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

PLOS ONE, Nov 2019

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

March Effectiveness of school food environment policies on children's dietary behaviors: A systematic review and meta-analysis Renata Micha 2 3 Dimitra Karageorgou 1 2 Ioanna Bakogianni 1 2 Eirini Trichia 1 2 Laurie P. Whitsel 0 2 Mary Story 2 Jose L. Peñalvo 2 3 Dariush Mozaffarian 2 3 0 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 1 Department of Food Science and Human Nutrition, Agricultural University of Athens , Athens , Greece 2 Editor: Manuel Portero-Otin, Universitat de Lleida- IRBLLEIDA , SPAIN 3 Friedman School of Nutrition Science and Policy, Tufts University , Boston, MA , United States of America - OPEN ACCESS Data Availability Statement: All relevant data are within the paper and its Supporting Information files. Funding: 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 Background Objective Methods 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; manuscript; or decision to submit the manuscript for publication. 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 investigatorinitiated 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. -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 sugarsweetened 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. Introduction Diets of most children and adolescents (hereafter referred to as children) remain poor, with tremendous consequences for metabolic diseases, overweight and obesity, and other nutritionrelated illness [1±4]. Childhood is also a critical period to establish lifelong eating habits which influence future risk of obesity and cardiometabolic diseases [5±7]. Youth consume between one-third to one-half of meals at school, making this a crucial setting for interventions that alter the food environment [ 8 ]. Considering that almost all children obtain some years of schooling, and of diverse ethnic and socio-economic groups, health promotion efforts in schools could have a broader impact on eating behaviors and future disease risk. Promising school food environment policies include direct provision of healthful foods/ beverages such as fruits and vegetables (F&V), quality standards for competitive foods and beverages (foods and beverages sold out (...truncated)


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Renata Micha, Dimitra Karageorgou, Ioanna Bakogianni, Eirini Trichia, Laurie P. Whitsel, Mary Story, Jose L. Peñalvo, Dariush Mozaffarian. Effectiveness of school food environment policies on children’s dietary behaviors: A systematic review and meta-analysis, PLOS ONE, 2018, Volume 13, Issue 3, DOI: 10.1371/journal.pone.0194555