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PLoS One. 2018 Mar 29;13(3):e0194555. doi: 10.1371/journal.pone.0194555. eCollection 2018.

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

Author information

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.

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.

PMID:
29596440
PMCID:
PMC5875768
DOI:
10.1371/journal.pone.0194555
[Indexed for MEDLINE]
Free PMC Article

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