review includes 55 studies (an additional 36 studies found for this update). The majority of studies targeted children aged 6-12 years.  The meta-analysis included 37 studies of 27,946 children and demonstrated that programmes were effective at reducing adiposity, although not all individual interventions were effective, and there was a high level of observed heterogeneity (I(2)=82%).  Overall, children in the intervention group had a standardised mean difference in adiposity (measured as BMI or zBMI) of -0.15kg/m(2) (95% confidence interval (CI): -0.21 to -0.09).  Intervention effects by age subgroups were -0.26kg/m(2) (95% CI:-0.53 to 0.00) (0-5 years), -0.15kg/m(2) (95% CI -0.23 to -0.08) (6-12 years), and -0.09kg/m(2) (95% CI -0.20 to 0.03) (13-18 years). Heterogeneity was apparent in all three age groups and could not explained by randomisation status or the type, duration or setting of the intervention.  Only eight studies reported on adverse effects and no evidence of adverse outcomes such as unhealthy dieting practices, increased prevalence of underweight or body image sensitivities was found.  Interventions did not appear to increase health inequalities although this was examined in fewer studies. We found strong evidence to support beneficial effects of child obesity prevention programmes on BMI, particularly for programmes targeted to children aged six to 12 years. However, given the unexplained heterogeneity and the likelihood of small study bias, these findings must be interpreted cautiously. A broad range of programme components were used in these studies and whilst it is not possible to distinguish which of these components contributed most to the beneficial effects observed, our synthesis indicates the following to be promising policies and strategies:·         school curriculum that includes healthy eating, physical activity and body image·         increased sessions for physical activity and the development of fundamental movement skills throughout the school week·         improvements in nutritional quality of the food supply in schools·         environments and cultural practices that support children eating healthier foods and being active throughout each day·         support for teachers and other staff to implement health promotion strategies and activities (e.g. professional development, capacity building activities)·         parent support and home activities that encourage children to be more active, eat more nutritious foods and spend less time in screen based activitiesHowever, study and evaluation designs need to be strengthened, and reporting extended to capture process and implementation factors, outcomes in relation to measures of equity, longer term outcomes, potential harms and costs.Childhood obesity prevention research must now move towards identifying how effective intervention components can be embedded within health, education and care systems and achieve long term sustainable impacts.  
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            Consistent dietary patterns identified from childhood to adulthood: the cardiovascular risk in Young Finns Study.

            Dietary patterns are useful in nutritional epidemiology, providing a comprehensive alternative to the traditional approach based on single nutrients. The Cardiovascular Risk in Young Finns Study is a prospective cohort study with a 21-year follow-up. At baseline, detailed quantitative information on subjects' food consumption was obtained using a 48 h dietary recall method (n 1768, aged 3-18 years). The interviews were repeated after 6 and 21 years (n 1200 and n 1037, respectively). We conducted a principal component analysis to identify major dietary patterns at each study point. A set of two similar patterns was recognised throughout the study. Pattern 1 was positively correlated with consumption of traditional Finnish foods, such as rye, potatoes, milk, butter, sausages and coffee, and negatively correlated with fruit, berries and dairy products other than milk. Pattern 1 type of diet was more common among male subjects, smokers and those living in rural areas. Pattern 2, predominant among female subjects, non-smokers and in urban areas, was characterised by more health-conscious food choices such as vegetables, legumes and nuts, tea, rye, cheese and other dairy products, and also by consumption of alcoholic beverages. Tracking of the pattern scores was observed, particularly among subjects who were adolescents at baseline. Of those originally belonging to the uppermost quintile of pattern 1 and 2 scores, 41 and 38 % respectively, persisted in the same quintile 21 years later. Our results suggest that food behaviour and concrete food choices are established already in childhood or adolescence and may significantly track into adulthood.
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              Development of food acceptance patterns in the first years of life.

              As young omnivores, children make the transition from the exclusive milk diet of infancy to consuming a variety of foods. They must learn to accept a set of the foods available in their environmental niche, and they 'come equipped' with a set of predispositions that facilitate the development of food acceptance patterns, constrained by predisposition and limited by what is offered to them. While children are predisposed to like sweet or salty foods and to avoid sour or bitter foods, their preferences for the majority of foods are shaped by repeated experience. The predispositions that shape food acceptance patterns also include neophobia and the predisposition to learn to prefer and accept new foods when they are offered repeatedly. In addition, the predisposition for associative conditioning affects children's developing food acceptance patterns, resulting in preferences for foods offered in positive contexts, while foods presented in negative contexts will become more disliked via the learning of associations with the social and environmental contexts. Children also learn to prefer energy-dense foods when consumption of those foods is followed by positive post-ingestive consequences, such as those produced when high-energy-density foods are eaten when hungry. Although children are predisposed to be responsive to the energy content of foods in controlling their intake, they are also responsive to parents' control attempts. We have seen that these parental control attempts can refocus the child away from responsiveness to internal cues of hunger and satiety and towards external factors such as the presence of palatable foods. This analysis suggests that taking a closer look at what children are learning about food and eating may provide clues regarding the formation of children's food acceptance patterns, and that this approach also suggests potential causative factors implicated in the aetiology of obesity and the emergence of weight concerns. Current data, although limited, suggest that child-feeding practices play a causal role in the development of individual difference in the controls of food intake, and perhaps in the aetiology of problems of energy balance, especially childhood obesity. These relationships should be pursued in future research.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Project administrationRole: ResourcesRole: SupervisionRole: ValidationRole: VisualizationRole: Writing – original draftRole: Writing – review & editing
                Role: Data curationRole: Formal analysisRole: MethodologyRole: ResourcesRole: ValidationRole: VisualizationRole: Writing – original draftRole: Writing – review & editing
                Role: Data curationRole: Formal analysisRole: ResourcesRole: VisualizationRole: Writing – review & editing
                Role: Data curationRole: Formal analysisRole: ResourcesRole: Writing – review & editing
                Role: MethodologyRole: ValidationRole: Writing – review & editing
                Role: MethodologyRole: ValidationRole: Writing – review & editing
                Role: MethodologyRole: ValidationRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: SupervisionRole: ValidationRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                29 March 2018
                2018
                : 13
                : 3
                : e0194555
                Affiliations
                [1 ] Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, United States of America
                [2 ] Department of Food Science and Human Nutrition, Agricultural University of Athens, Athens, Greece
                [3 ] Policy Research, American Heart Association, Dallas, TX, United States of America
                [4 ] Global Health Institute and Community and Family Medicine, Duke University, Durham, NC, United States of America
                Universitat de Lleida-IRBLLEIDA, SPAIN
                Author notes

                Competing Interests: Dr. Micha, Dr. Peñalvo and Dr. Mozaffarian report grants from NIH/NHLBI during the conduct of the study. Dr. Micha is PI of a research grant from Unilever on an investigator-initiated project to assess the effects of omega-6 fatty acid biomarkers on diabetes and heart disease, and reports personal fees from the World Bank; all outside the submitted work. Dr. Mozaffarian reports personal fees from the World Bank, Bunge, Life Sciences Research Organization, Astra Zeneca, Boston Heart Diagnostics, GOED, DSM, Haas Avocado Board, Pollock Communications, and UpToDate; and scientific advisory board, Omada Health and Elysium Health; all outside the submitted work. All other authors declare no competing interests. We affirm that this does not alter our adherence to PLOS ONE policies on sharing data and materials.

                Author information
                http://orcid.org/0000-0002-3983-1632
                Article
                PONE-D-17-29813
                10.1371/journal.pone.0194555
                5875768
                29596440
                92ea65eb-0964-49c9-80a9-7387da576927
                © 2018 Micha et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 16 August 2017
                : 6 March 2018
                Page count
                Figures: 4, Tables: 2, Pages: 27
                Funding
                Funded by: funder-id http://dx.doi.org/10.13039/100000050, National Heart, Lung, and Blood Institute;
                Award ID: R01 HL130735
                Award Recipient :
                Funded by: funder-id http://dx.doi.org/10.13039/100000050, National Heart, Lung, and Blood Institute;
                Award ID: R01 HL115189
                Award Recipient :
                This research was supported by the NIH, NHLBI (R01 HL115189, PI Mozaffarian; R01 HL130735, PI Micha). The funding agency did not contribute to design or conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.
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