fostering health nutrition and well being essay

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A major segment of our community comprises the under-served sections of society .
Due to poor economical conditions, children are deprived of proper diet and suffer from severe malnutrition from a tender age, impairing their overall growth .
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Fostering Nutrition, Health and Wellness for All Children

I recently read an alarming statistic in a pediatric news article: over 90 percent of parents surveyed purchase at least one meal per week for their children in a fast food establishment. Admittedly, fast food is a low cost, convenient and readily available option, especially in our cities where grocery stores may be less accessible. However, fast food tends to be higher in fat, sugar and salt than is recommended for children’s consumption, thereby making it an unhealthy option that can lead to negative health consequences such as obesity and diabetes. An article published recently in American Journal of Public Health reported that less than 20 percent of kids’ meal packages automatically include healthy sides and beverages, with most offering French fries coupled with soda or juice as a beverage.

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To improve the quality of kids’ meals in fast food and other restaurants and to negate some of the deleterious health impacts, lawmakers should pass laws that require healthier drinks and sides as the default option. That way, menu items such as french fries and soda would automatically be replaced with healthier sides such as apple slices and unflavored milk or water. California passed such a law last year, and in the current Connecticut legislative session, the Committee on Children is considering Raised Bill No. 7006, An Act Prohibiting the Inclusion of Certain Beverages on Children’s Menus . This bill would allow parents to choose from a list of healthier beverages for their children when they are eating out.

A recent report from the UConn RUDD Center for Nutrition Policy and Obesity found an increase in fast food advertising to children, with a total of almost $4 billion spent on fast food advertising to all consumers. The report also found increased disparities in advertising nutritionally poor, unhealthy foods, including fast food, candy, sugary drinks and snacks, to Black and Hispanic children and teens. The most recent Centers for Disease Control and Prevention obesity data shows that Hispanic (26%) and non-Hispanic Black (22%) children aged 2-19 years have higher obesity rates than non-Hispanic white (14%) children, and targeted advertising of unhealthy foods to these vulnerable populations likely contributes to these disparities.

Optimal nutrition is a critical factor in children’s overall health and wellness, especially for this at risk population. The Kohl’s Start Childhood Off Right (SCOR) program, within Connecticut Children’s Office for Community Health, uses both community outreach worker training and community wellness events to educate parents of infants and toddlers about healthy nutrition from birth. Such education includes the promotion of breastfeeding, responsive feeding, and the introduction of healthy complementary foods as young children develop their taste and food preferences. In addition to healthy nutrition, SCOR also promotes healthy beverages, especially water, physical activity, sleep and minimal screen time, all of which are essential to children’s overall health and wellness. The Hartford Childhood Wellness Alliance, a network of stakeholders with an interest in healthy nutrition and obesity prevention that was re-activated by SCOR, works to create cross-sector solutions that support community wellness, including policy promotion, healthy food access, reducing sugar sweetened beverage consumption, community gardens, and opportunities for physical activity.

Childhood obesity continues to be a complex problem in need of a comprehensive system’s approach. Such an approach must go beyond a primary care provider’s office to include legislative and community efforts that advocate for and create an environment that fosters health and wellness. Passing legislation to make fast food meals healthier for the children eating them is a small step in a healthier direction.

Nancy Trout, MD, MPH is co-director of Kohl’s Start Childhood Off Right, which is an initiative of Connecticut Children’s Office for Community Child Health.

To sign up to receive E-Updates from Connecticut Children’s Office for Community Child Health, click here .

Foster Parents’ Nutritional Strategies and Children’s Well-Being

Published: 11 August 2016
Volume 34 , pages 159–169, ( 2017 )

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fostering health nutrition and well being essay

Jesse J. Helton 1 ,
Jill C. Schreiber 2 &
Barbara H. Fiese 3

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Among their many responsibilities, foster parents are tasked with providing healthy food and proper nutrition to children with a variety of physical, psychological, and emotional needs. Using the lens of symbolic interactionism, this exploratory mixed methods study examined how foster parents attend to the nutritional needs of abused and neglected children. Methods used included both quantitative surveys and qualitative follow-up interviews. Surveys were completed by 23 foster parents in a large, Midwest metropolitan area. Parents reported they provided their children balanced meals, although one-third of households reported instances of food insecurity. During qualitative interviews, foster parents ( N = 9) described how children arrived at their home with a variety of unhealthy eating habits, some severe in nature. Parents discussed strategies used to modify and improve eating patterns, including offering healthy food choices, having children plan meals, and gathering as a family for daily dinners. In general, parents understood the link between unhealthy eating and past childhood trauma, but also reported being unprepared for more serious eating problems like hoarding. Findings indicate that foster parents need food assistance to increase food security as well as training in assessing and responding a variety of unhealthy child eating behaviors.

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Acknowledgments

We would like to thank Ruth Ann Jennings and Steven McCarty, as well as Melissa Smith and Jessica Harms of Ascend CHC in Champaign, Illinois for reviewing this manuscript.

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Jesse J. Helton

Department of Social Work, Southern Illinois University at Edwardsville, Edwardsville, IL, USA

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This study was supported, in part, by a grant from the Christopher Family Foundation Food and Family Program awarded to the Family Resiliency Center at the University of Illinois at Urbana-Champaign.

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Helton, J.J., Schreiber, J.C. & Fiese, B.H. Foster Parents’ Nutritional Strategies and Children’s Well-Being. Child Adolesc Soc Work J 34 , 159–169 (2017). https://doi.org/10.1007/s10560-016-0454-4

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Published : 11 August 2016

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DOI : https://doi.org/10.1007/s10560-016-0454-4

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The Impact of Nutrients on Mental Health and Well-Being: Insights From the Literature

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1 Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy.
PMID: 33763446
PMCID: PMC7982519
DOI: 10.3389/fnut.2021.656290

A good nutritional status is important for maintaining normal body function and preventing or mitigating the dysfunction induced by internal or external factors. Nutritional deficiencies often result in impaired function, and, conversely, intakes at recommended levels can resume or further enhance body functions. An increasing number of studies are revealing that diet and nutrition are critical not only for physiology and body composition, but also have significant effects on mood and mental well-being. In particular, Western dietary habits have been the object of several research studies focusing on the relationship between nutrition and mental health. This review aims to summarize the current knowledge about the relationship between the intake of specific micro- and macronutrients, including eicosapentaenoic acid, docosahexaenoic acid, alpha-tocopherol, magnesium and folic acid, and mental health, with particular reference to their beneficial effect on stress, sleep disorders, anxiety, mild cognitive impairment, as well as on neuropsychiatric disorders, all significantly affecting the quality of life of an increasing number of people. Overall data support a positive role for the nutrients mentioned above in the preservation of normal brain function and mental well-being, also through the control of neuroinflammation, and encourage their integration in a well-balanced and varied diet, accompanied by a healthy lifestyle. This strategy is of particular importance when considering the global human aging and that the brain suffers significantly from the life-long impact of stress factors.

Keywords: alpha-tocopherol; docosahexaenoic acid; eicosapentaenoic acid; folic acid; inflammation; magnesium; mental health; well-being.

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Summary of the main molecular and physiological effects exerted by omega-3 PUFAs, alpha-tocopherol,…

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Fostering Health and Nutritional Awareness in Children

W hile current health news articles warn of the expanding problem of obesity in adults, our children are growing into the problem as well. Dr. Peter Carter, chief executive and general secretary of the Royal College of Nursing in the United Kingdom, said in a press release, “Obesity is this country’s single biggest health issue and is threatening the health and well-being of the two thirds of adults, and a third of children, who are overweight or obese.”

In the United States, the Centers for Disease Control (CDC) reports that the prevalence of overweight in children is increasing, and obese children have a 70 percent chance of becoming obese adults. On the other side of the globe, India is also facing problems with obesity as a new middle class emerges. R.V. Bhavani, project director of the B.V. Rao Center for Sustainable Food Security, told Vision , “Junk food has entered the market, and urban schoolchildren and the middle class are more open to these kinds of foods. On one side we have this huge population of hungry and malnourished [children], but the manifestations of the problem of obesity and related issues are also surfacing. These foods are finding their way even to rural areas at a faster pace, so unless there is more awareness of the right kinds of food to consume, we are going to have problems.”

Some countries are generating awareness about nutrition and health by implementing educational programs in the schools while changing what they feed the students. In an exclusive interview with Vision , Prue Leith, internationally known food expert and chair of the United Kingdom’s School Food Trust, explained that Finland’s successful solution to their obesity problem began with the children. “The government decided to tackle it through school dinners. Everything the children eat is nutritionally balanced, and there’s very little choice.” Each meal is part of their education. The students are involved with meal preparation and cleanup, so they learn to understand the process. They serve themselves so they can take as little or as much as they like, but they are expected to eat what they take so there is no waste. Food is prepared as it is needed, so it is always fresh and appealing when the children come through the lines. Leith encourages others to learn from Finland’s experience and apply these lessons in the battle against obesity in the United Kingdom. “The scale of the problem is really scary. We now have 35 percent of obese children, which is what Finland had before. Now they have 2 percent, so it can be done.”

Schools in the United States are also addressing the obesity problem by emphasizing whole grains, fruits and vegetables while cutting back on transfats, added sugar and sodium, according to a July 2008 survey by the School Nutrition Association. U.S. schools are offering a greater variety of fruits, vegetables, whole grain products and other more nutritious foods despite dealing with increasing costs. Other improvements involve building awareness of nutrition and wellness among students, teachers and staff while also trying to increase the appeal and utility of cafeteria spaces.

Such programs are laudable and should augment what parents teach and model for their children at home. It is never too early to begin. Leith advised, “We do know that the habits of eating are formed very, very young. And so, although it’s easier to change [the eating habits of] primary school children than secondary school children, it would be much easier if parents fed them the right things from four months old.”

Healthy eating habits begin even before a baby is born. What a mother eats during pregnancy has an effect on her unborn baby’s health as well as her own, so she must choose wisely.

Studies show that breastfeeding also has many positive effects on both mother and baby, including improved chances of the baby maintaining a healthy weight as an adult. What a mother eats while nursing affects the flavor of her milk, which in turn helps form her baby’s taste preferences.

As the baby grows, other habits can also shape taste preferences. For instance, some parents fall into the habit of offering fruit juice regularly. While juice may have some nutritional benefits, it is also high in calories and may encourage a fondness for sweet beverages (and excess calories) that will continue into adulthood. Artificially sweetened, no-calorie beverages have the same effect. Offering children water to quench their thirst is a better option for long-term health.

It is rare for young children to enjoy healthy vegetables the first few times they try them. But parents can affect their likes and dislikes by continuing to offer healthy foods until the child learns to like them. As Leith explains, “We now know that most foods are an acquired taste, so it’s no good giving a child a piece of broccoli and leaving it at that. . . . Children have to be persuaded to eat, and little ones are easy to persuade.” Since parents usually have a great deal of control over what young children eat, taking advantage of this opportunity and feeding them only healthy foods helps give children the best possible start.

For families with access to a garden or even just a few pots of tomato plants, learning about food and nutrition can be more holistic. Children who plant a seed, tend it, watch it grow and see the fruit develop usually look forward to tasting the fruit. Often the hardest part is waiting for the fruit to ripen. Even a visit to a farm or urban garden plot can spark interest. Leith advised, “As soon as children become interested in food they are more likely to care about what goes into their bodies.”

Some parents find that they begin to reevaluate their own eating habits as they see their children aping their habits. Children often want to help at this age, and it is the perfect time to encourage good habits by letting them help in the kitchen. Although it does take more time and effort to prepare meals with young children helping, the result will be capable, educated children who will not have to resort to unhealthy fast food or prepared frozen foods when they are on their own.

As children grow, activity is an important part of good health. Families who take walks, play ball, swim, ride bicycles or tricycles and just play together are forming important habits for the future. The converse of active playtime, using television and passive media as electronic babysitters, may be convenient but is ultimately counterproductive. Whether good or bad, patterns formed now become patterns followed later.

When children are able, learning to read nutrition facts on packaged foods helps them become aware of portion sizes and healthy options. Some families make a game of this, asking siblings or parents to guess the calories, fat grams or sugars in a package. The answers can be surprising, and the game does foster nutritional awareness.

Busy parents and children alike will eat what is readily available, so having a bowl of fruit on the table (instead of doughnuts and cookies) or washed and sliced vegetables in the refrigerator (instead of chips and cookies in the cupboard) helps encourage healthy choices for all.

Serving a variety of foods ensures that children will get a range of nutrients essential for optimal health. For example, myriad breakfast options abound involving fruit, grains, vegetables, dairy products, eggs and other proteins. Yet all too often, this important meal defaults to a boxed-cereal-and-milk routine. To counter this tendency, Leith encourages serving different foods for children each day, with no default choices. “Otherwise children will eat the same thing every day. If you eat the same thing every day, no diet is good for you.”

Busy families may be tempted to snack and eat on the run instead of sitting down to family meals together. Yet the overwhelming consensus of multiple studies is that family meals are enormously beneficial. And it is more than just physical benefits from the healthier foods that are usually consumed at sit-down family meals. Children and teens who eat with their families get better grades in school, are less likely to be in trouble with the law and are less likely to be involved with drugs, alcohol or premarital sex.

Children have cycles of weight gain followed by growth, so if a child is active and is eating proper portions of nutritious foods, parents need not worry about an occasional increase in weight. Body Mass Index (BMI) charts for children can be helpful, but some children have larger muscle mass and bone density than others, so these charts can be misleading. Nagging children about their weight may result in eating disorders and other problems, but helping children learn about proper portion sizes, nutrition and exercise will most likely result in healthy weight. If these measures do not help, there may be underlying medical concerns. It may be time to consult with a medical professional.

Parents bear the responsibility for their children’s health and nutrition and wield great influence from the very beginning. As children grow and mature, teaching them how to cook and to make healthy choices is important, but the example of the parents is vital. Not surprisingly, children tend to follow parental examples more than verbal advice. What they learn now and the examples they follow will help determine their future health and well-being. This takes effort, but children will not grow out of obesity without help from their parents, and the obesity problem among children today is the obesity problem among tomorrow’s adults.

Leith agrees. “Yes, it’s quite difficult to do, but it is really worth doing,” she says. “You do not want children to die at an earlier age than you’re going to die. You want them to have a happy life. And frankly, obese children do not have happy lives.”

Helping our children achieve long, happy, healthy lives certainly is a compelling reason to foster their health and nutrition awareness.

Open access
Published: 12 September 2023

Addressing schoolteacher food and nutrition-related health and wellbeing: a scoping review of the food and nutrition constructs used across current research

Tammie Jakstas 1 , 2 ,
Berit Follong 3 ,
Tamara Bucher 2 , 4 ,
Andrew Miller 5 , 6 ,
Vanessa A. Shrewsbury 1 , 2 &
Clare E. Collins ORCID: orcid.org/0000-0003-3298-756X 1 , 2

International Journal of Behavioral Nutrition and Physical Activity volume 20 , Article number: 108 ( 2023 ) Cite this article

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Teachers form a large and essential workforce globally. Their wellbeing impacts personal health-related outcomes with flow on effects for the health, and wellbeing of their students. However, food and nutrition (FN) interventions that include teachers, typically neglect the impact of personal FN factors on a teachers’ ability to achieve optimal nutrition-related health and wellbeing, and successfully fulfil their professional FN roles as health promoters, gate keepers, educators’, and role models. The aim of this review was to scope FN constructs that have been studied internationally regarding teacher FN-related health and wellbeing.

Six databases were searched, and papers extracted in June/July 2021. Eligibility criteria guided by the population, concept, context mnemonic included studies published after 2000, in English language, with an aspect of personal FN-related health and wellbeing, among in-service (practising) and pre-service (training), primary, and secondary teachers. Screening studies for inclusion was completed by two independent researchers with data extraction piloted with the same reviewers and completed by lead author, along with complete descriptive and thematic analysis.

Ten thousand six hundred seventy-seven unique articles were identified with 368 eligible for full text review and 105 included in final extraction and analysis. Sixty-nine descriptive studies were included, followed by 35 intervention studies, with the main data collection method used to assess both personal and professional FN constructs being questionnaires ( n = 99 papers), with nutrition knowledge and dietary assessment among the most commonly assessed.

FN constructs are used within interventions and studies that include teachers, with diversity in constructs included and how these terms are defined. The evidence from this scoping review can be used to inform data collection and evaluation in future epidemiological and interventional research that addresses teacher FN-related health and wellbeing.

Teachers’ health and wellbeing, including food and nutrition (FN) practices are influenced by professional workload and school environment [ 1 ], while they in turn have an influence on the students within their care as role models [ 2 ], health promoters [ 3 , 4 ], gate keepers [ 5 ], and FN educators [ 6 ]. While high rates of teacher work-related stress and burnout have been identified as contributors to teacher turnover, highlighting the impact of teacher wellbeing on performance of work-related tasks, the influence of FN practices on teacher wellbeing has not been explored [ 1 , 7 , 8 , 9 ].

Indicators and predictors of food choices and eating behaviours are unique to everyone and acknowledged as complex in the Determinates of Nutrition and Eating (DONE) Framework, which identifies 51 determinate groups across four key domains of individual, interpersonal, environmental and policy [ 10 , 11 ]. FN constructs known to be indicators of healthy dietary patterns such as positive food agency, cooking skills and food skills [ 12 , 13 ] are increasingly used along with forms of food literacy measures [ 14 ], in mental health and wellbeing interventions, targeting an individuals’ wellbeing and dietary outcomes [ 15 , 16 ]. Despite this, few studies with teacher participants include an examination of FN constructs beyond measuring dietary assessment and/or nutrition knowledge which provides limited information on the overall influence of FN to the related health and wellbeing of teachers.

Poor diet quality, specifically low intake of vegetables, fruit and wholegrains are well established as risk factors of chronic disease and contributors to global burden of disease [ 17 ]. To this, FN-related constructs such as cooking confidence and diet quality are increasingly included in research that considers the links between mental health outcomes, including depression and anxiety [ 18 , 19 ]. With teacher wellbeing known to be impacted by stress and burnout, and the growing evidence supporting the role of diet and potential benefits of culinary practices in mediating mental health outcomes, there is a need to consider a greater focus be given to a teachers’ personal FN-related health and wellbeing.

Teachers need support and education on how to optimise their own FN-related health and wellbeing to help them in fulfilling their professional FN roles as healthy role models and advocates for the students in their care [ 20 , 21 ]. Previous review studies have explored the impact of work-related factors on the health and wellbeing of early learning educators; but not schoolteachers, with limited review of FN beyond brief dietary indicators [ 22 , 23 , 24 , 25 , 26 ]. Although, more recent reviews and research have looked at the concept of, and/or contributors of wellbeing in primary and secondary schoolteachers [ 1 , 7 , 9 , 27 , 28 , 29 , 30 , 31 , 32 ], including mental health, stress, and burnout, they have not considered the influence or role of FN factors. One systematic review and meta-analysis on teacher nutrition education professional development interventions was identified, but it did not consider the impact of this education on teacher wellbeing [ 33 ]. This highlights a clear gap to investigate research that has included aspects of teacher FN, how the FN constructs were measured and what, if anything they can tell us about the potential influence FN factors have on teacher-related health and wellbeing.

Therefore, the current scoping review aims to summarise the range of FN constructs included across research on teacher’s personal FN-related health and wellbeing. The review will map evidence on teacher FN-related health and wellbeing and how this has been evaluated to inform future research.

A scoping review methodology was selected to both enable research from a diverse collection of areas across education, and health, while providing a structed yet iterative process that provided a clear review framework with the flexibility to refine parameters as references were collected and information sourced. The term FN-related health and wellbeing is used within the current review to encompass the complexity of individual, interpersonal, environmental and policy related constructs that influence an individuals’ FN decisions and healthy eating behaviours. For the purposes of this review a distinction is made between personal and professional FN constructs, as outlined in Table 1 . Personal FN constructs relate to the individual teachers, primarily in their personal lives, even though these may have downstream effects on student FN factors e.g., through role modelling eating behaviours or a capability to transfer deep FN-related knowledge and skills. Professional FN constructs are defined here as those specifically related to the teachers’ professional role, even though these may potentially also influence personal FN.

A scoping review protocol was developed, guided by the Joanna Briggs Institute (JBI) guidelines [ 47 ], the preferred reporting items for systematic reviews and meta-analysis extension for scoping reviews (PRISMA-Scr) checklist [ 48 , 49 ] (Additional file 1 ) along with complementary papers [ 50 , 51 ] and research guidelines [ 52 ].

Eligibility criteria

Early learning preservice and in-service teacher/educators were not included within this review as earlier scoping reviews exploring this population were identified [ 22 , 23 , 24 , 25 , 26 ] and for the differences noted between school-based teachers and early learning teacher/educators. Many studies identified in screening often used the terms educators and teachers interchangeably making it difficult to distinguish between them, with notable differences recognised in in their daily responsibilities or workload and the training required to become an early childhood teacher (e.g., a 3–4-year university degree) or an early childhood educator (e.g., a variety of Technical and Further Education (TAFE) certificates or diplomas). Table 2 provides a full summary of the inclusion and exclusion criteria.

Literature search strategy

In June/July 2021 six databases were searched: PsychInfo, ERIC via PROQUEST, CINAHL, Medline, Embase, Scopus. Database specific search strategies were developed in consultation with two senior University of Newcastle librarians’ using the population, concept, context, (PCC) mnemonic [ 47 ]. The Medline search strategy is shown in Table 3 , with all database search strategies documented in Additional file 2 . The reference list of included papers was screened for additional eligible papers.

Study selection

Screening of papers was conducted by two independent reviewers (BF, TJ) using Covidence systematic review software, Veritas Health Innovation, Melbourne, Australia, available at www.covidence.org . Title and abstract screening, and full text screening were conducted by BF, TJ with conflicts resolved by discussion and by a third independent reviewer when conflicts could not be resolved. Reference lists of excluded full text papers, flagged reviews, and study protocols identified, were also screened for potential papers of interest.

Data extraction

A data extraction instrument was created by lead author (TJ) guided by the JBI manual for evidence synthesis [ 47 ] and piloted with a sample of selected papers by two independent researchers (BF, TJ). Extractions were compared for similarity and refinements made to the extraction tool with input from the research team. A summary table of the qualitative and quantitative data extraction tool is provided in Additional file 3 . When data from a study was reported across multiple papers, all were extracted individually to capture each FN construct investigated, to address the unique aims of each paper. Initial extraction was completed within the Covidence review system software by lead author (TJ) with the second reviewer (BF) independently conducting data extraction on approximately 10% of included full text papers to ensure consensus in extraction. As the purpose of a scoping review is to map evidence, few include a critical appraisal step, with the focus of the current review to investigate and map what types of FN constructs could be found and how these were measured across studies, a critical appraisal step was not conducted to assess study design quality [ 50 ].

Data analysis

Papers were grouped for descriptive analysis based on study type to assess distribution of included study characteristics and data collection methods. FN constructs were initially dichotomised as personal or professional, with constructs allocated to thematically appropriate groups based on the content description and sample questions provided in each eligible research paper. Where a description of the construct was not provided, it was placed in a suitable group based on name only.

No formal statistical analysis was conducted to assess trends in different areas of teacher FN-related health and wellbeing such as nutrition knowledge or dietary intake due to the diversity of construct terminology identified across studies. Instead, further descriptive analysis was conducted using the primary study aim to allocate each paper to one of five groups: Teacher Personal FN, Teacher Professional FN, Student FN, Teacher and Student Personal FN, or Other. Final summary tables were transferred from Microsoft Excel spreadsheets into Microsoft Word and simplified for final presentation.

Figure 1 illustrates the flow of papers through the different phases with 10,677 unique references screened identifying 368 papers eligible for full text review and a final 105 for inclusion and data extraction. Of the 105 papers, in-service teachers ( n = 93) were the main participants, with the remaining 12 papers utilising pre-service teachers. Thirty-two papers included teachers with other participants such as guidance teachers’, assistant teachers’, administrative staff, transition teachers and in one instance other health fund members (professions not specified), with a complete summary provided in Additional file 4 .

Flow of papers through the different screening phases

Where some papers specifically mentioned the participant population were teachers, some did not clearly describe them as primary, secondary, or relevant international categories (e.g., junior, middle, high or senior school, and elementary). Where applicable, to clarify this aspect emails ( n = 24) were sent to authors who were provided a month in which to respond. Thirteen papers where authors’ response was not received were excluded under the “Participants ineligible” exclusion reason as participant population was unable to be confirmed.

Figure 2 indicates that studies were predominately from the United States of America ( n = 44), Australia ( n = 7), Iran ( n = 7), Brazil ( n = 6), South Africa ( n = 5), Canada ( n = 4) and Indonesia ( n = 4). Country of study origin is provided for all included papers in Additional file 4 .

Global distribution of included papers

Included papers were grouped by study type as defined by Yoong et al. [ 53 ] which utilises three groups, descriptive ( n = 69), intervention ( n = 35), and measurement ( n = 1). Included papers being further grouped using the primary study aim into five main groups for analysis of key characteristics and the types of FN constructs used based on the study purpose (Additional file 4 ). The five groups were labelled, Teacher Personal FN ( n = 37), Teacher Professional FN ( n = 30), Student FN ( n = 11), Teacher and Student Personal FN ( n = 6) and Other ( n = 21). Papers that focused on student-related aims favoured incorporating professional teaching FN constructs over personal FN constructs with the main personal FN constructs across these being nutrition knowledge, including food safely knowledge and skills, dietary assessment, and food attitudes. Papers within the ‘Other’ category most often included research focused on diet-disease relationships with teachers acting as a convenience sample with the focus solely on ‘personal FN’ or other health-related and wellbeing covariates or constructs.

Across papers, a wide variety of personal and professional FN constructs were included, with differences noted in how similarly named constructs, such as nutrition knowledge were defined. A summary of all FN constructs identified and thematically grouped based on content descriptions and sample questions is provided in Table 4 , with a further breakdown given in Additional files 5 and 6 . The four main categories of personal FN: dietary assessment, nutrition knowledge, food or eating habits and behaviours, and nutrition attitudes, are provided in separate tables with content descriptions and sample questions included (Additional file 7 ).

Of the 105 papers, 66 captured one personal FN construct, with dietary assessment ( n = 31), followed by, nutrition knowledge ( n = 12) and food or eating habits and behaviours ( n = 8) being the most prominent, (body mass index and waist circumference were not included as a construct in this description). The remaining 38 papers captured two or more constructs, with different combinations represented including knowledge, attitudes [ 54 ], and behaviour or practices [ 55 , 56 ]; skills, knowledge, practices [ 57 ] and behaviour or attitudes and practices [ 58 ] as a few examples. Thematic instead of a definitive analysis breakdown was employed to group the most common constructs, due to the lack of consistent terminology, especially in how similarly named constructs were defined across included references. Results of this thematic analysis have been summarised and outlined below, broken down to explore the most common constructs observed across the three main categories of Personal FN, Professional FN and Other-related Health and Wellbeing constructs or covariates.

Personal food and nutrition

Dietary assessment ( n = 41) and nutrition knowledge ( n = 33) were the two most utilised constructs across papers, followed by food or eating habits and behaviours ( n = 23) and nutrition attitudes ( n = 15). Additional file 7 provides a summary of the four main construct groups identified using the term provided in the paper of origin to demonstrate the diversity of terminology and ways in which constructs have been defined. Culinary FN constructs were identified across five included papers [ 59 , 60 , 61 , 62 , 63 ], or included as an element within another construct [ 64 ] and are summarised in the “ Culinary ” section of Additional file 5 .

Dietary assessment

Dietary assessment construct terms included dietary intake ( n = 36, Additional file 7 ), dietary habits ( n = 1) [ 65 ], behaviours ( n = 1) [ 54 ], nutrition practice ( n = 1) [ 66 ] and nutrition patterns ( n = 1) [ 67 ], with additional dietary pattern analysis or dietary quality scores being calculated ( n = 3) [ 68 , 69 , 70 ]. Papers measuring dietary intake varied in methodology, using food frequency questionnaires (FFQ) ( n = 18) [ 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 ], fruit and vegetable screeners ( n = 6) [ 87 , 88 , 89 , 90 , 91 , 92 ], fat screeners ( n = 2) [ 37 , 43 ], dietitian conducted 24-h recalls ( n = 3) [ 93 , 94 , 95 ], automatic 24-h recalls ( n = 3) [ 68 , 96 , 97 ], a one week food diary ( n = 1) [ 98 ], short food frequency measure ( n = 1) [ 99 ] or brief questions to measure food frequency across select food groups ( n = 2) [ 60 , 100 ].

Nutrition knowledge

Nutrition knowledge was measured across 33 papers (Additional file 7 ), with 15 using the construct term ‘ Nutrition knowledge ’ with various FN-focused questions observed, including local dietary guideline recommendations ( n = 8) [ 63 , 71 , 101 , 102 , 103 , 104 , 105 , 106 ], nutrient content and/or functions ( n = 7) [ 56 , 63 , 71 , 77 , 104 , 105 , 107 ], diet-disease relationship ( n = 4) [ 63 , 104 , 106 , 108 ], food safety and/or hygiene ( n = 5) [ 71 , 77 , 106 , 107 , 108 ]. Seventeen additional papers included nutrition knowledge under different construct terms or scores including nutrition literacy [ 109 ], knowledge of nutrition score and a knowledge of nutrients functions score [ 66 ], healthy food choices knowledge score [ 110 ], or combined in a multi-faceted construct that included nutrition knowledge along with attitudes and practices questions [ 111 ]. Where constructs were identified separately as knowledge or attitudes they have been allocated to each specific thematic category. Those that did not provide clearly separated constructs and were included together are identified in the thematic analysis of only one category based on the content description provided. While some papers within this category included food safety questions ( n = 4) [ 55 , 77 , 106 , 108 ], those that focused solely on food safety knowledge, practices or skills were grouped separately under food safety practises or knowledge ( n = 5) [ 57 , 112 , 113 , 114 , 115 ]. Ten papers provided sample questions [ 2 , 64 , 101 , 102 , 106 , 110 , 116 , 117 , 118 , 119 ], with two papers stating nutrition knowledge was assessed, with another providing two nutrition knowledge scores, but none of these provided a description, tool reference or sample question to identify how nutrition knowledge was defined [ 54 , 66 , 120 ].

Food or eating habits and behaviour, and nutrition attitudes

Within the food or eating habits and behaviours category a range of construct terms were identified across the 23 included papers (Additional file 7 ). The most common were eating habits, including frequency of meals or snacks consumed daily ( n = 4) [ 60 , 61 , 71 , 121 ] or meal skipping practices ( n = 2) [ 66 , 122 ]. Six papers used or included an adapted version of the Personal Health Index [ 43 ] which has six single item questions around teacher health perceptions, level of satisfaction with their eating habits and regularity of consuming recommended fruit and vegetable serves [ 2 , 37 , 43 , 46 , 99 , 123 ]. Self-regulation of diet was assessed in two papers utilising the Treatment Self-Regulations Questionnaire for Diet that incorporates the self-determination theory approach [ 124 , 125 ]. One study indicated evaluating dietary and hygienic habits without description of construct content [ 126 ]. Of the 15 papers (Additional file 7 ) that included a nutrition attitudes construct, two included no description of the content covered [ 55 , 127 ], three papers included attitudes with practice or behaviours [ 56 , 58 , 103 ] with one paper capturing two attitude scores including food value orientation and food waste attitudes [ 58 ].

Body image, disordered eating, dieting status and weight change behaviours

Body image ( n = 7), disordered eating ( n = 5), dieting status and weight change behaviours ( n = 9), (See Additional file 5 ) were not included within the food or eating habits and behaviour, or nutrition attitudes categories, remaining as separate construct categories due to the specificity of the health and psychological behaviours being explored.

Five papers measured culinary focused constructs [ 59 , 60 , 61 , 62 , 63 ] with one paper including more than one construct (e.g., cooking attitudes, frequency of home meal preparation and average time spent preparing a meal) [ 59 ]. One paper [ 60 ] used two single item questions to identify basic cookery practices in relation to health, including use of salt in cooking and type of fats and oils used, with two further studies measuring confidence and self-efficacy in conducting culinary practices or an individual’s level of food literacy [ 61 , 62 ]. Another paper included two single item questions to identify which participants were responsible for home meal preparation and frequency of meal preparation [ 63 ]. Finally, to demonstrate the diversity of construct terminology, one paper not counted as including a culinary construct did identify single item questions with a culinary focus, within their nutrition knowledge and behaviour construct that measured a participant’s ability to identify healthy cooking practices (e.g., steaming) [ 64 ].

Professional food and nutrition

Of 42 papers measuring some aspect of professional FN (Additional file 6 ), all had a Teacher Professional FN primary aim apart from six papers that identified a student FN [ 128 , 129 , 130 , 131 , 132 , 133 ] primary aim (Additional file 4 ). The school practices attitudes and beliefs category ( n = 18, Additional file 6 ) was the largest Teacher Professional FN category observed among included papers, with one paper identified multiple times using three constructs to collect data on teacher perceptions of school wide food practices, beliefs regarding the school-food environment and food-related school policy [ 134 ]. Another paper measured two aspects of school practices, attitudes, and beliefs, being, the school food environment and teachers’ perceptions of the importance of aspects of food literacy [ 62 ]. The classroom practices and role modelling category were the next largest ( n = 15), followed by, nutrition education self-efficacy ( n = 11). These were also the most frequently observed construct groups with common tools used across included papers including the Classroom Food Practices construct, the School Food Environment Index [ 43 ] and the Nutrition Teaching Self-Efficacy Measure [ 44 ].

Other-related health and wellbeing covariates and constructs

Physical activity and/or exercise, including self-regulation of these was the most common covariate or construct included across 43 of the included papers, followed by smoking and/or smoking status and tobacco use ( n = 23), alcohol intake ( n = 11), and sleep ( n = 5). With mental health and wellbeing measured in 11 [ 60 , 68 , 90 , 91 , 92 , 122 , 135 , 136 , 137 , 138 , 139 ] of the 105 papers, including perceived stress [ 122 ] and perceived occupational stress [ 68 ]. Three papers utilised a personal health assessment to report work related aspects of job performance, along with life satisfaction, and related mental health outcomes such as depression, stress, and loneliness [ 90 , 91 , 92 ]. One study included an aspect of mindfulness [ 137 ] with two papers using different measures to assess an Individual Lifestyle Profile and the Assessment Scale of the Quality of Life at Work Perceived by Primary and Secondary School Physical Education Teachers, which included aspects of work conditions and opportunities, job autonomy and social integration in the workplace [ 135 , 136 ]. Perceived organisational commitment to employee health was measured in one study [ 139 ]. Frequency of practicing a collection of five healthy habits, including mental health was included in a larger measure of one paper [ 138 ], with a final paper using two single item questions to evaluate if participants had any organic or psychiatric diseases in a yes and no style question format [ 60 ].

Characteristics of the tools used to collect food and nutrition data

Table 5 demonstrates the distribution of data collection methods used across included papers with questionnaires ( n = 99) being the predominate data collection method, with participants self-reporting responses in paper-based or digital format. Five papers used researcher assistance to complete questionnaires [ 126 , 131 ] with three being a part of the one study [ 72 , 73 , 74 ]. Few papers that used questionnaires listed the average completion time, with those that did, indicating completion took between 10–20 minutes [ 60 , 88 , 103 ], two others mentioned either a longer completion time of 45 minutes [ 139 ] or shorter, approximately eight minutes [ 92 ]. Other data collection methods included anthropometric data ( n = 51), followed by health-related data, which included blood pressure or fasting blood samples ( n = 15). Physical assessment was measured in four papers with three papers, from the same study, using accelerometers with participants [ 93 , 94 , 95 ]. Linkage data used in eight papers provided data from state mortality files with qualitative data collected in fifteen papers using interview methods of data collection ( n = 11) or focus groups ( n = 4). Validation and reliability testing methods were reviewed for the data collection methods used across included papers with descriptions of psychometric testing often unclear, missing or a reference provided to indicate additional information on tool development and/or testing was reported elsewhere. Of the 105 papers reviewed only 22 papers included a clear description of validation methods used, with 13 providing an explanation of the reliability testing conducted. Further analysis of psychometric testing of data collection methods reviewed was beyond the scope of this current review (Additional file 4 ).

The current scoping review has summarised study characteristics and data collection methods used to measure FN-related health and wellbeing in teachers. The aim was to examine the types and range of FN constructs that have been used to date, particularly in reporting personal FN constructs. The results indicate that FN constructs have been reported across a range of study designs with diverse aims and disciplines, to measure data on personal and professional aspects of FN-related health and wellbeing in teachers. The major finding is that the constructs used in research to date are highly variable and lack consistency in construct terminology. Dietary habits were one construct appearing in two included papers [ 60 , 65 ], with another four including dietary habits examining eating habits [ 135 , 136 ], eating behaviours [ 122 ] or hygienic behaviours [ 126 ], yet these were placed in three different construct groups during thematic analysis based on content variations within the papers. The three construct groups dietary habits appeared in were dietary assessment [ 65 ], food or eating habits and behaviours [ 122 , 126 , 135 , 136 ], and culinary [ 60 ]. Given that papers have been published internationally, some diversity in construct content is to be expected due to global differences in food based dietary guidelines, cultural food preferences and practices, and local food sources. However, the diversity extends beyond these expected variations with this clearly demonstrated in detail across Additional files 5 , 6 and 7 where each construct identified is listed by the names given or described across included papers. Therefore, to assess those most frequently used and to identify common themes and gaps, thematic analysis was conducted. Where possible the results of common construct themes are discussed in relation to the DONE framework as a guide to the variety of determinates that impact healthy eating as well as their potential modifiability, population level of effect and suggested research priorities [ 10 , 11 ].

The DONE framework identifies 51 determinate groups, that contribute to or influence FN choices and healthy eating actions of individuals [ 10 , 11 ]. These determinates are placed into four categories of individual, interpersonal, environmental and policy, and have been rated within this framework based on their modifiability, population level of effect and the relationship strength between the two. Determinates with a higher ranking in all three areas are then listed in order of potential research priority.

Measuring teacher personal food and nutrition-related health and wellbeing, the determinates, and correlates to consider

Results of the current review indicate dietary assessment was the most used construct across all studies, especially within papers that included only one personal FN construct. Diet quality is an established correlate of health-related outcomes, used globally to assess dietary risks regarding morbidity and mortality [ 149 , 150 ] and used across a range of study designs. The use of FFQ or dietary screeners, like those used within included papers (Additional file 7 ), make the assessment of dietary intake practical and efficient to incorporate within research studies, with brief dietary screeners providing indicators of diet quality while reducing researcher and participant burden [ 34 ].

Diet quality indexes have recently been used as a diet-related health indicator in mental health and wellbeing interventions [ 14 ]. However, despite the recognition that teacher populations globally experience high levels of stress and burnout [ 29 , 31 ], especially with additional pressures observed throughout the COVID-19 pandemic [ 151 ], only 11 of the current included review papers utilised a measure of mental health and/or wellbeing such as quality of life [ 135 , 136 ] or perceived stress [ 152 ]. It is important that future research in teacher FN-related health and wellbeing includes investigation or consideration of the impact of key mental health-related factors such as stress, anxiety and/or burnout on teacher diet quality and other FN-related factors.

Despite nutrition knowledge being acknowledged within the DONE framework as a determinate of healthy eating and being potentially modifiable [ 10 , 11 ], it only has a weak positive correlation with overall health and wellbeing [ 153 ] . Nutrition knowledge can be modified by education programs, which likely explains its frequent inclusion within included papers of this review and was the second most utilised construct observed [ 55 , 102 , 108 , 154 ]. However, nutrition self-efficacy, dietary knowledge, and food knowledge all appear as stronger research priorities within the DONE framework determinate category that nutrition knowledge is grouped with. Nutrition education self-efficacy was captured as a professional FN construct in five of the included papers, with other papers exploring aspects of self-efficacy [ 46 , 101 , 102 , 123 , 129 ] and confidence to teach FN curriculum [ 105 ] or intervention materials [ 87 ]. Only one paper developed a specific measure to assessed personal food literacy self-efficacy [ 62 ], with others exploring aspects of healthy eating confidence by single items questions [ 105 ]. Overall, nutrition knowledge has a weak positive correlation with dietary intake [ 153 ] with other constructs that incorporate aspects of nutrition knowledge, nutrition self-efficacy and dietary knowledge such as food agency [ 13 ] and food skills confidence [ 12 ] identified as stronger correlates of health-related outcomes, including diet quality. Therefore, future research that investigates the connections between FN factors and health and wellbeing outcomes of teachers should consider incorporating constructs that measure aspects of nutrition knowledge yet have potentially stronger relationships with FN-related health and wellbeing outcomes.

Within the DONE framework the Individual/psychological section includes nine determinate categories, of which health cognitions, followed by food habits, food knowledge, skills and abilities, and food beliefs are the top research priories in relation to healthy eating practices of individuals and populations [ 10 , 11 ]. Within the current review food and eating habits and behaviour and nutrition attitudes were the third and fourth most commonly measured constructs in teacher participants. Six papers within the current review included a version of the Personal Health Index [ 43 ] or used an alternate measure to assess perceived health or health status [ 67 , 90 , 91 , 92 , 144 ]. Within the health cognitions determinate category of the DONE framework perceived health ranks the lowest, with health consciousness, health concerns, healthy eating motivation and healthy eating intentions listed as determinants with higher research priorities, potentially higher modifiability, and/or population level of effect [ 10 , 11 ]. Healthy eating motivations and intentions were minimally covered across included papers [ 42 , 110 ] and could present a potential area of further exploration in future teacher FN focused research.

Within the current review eight papers included at least one construct related to body image, disordered eating, dieting status and/or weight change behaviours with three focused on teacher professional responsibilities. The remaining studies were classified within the current review as papers with personal aims, however, the focus did not include consideration of how these constructs may influence teacher overall health and wellbeing. Weight control cognitions and behaviours is noted within the individual/psychological level/category of the DONE framework, however, when considering the potential modifiability, population level of effect and overall research priority ranking only weigh loss intentions is included within the top few below nutrition knowledge, dietary knowledge, health consciousness and cooking skills [ 10 , 11 ].

Of the five papers that included a culinary construct, two measured participant food involvement or level of meal preparation participation which is included within the food beliefs determinate category of the DONE framework [ 10 , 11 ]. However, none of these measured cooking skills which is a factor identified, within the food knowledge, skills, and abilities determinate group. With culinary inclusive interventions exploring the use of cooking skills [ 38 , 155 ] in connection with dietary intake, and cooking confidence as a potential correlate of wellbeing outcomes in adults, not teacher participants [ 14 , 15 , 16 ], future FN research in teachers might consider further exploration of these two culinary constructs.

Other-related health and wellbeing constructs and covariates

Within the related health behaviours determinate category physical activity level is identified, along with alcohol consumption as covariates of health and diet related outcomes. Sleep was measured in five of the 105 included studies often as a single item question to assess sleep quality or quantity. While sleep ranks relatively low as a research priority connected to healthy eating within the DONE framework [ 10 ], it is acknowledged as a contributor and potential correlate of mental health and wellbeing outcomes [ 156 ]. Considering these findings, future teacher FN-related research should consider the covariates or other health related constructs that may contribute to or influence both the FN and related-health and wellbeing of teachers.

Measuring teacher professional food and nutrition, and student impact

The focus of the current review was to evaluate how and where personal FN constructs have been reported in research assessing FN-related health and wellbeing in teachers. This is an important factor to consider given the additional FN roles and responsibilities teachers hold and their potential to impact the school environment and students within their care [ 1 , 157 ]. Of 42 papers that included one or more professional FN constructs, eight categories were created to collate the observed constructs. While variety in terminology was also an issue that impeded overall analysis, it was observed that what is being assessed in relation to teacher professional FN roles was better defined than teacher personal FN constructs. Although these findings should be interpreted with caution as only studies that included at least one personal FN factors were considered for inclusion in this review and used in the current analysis.

Classroom food related practices

Food rewards are commonly used by teachers globally as a classroom incentive, with energy-dense, nutrient-poor food items and beverages such as candy, pizza and sugar sweetened beverages most often selected over the preferred healthier options [ 158 ]. Within the DONE framework, food used as an incentive is identified within the parental feeding styles and parental behaviours determinate categories and is acknowledge as being impactful to healthy eating outcomes of children [ 10 , 11 ]. Teachers’ have been viewed similarly as gatekeepers of influence within the school environment, through the provision and use of food rewards, measured in many of the papers in the current review within nutrition-related classroom practices, food-related classroom practices, or in the case of pre-service teachers, their future classroom intentions [ 37 , 46 ]. Of the 10 papers that measured this determinate, half explored the connection between a teacher’s personal FN factors and their use of food rewards [ 2 , 37 , 43 , 46 , 97 ]. While different methods were used to explore this across included papers, personal FN factors such as diet quality, nutrition knowledge and personal health perceptions were noted as indicative of use of food rewards and level of teacher engagement in their professional FN roles. Of included papers, one reported that pre-service teachers with lower personal health perceptions and higher BMI were more likely to report using food rewards [ 46 ] with another identifying that diet quality within their study was positively correlated with better classroom nutrition practices [ 97 ]. Teachers of subject areas who most frequently receive some nutrition education such as physical education and consumer science (e.g., home sciences or home economics) were noted in one paper to be more likely to role model healthy habits and less likely to provide low nutritive food rewards [ 43 ]. Future studies should consider this connection in acknowledging how a teachers’ FN-related health and wellbeing can potentially impact student-related health and wellbeing.

Teacher personal and professional food and nutrition

The professional FN roles and responsibilities of teachers have been the focus of research to date, with personal FN being explored more frequently in the last two decades. However, the two should not be considered in isolation with this review highlighting the many personal FN determinates such as nutrition knowledge [ 46 , 108 ], food related practices [ 43 , 90 , 116 ], and beliefs about healthy nutrition [ 42 ], that may impact a teacher’s ability to be positive FN role models, health promoters, gate keepers and FN educators. Teachers need to be supported to achieve and maintain good personal FN practices to better support them in healthfully approaching their professional FN roles and general teacher practices towards achieving positive health promoting school environments.

Data collection methods

Questionnaires were the main method of assessing many different constructs ( n = 99). Self-reported questionnaires have lower participant burden and can incorporate multiple constructs of interest to address a wide range of study designs. While this method can be prone to participant completion error or bias, when conducting research with teacher participants reducing teacher participation time is a key factor for this population group who are usually time poor. Reducing participant burden as a strategy to increase study participation using questionnaires with close-ended responses may therefore be an effective way to optimise questionnaire completion. Within the current review descriptions of psychometric testing conducted on included data collection methods was limited and often unclear, with complete descriptions of items and scales used within questionnaires rarely included. This lack of validation and reliability descriptions and clear outline of the items or scales included within questionnaires makes comparison between tools challenging and limits other researchers in utilising these tools in future research.

Implications for research

The current scoping review mapped the research examining how teacher FN-related health and wellbeing has been studied across a wide range of study designs, and the main FN constructs used to assess it identifying key gaps. Results can be used to guide future school and teacher focused research, that incorporates teacher’s personal and professional FN constructs and their impact on individual teacher-related health and wellbeing.

Strengths and limitations

The current review study is the first to comprehensively investigate where and how personal FN constructs and related health and wellbeing factors have been used or measured across education and health research that included teacher participants. Recommended guidelines for scoping review [ 47 ] methodology were observed at all stages and allowed a wide net to be cast, gathering papers from various fields of research. While this added to the diversity of study designs, themes and gaps mapped, it limited traditional data synthesis due to the heterogeneity of construct terminology identified. While all included papers were published in peer reviewed journals a formal critical appraisal was not conducted.

Where papers did not provide a clear description of teacher FN component(s) in the abstract, potentially relevant papers may have been excluded in screening phase. Hence, although many studies are included, results should be interpreted with caution. Additionally, studies that indicated a teacher FN component, but did not provide a clear description within the methods were excluded at full text screening for lack of detail.

While thematic analysis provided a broad overview of the common themes and gaps, it is acknowledged that the strength of the current review is the mapping of the definitions, descriptions, and sample questions detailing FN-related constructs provided in the included papers. Therefore, where limited description was provided, these constructs may have been incorrectly placed within a construct category. However, this further highlights the need for more clarity and detailed descriptions of constructs used within teacher interventions and the possible sharing or inclusion of sample questions, to ensure research is represented as intended in future studies and the need for standardisation of construct terminology.

This is the first review to map where and how teacher personal FN have been reported across international research including student and school focused papers. While facets of teacher FN have been studied across a wide range of research areas, the lack of validated tools or clearly defined evidence-based FN constructs used in research to date makes comparisons or assessment of teacher population personal FN status challenging. Future research is needed to address these gaps.

Availability of data and materials

Not available.

Abbreviations

Food and Nutrition

Determinates Of Nutrition and Eating

Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews

Population Concept Context

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Nicole Faull Brown and Debbie Booth who assisted with search strategy development and database management.

This study is part of a larger study funded by the Teachers’ Health Foundation (This funding body had no role in the design or conduct of this study). TJ is supported by a Higher Degree Research Scholarship (Research Training Program) and Stipend (Research Training Program Allowance) at The University of Newcastle and a King and Amy O’Malley Postgraduate Scholarship; CEC is supported by a National Health and Medical Research Council of Australia Leadership Research Fellowship; VS is supported by a Hunter Medical Research Institute Research Funding.

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Jakstas, T., Follong, B., Bucher, T. et al. Addressing schoolteacher food and nutrition-related health and wellbeing: a scoping review of the food and nutrition constructs used across current research. Int J Behav Nutr Phys Act 20 , 108 (2023). https://doi.org/10.1186/s12966-023-01502-5

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This article presents lessons learned from collaborative service-learning projects aimed at bridging the gap between theory and practice by providing students design experiences in authentic settings. Interior design students gained disciplinary and civic benefits while problem solving for a preK-5 elementary school calming room, dining room, and teacher sanctuary. The elementary school teachers and staff reported the redesigned calming room supported students’ emotional and self-regulation skills. Teachers and staff also reported the dining room and teacher sanctuary supported the school community well-being. The authors’ present findings and hope the article can serve as a model for educators interested in community building service-learning projects in school environments.

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Author Information

Abimbola o. asojo *.

University of Minnesota, College of Design, USA
Architectural Studies, University of Missouri, USA

Chelsea Hetherington

Department of Human Development and Family Studies, University of Illinois at Urbana-Champaign, USA

Sarah Cronin

Psychology Department, Bemidji State University, USA
UMN Extension Children, Youth and Family Consortium, University of Minnesota, USA

*Address all correspondence to: [email protected]

1. Introduction

Several researchers have presented how community engagement enhances partnerships between the University and the public while providing positive impacts on learning experiences [ 1 , 2 ]. This article discusses a partnership between a school community and University in the design of the school calming room, dining room, and teacher sanctuary. Calming rooms have been found to support the well-being of children and youth, particularly in improving their self-regulation skills. Calming rooms are spaces that students can retreat to when they feel particularly agitated or dysregulated [ 3 ], and trauma-informed care approaches support the creation of such spaces where students can learn to better self-regulate [ 4 , 5 , 6 ]. Such spaces utilize design elements that facilitate calming and relaxation, such as soothing colors, like blue, green, and violet color palettes, and minimal stimulation [ 3 , 7 ]. Calming rooms, or “sensory rooms”, have largely been implemented with children and youth in residential psychiatric settings and juvenile justice facilities. For schools, this is a relatively novel approach, with limited empirical research on its impacts. Anecdotally, teachers have reported that calming rooms in schools have led to improvements in self-regulation [ 4 ]. Teachers have also reported that children have a positive view of calming rooms as a quiet, peaceful space to retreat to when something is bothering them [ 8 , 9 ]. As such, improving self-regulation skills, which are often negatively impacted by chronic stress and trauma [ 10 , 11 ], is a fundamental goal in supporting children’s health and well-being. Dining and cafeteria spaces can be another source of influences on students’ mood. A friendly, family-like, and collaborative eating environment boosts comfort and relatedness in children [ 12 ]. While elementary students can experience the primary effects of trauma and stress, other school personnel also suffer from secondary effects. Teachers and staff are involved in students’ development, and in need of health and well-being support [ 13 , 14 ]. A teacher sanctuary provides space for teachers and staff to refuel and rejuvenate in the school environment.

2. Elementary school calming room project

The University of Minnesota Extension Children, Youth, and Family Consortium collaborated with Bruce Vento, a local elementary school, to capitalize on the strengths of the school and its community in supporting its students [ 15 ]. The project partners worked together to identify the biggest areas of need in this East Saint Paul school, which is under-resourced with a diverse student body, many of whom experience chronic stress and behavioral dysregulation. During the process, the implementation of a calming room to provide a space for students to develop self-regulation skills was derived. The University personnel then connected with the Interior design program to join the project partners in the design process. This led to the integration of the calming room project in a sophomore level interior design course at the University of Minnesota in spring 2015 taught by the first author. Interior design students were able to connect directly with the community through site visits and working with the school staff to learn more about the design problem and existing conditions ( Figure 1 ).

Bruce Vento School Exterior and former Calming Room Interior Condition (Source: Pictures by Author 1).

2.1 The design

The project goal was to redesign the existing institutional looking calming room in Bruce Vento elementary school to foster students’ self-regulation. In several days in a design studio course, 23 interior design students worked in groups of three to design a safe place for children to express emotions, develop effective coping skills, and learn self-regulation skills. On day one, students visited the school to meet with the principal, counselor, and teachers in the existing calming room. On day two, students presented their existing space analysis and building system report then developed their concept and schematic designs (2D floor plan and 3D interior vignette sketches) in studio. On day three, students presented their concept and schematic design to the clients and for their feedback. Days four and five were spent in the studio finalizing the design with the instructor’s feedback and desk critiques. On day six, students presented finalized design drawings to the school principal, counselor, representatives from the University of Minnesota Extension Children, Youth and Family Consortium, a local architect, instructors, and their peers.

After the presentations, two groups had their design solutions selected and incorporated in the actual space. The first group proposed a design to allow children experience a personal adventure ( Figure 2 ). The second student group proposed the space to be a haven for students and enable them to self-regulate quickly, efficiently ( Figure 3 ). The implementation of the final calming room ( Figure 4 ) was within a limited budget of $4975. A large bean bag chair and four cubbies filled with soft pillows were incorporated in the space to help students relax and regulate their emotions. The cubies provided a crawl and snug space for students. Nature inspired imagery were placed on the wall since the space lacked direct sunlight to provide connection to the natural environment. Cloud ceiling panels were used to soften the harsh fluorescent lighting and the huge rug softened the space and provided connection to nature. The wall labyrinth mural, blues, greens and earth tones colors in the space were used to create a soothing atmosphere for the students. A dark blue color accent on the upper portion of the wall was used to reduce the impact of the high ceiling and make the anthropometric proportion and height of the room more relatable for the students. The simplicity in the new space was to avoid over stimulating the students and help them relax and self-regulate.

Design proposal by student team to allow children experience their personal adventure (Source: Emily Devore, James Thoma, and Hailey Wrasman, Spring 2015 IDES 2604 Interior Design IV course).

Design proposal by the student team proposed the space to be a haven for students and enable them to release their anger quickly, efficiently, and safely. Light and dark blues with small amounts of light pink and dull yellow were used to create a tranquil environment. Curved lines were repeated throughout the space to imitate the soft curves of waves and clouds (Source: Rachel Grothe and Hannah Segar, Spring 2015 IDES 2604 Interior Design IV course).

Finalized Calming Room Space from University of Minnesota Extension (Source: https://bventoumn.wixsite.com/bvento/calmingroom ).

2.2 Evaluation

To study the impact of the redesigned calming room, interviews were conducted with teachers and staff in fall 2016 (n = 20). 11 participants reported being teachers, 5 were behavioral staff (e.g., school social workers), and 4 were other school staff. In the first part of the interview, two interviewers asked teachers and staff to reflect on the impact that the calming room had on students and the school environment. In a second part of the interview, teachers and staff were asked about the impact of other aspects of the partnership, though those results are not detailed here. Interviews were then transcribed and coded for themes.

Seven themes were identified as follow (1) teachers and staff play a role in helping students calm down, (2) that the use of the calming room supports students in getting back to class sooner, (3) that the calming room has improved the school environment, (4) that students ask to visit the calming room, (5) that the calming room has improved students’ self-regulation, (6) that the calming room has increased physical safety, and (7) the importance of simplicity in the calming room design.

2.2.1 Theme 1: Staff help calm

The most prevalent theme (81% of interviews) mentioned in teacher and staff interviews reflected the importance of staff when using the calming room. Even though the calming room was designed with features that promote self-regulation in students, the staff are also an important component to the success of the room:

“It gets them back on task again. When they’re ready, we can tell and then the students [are] able to talk, you know, we can... process with them a little bit and see what’s going on. By the time they go back to the classroom, they’re ready.”

The school staff are also important supports that help students stay calm outside of the calming room:

“The social workers in our building have been training the entire staff on trauma and how that affects students and what can help students... to self- regulate when they’re in the classroom and try and catch on before it escalates.”

Staff also play a role in helping students see and realize that the calming room is a safe space for them – not a place where they are being sent as a punishment:

“When they walk into the room, they think they’re being isolated… [I say] ‘This is just to reset you, to get you back on track.’ So in the beginning, you have to explain to them, ‘No, this is not a punishment, this is not a secluded room for you, this is a room that’s supposed to be soothing and getting you to know what you’re supposed to be doing, getting you back on track.”

These examples provide evidence to the value added by teachers and staff both in the calming room itself and in supporting students’ emotion regulation.

2.2.2 Theme 2: Back to class

Another key theme (69% of the interviews) uncovered in the data was that due to the implementation of the calming room, students are returning back to class sooner and more regulated than they did before the calming room was re-designed. One staff member described:

“I think it can help kids get back to class faster... whereas before…they did not have that place.”

This outcome is particularly important – if the use of the calming room is leading students to return to the classroom more quickly than before, then they are losing out on less classroom time and can spend more time learning. Students are returning to class more focused and more regulated after having used the calming room:

“Once we leave [the calming room], they’re more engaged when they go back to the classroom. I think they’re more engaged then when they first come into the building in the morning.”

This has also had an impact for students who do not spend time in the calming room, in that their classmates who do use it are returning to class more calm and are less distracting:

“It not only helps them, but it also helps the rest of the class so the learning can continue for the other 27 students while that student is calming themselves down, and they come back a lot calmer. ... It’s been a lot better than trying to deal with it all in the classroom.”

2.2.3 Theme 3: Improved school environment

The calming room has also benefited the overall school environment (69% of the interviews). Teachers and staff across all types of backgrounds and experiences commented on the reduction in “chaotic movement” in the school. A staff member who spends most time outside of the classrooms reported a notable change in the overall environment:

“I know that before the calming room... [it] wasn’t as great and it has improved. I can tell that the building is calmer in general.”

Another staff member said, “We don’t have as many things being damaged since the room has come into play.”

Due to the calming room, students are damaging less and not roaming the halls as much as they did in the past. One staff member even noted the calming effect that the room has had on staff:

“I think it’s also calming for the staff, I really do. To know that they’ve got a specifically designed place to take their students, that they’re not going to be judged by administration. They’re not going to be judged by other staff members... Sometimes if they are going to the library, or the family center it’s like ‘Oh, they are messing around.’... ‘Are they just being allowed to do whatever they want?’ But in the calming room, they’re not judged there. You take your student there for a specific purpose and you’re not judged, so I think it’s good for the staff too.”

2.2.4 Theme 4: Students ask

Another theme (69% of the interviews) revealed in the data is that students request to go to the room when they need to calm down. One staff member said: “Some of them have even said, you know, ‘I need a break, can I go to that room?”. Another staff member reflected upon the usefulness of the calming room for a specific student:

“After a while it would seem like he knew that’s where he was going so [he would] go and run, he would like run to the room and it’s unlocked. And it happened at least once I remember, where he was somewhere in the building… and I found him in there on the bean bag [in the room].”

Students recognize that the calming room is a positive space they can retreat to when they being to feel dysregulated:

“I know that students are being a little more proactive. They’re asking to go to the calming room if they kind of starting to get agitated … they kind of start to get a little agitated or escalating behavior so and they’re asking to go there before like: “I just need a break can I go there?” … It’s giving them a tool to kind of regulate their own behavior and you know kind of notice where they are themselves you know some kind of watch themselves.”

Students ask to use the room, willingly take themselves there, and are learning to monitor themselves to know when they should visit it proactively provides evidence that students recognize the value of the calming room.

2.2.5 Theme 5: Emotional regulation

Many of the interviewees reported the room helps students with emotion regulation (63% of interviews). A specially designed space such as the calming room is a key important factor to encouraging students to learn emotional regulation. For example, one respondent said:

“The kids seem to be very engaged when they are in there and it does seem to really work its purpose.”

Another staff member commented on the significance of having a room specifically devoted to student emotional regulation rather than a space designed for academic uses:

“They stop things from escalating, you know, they gave the student a safe place to go. It wasn’t a teacher’s office, it wasn’t an academic setting per se, so he was able to just go and de-escalate… It’s giving them a tool to kind of regulate their own behavior.”

Other staff members also reported how beneficial it was to have a space specifically designed as a calming room:

“Before it was there... we would take them to a room and just calm them down but... it didn’t have the same calming effect.”

2.2.6 Theme 6: Safety

Teachers and staff reported that the design of the calming room promotes physical safety for students (63% of interviews).

“Especially compared to the way it was before the renovation, it’s safer now. That’s number 1… We’re able to just let them be and we don’t have to stop them from playing with the sink or go to the pipes or the TV or whatever you know… It’s a safer space.”

Interviewees reflected that students are able to express themselves safely in the calming room. One respondent said: “They know it’s a safe place.” Another component of the theme of safety is that because the students ask to go to the calming room and feel it is safe, staff are less frequently required to use less physical escorts with students:

“[Students] are more than willing to walk there without having to be physically escorted.”

The need for fewer physical escorts promotes increased student safety. One teacher commented on the value of having a safe calming room:

“I can’t imagine not having a safe space like that for when someone gets really dysregulated.”

2.2.7 Theme 7: Simplicity supports regulation

The minimalist, simple design of the calming room is a key facet of its success (25% of interviews). One staff member commented that when a student escalates emotionally they need to “get away from the stimuli.” A staff member described the importance of a simple space to promote emotion regulation:

“Less is more. So the more things in the room, the more distractions, the more heightened alertness and everything the students already have that they have to deal with.”

A minimalist design also promotes student safety:

“[Students] try to find something to break and there’s nothing to break, which is great.”

3. Elementary school dining room project

As a result of the positive feedback from the school community about the redesigned Calming room ( Table 1 ), the University of Minnesota Extension Children, Youth and Family Consortium initiated another project. This time, the dining hall at Bruce Vento became the venue for renovation. An undergraduate Interior design student collaborated with the first author in a funded undergraduate research project to develop design solutions for the dining space taking into account the need for a healthy eating and trauma-sensitive space [ 16 ]. The project goal was to reduce the noise level and address circulation issues in the existing dining space. The original dining hall’s loud eating environment, institutional atmosphere, and a limited amount of natural light contributed to a sterile environment ( Figure 5 ). These characteristics can negatively impact disruptive behavior especially in students with behavioral challenges. The University of Minnesota Extension Children, Youth and Family Consortium staff, interior design team (author 1 and interior design student), and the Bruce Vento team explored best practices to have a positive impact on the dining hall at the school and toured the design spaces of a leading edge school, the Creative Arts School in St. Paul to study best practices and gain inspiration.

Theme	Percentage of sample
Staff help calm	81.25%
Back to class	68.75%
Improved school environment	68.75%
Students ask	68.75%
Emotional regulation	62.5%
Safety	62.5%
Importance of simplicity	25.0%

Themes related to the calming room (n = 16).

Bruce Vento dining hall former Interior condition. (Source: Picture by Author 1)

3.1 The design

To create a welcoming and nurturing dining environment to foster students’ learning and to support their health several ideas emerged from research, ideation and team brainstorming. The ideas included creating a teaching kitchen space for nutrition educators to use with students and families, promoting family dining style and healthy eating through round tables, and solving acoustical problems by adding sound absorbing materials in the dining space ( Figure 6 ). Recognizing there is no simple solution and “one size does not fit all,” the team prioritized six design solutions ( Figure 7 ): (1) sound reduction materials, (2) family style eating to increase times for eating, (3) natural elements create calming and restorative environment, (4) teaching spaces for students and parents, (5) communal eating spaces, and (6) glass walls that provide light and open feeling. However, due to the financial restriction, the team was only able to implement a design that reduced noise levels and enabled positive interactions. The team focused on one major change, which is a shift from long, rectangular tables to round tables ( Figure 8 ). The round tables were funded through an internal grant received from the University of Minnesota by Author 1.

Bruce Vento dining hall schematic design. (Source: Rendering by Miranda McNamara).

Six prioritized design solutions for Bruce Vento dining hall redesign (Source: https://bventoumn.wixsite.com/bvento/calmingroom ).

Finished condition of Bruce Vento dining hall with the round tables (Source: https://bventoumn.wixsite.com/bvento/calmingroom ).

3.2 Evaluation

As mentioned earlier, the team was able to only change one major thing, the furniture which is a change from long and rectangular tables to round tables. One small change was enough to make a big difference. In the new layout, condiments, napkins, and utensils were placed in the center of each table, based on dining room workers’ input. This placement reduced noise levels dramatically because students did not need to get up and retrieve condiments or utensils from the other end of a long table. Both the dining hall workers and students noticed the change and liked it. In a quieter and calmer dining hall, students’ stress levels may decrease and they are making better food choices and having richer interactions with their friends. A 5th grader told 5abc Eyewitness News, in an interview regarding the design intervention at Bruce Vento elementary school, “Last year it was very loud, and this is a little bit more quiet… when nothing is loud, it is all peaceful” [ 17 ].

The teachers’ feedback on the dining hall renovation was also positive. 91% of the teachers surveyed preferred the new round tables in the dining hall. The teachers reported the round table, above all, created senses of “inclusivity” and family style dining which encouraged students to interact and socialize while staying seated. As the staff observed, the dining hall became less “institutional” and more “communal” which turned the overall atmosphere into “kinder” and “gentler”. Suggestions for future improvements of the dining hall include “adding more components to contribute more to the family feel”, adjusting current lighting conditions (e.g., “too harsh”, “lower light”, etc.), and providing wall storages to optimize student circulations.

4. Elementary school teacher sanctuary project

Both the calming room and dining hall contributed to the healthy development of elementary students in Bruce Vento School. These benefits of the new environments had to be extended to the school resource staff and teachers. As influencers who make significant differences in student success, teachers and school staff need the time and space to recharge and refuel for their important job of leading children’s development. This led our interdisciplinary team and the school to collaborate on renovating the current teacher lounge ( Figure 9 ). The goal of the space was to accommodate the needs of teachers, paraprofessionals, and other support staff during the day [ 18 ].

Bruce Vento teacher lounge former Interior condition. (Source: Picture by Author 1)

4.1 The design

As the first step of the design process, a need-analysis was conducted by engaging teachers to understand their expectations and necessities. The need analysis involved a wide range of methods including face-to-face conversation, in an online survey, and in an informal focus group in their lounge space. Throughout the processes, the team learned that the current lounge was not used frequently by many teachers due to several reasons (e.g., not an appealing environment, not properly functional amenities like the sink and cupboards, and lacked a sense of permanence with frequent changes in physical location). Based on these current problems and the teachers’ needs, three guiding principles and strategies for the new teacher sanctuary were defined: (1) start small, and add more later; (2) build for multiple uses: community, relaxation, eating, and refueling; and (3) accommodate both teachers and teaching support staff.

“Relaxing lighting, comfortable seating, food preparation [space],[piped-in] music, wall decorations, [a] staff kudos board, places for information to share with staff. So much opportunity!”

Within the three guiding principles, the team took several considerations for the project: (1) infusing natural light through lamps; (2) creating distinct spaces with partitions; (3) adding a communal table to facilitate communications; (4) maintaining computers in the room for staff needs; (5) creating ample space for meal prep and easy clean up; and (6) improving overall appeal with colored walls and few, but high impact design touches.

After a year, the project was completed during the summer break in 2017. Figure 10 offers a comprehensive timeline description of the design and implementation process from start to finish. The final solution features a straightforward and functional layout. A central interactive area was a major portion of the space and it opened opportunities for collaborations and communications between teachers, staff and related personnel. At one end of the room, the relaxation space provides a location where teachers sit down and rejuvenate their energy plus motivation ( Figure 11 ). For the implementation, Room and Board, a home décor retailer in Golden Valley Minnesota, inspired by the project and its purpose donated furniture to implement the proposed design at the school ( Figure 12 ).

The design and implementation process of Bruce Vento teacher sanctuary from 2016 to 2017. The steps are finding the research, engaging school personnel, finding U of M partners, conducting teacher survey and meeting, assessing school resources, creating blueprint, raising fund, revealing room, and ongoing reflection (Source: https://bventoumn.wixsite.com/bvento/calmingroom ).

The Bruce Vento teacher sanctuary proposed design (Source: Drawings by Noah Exum and Abigail Lundstrom).

The renovation of Teacher sanctuary space (Source: https://bventoumn.wixsite.com/bvento/calmingroom ).

4.2 Evaluation

The school staff and teachers started using the completed space in summer 2017. The design, layout, and overall environment of the new space was different from the previous teacher’s lounge. The school started to stock the cupboards with staple items, utensils, and extra coffee machines. According to the feedback from the teachers, they were satisfied with the new space which aligned with the initial project objectives. The teacher sanctuary, like all the initiatives undertaken at Bruce Vento Elementary School, will continue to evolve as users’ needs and circumstances change.

After the project, an interview was conducted to learn how the teachers think about the new space. The teachers, especially, thought the redesigned space supports their well-being because it is relaxing with soothing colors, gives peaceful energy to recharge, and provides a comfortable place to get away. They also perceived the new space as welcoming and inviting space to meet their colleagues. There was a comment about cleanliness. The tables are not as dirty as they used to be, and that may be because the attractiveness inspires people to clean up after themselves. One teacher, in particular, mentioned that they used the space as an area to regroup and refocus after helping students that are having a hard time. Therefore, there is no doubt that people use the new space to refresh themselves and like the space.

In addition, the teachers also thought the new space supports community building for school staff, mainly because they use the space for various purposes. They used the space as a gathering place, and they liked to see more people in the space, as the space is bigger than the previous staff lounge. In addition, they have a bi-weekly staff treat in the space. The teachers mentioned that as the space has plenty of room to have a nice spread of food, many utensils and supplies, it is a great place to accommodate many staff at once. One teacher said that food is set out in the new lounge, and different staff eat together in the lounge. Another teacher also mentioned that the new space is very nice for substitute teachers to eat or relax during prep time. Based on the teachers’ responses, they appreciated the spacious and relaxing space for them.

“It’s a welcoming, calm environment that provides some solace in the midst of a sometimes challenging day. [The new space supports staff community-building because] there’s more people, more connections, and higher morale.”

5. Conclusion

Findings from the teacher and staff interviews support the literature about the impact of calming rooms and dining spaces in supporting students’ emotional and self-regulation at the Bruce Vento School environment. There was an overall improved environment in the school, likely because students are able to regulate themselves and are asking to go use the calming room – a safe space where they can get the support they need and return to class. The new space allows staff to support and help students learn how to self-regulate, calm down, and then return to class sooner than before the space was redesigned. As in previous studies [ 9 ], students at the school ask to visit the calming room and recognize that it is a dedicated space where they can retreat to and feel safe. Also mirroring previous efforts in non-school settings, the implementation of the calming room leads to reductions in the amount of physical restraints staff had to use with students [ 19 , 20 , 21 ], thus increasing student safety. The data reinforced the strengths of approaching design problem solving through partnerships that seek out multiple perspectives. The simplicity of the final design solution implemented resulted from engaging multiple perspectives through interview of the clients, site visit, research, presentation, and feedback from clients. Likewise, the school community reported the new dining space created an inclusive and communal family style dining environment [ 22 , 23 , 24 , 25 , 26 , 27 ]. The round family style dining tables reduced students’ traffic and movement to retrieve condiments or utensils from the other end of a long table and this reduced the noise level in the dining space. The school staff observed the family style dining encouraged interaction and socialization among students and the dining space became less institutional and more communal. Additionally, the new teacher sanctuary extended the benefits of the new environment to the school resource staff and teachers. The teacher sanctuary created a space for school staff to rejuvenate and to help support their job of leading children’s development [ 28 , 29 , 30 ].

Finally, through this collaborative process, interior design students gained disciplinary and civic benefits such as application of their course knowledge, opportunities to connect to the community through real life design issues. The opportunity to visit the existing space and tour with the users to gather information and experience the space physically gave students better understanding of the space, building systems, and requirements for the projects. Overall, all the three design projects led to positive outcomes for the school community. Through the partnership with Bruce Vento Elementary School, a calming room, teacher sanctuary, and family style dining hall were all implemented in the school to build community and create a trauma sensitive environment. Anecdotal evidence shows that this Bruce Vento community building model of creating a trauma sensitive environment that fosters health and well-being has been used as a precedent for other school districts in Minneapolis St Paul.

1. Boston D, Ross B, Weglarz P. Playful Thursday project: Community/university partners and lessons learned in a longitudinal study. J Community Engagement Scholarship. 2017;10(1):13
2. Casapulla S, Hess ME. Engagement education: A model of community-youth engagement in rural Appalachia. J Community Engagement Scholarship. 2017;9(2):5
3. Burrell S. Trauma and the environment of care in juvenile institutions. Retrieved Sept. 2013;9:2014
4. Fraser K, MacKenzie D, Versnel J. Complex trauma in children and youth: A scoping review of sensory-based interventions. Occup Ther Ment Heal. 2017;33(3):199-216
5. Renwick F, Spalding B. Research Section:‘A Quiet Place’Project: an of Early Therapeutic Intervention within Mainstream Schools. British Journal of Special Education. 2002 Sep;29(3):144-50
6. Blackburn, R. Many parents and pros advocating ‘calming rooms’ for schools [Internet]. Athens Banner Herald. 2010 [cited 2021Mar31]. Available from: http://onlineathens.com/stories/051110/new_637263838.shtml/#.WgYVwTBry70
7. Chagaris C. How to Design a Calming Room for Autistic Kids [Internet]. 2015 [cited 2021 Jan 2]. Available from: http://www.nymetroparents.com/article/How-To-Design-a-Calming-Room-for-Autistic-Kids
8. Moore K. Sensory Room for adults or adolescents in mental health setting [Internet]. The Sensory Connection program. [cited 2021Mar31]. Available from: http://www.sensoryconnectionprogram.com/sensory_room.php
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11. Peter Kraftl. Environment for children: passive lessons from the everyday environment. Children's Geographies. 2008; 6:1: 109-110, DOI: 10.1080/‌14733280701791983
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13. MacDaniel, M., Van Bramer, J., Hogan, M. F. Comfort rooms: A preventative tool used to reduce the use of restraint and seclusion in facilities that serve individuals with mental illness [Internet]. New York State’s Office of Mental Health. n.d. [cited 2021Mar31]. Available from: https://omh.ny.gov/omhweb/resources/publications/‌comfort_room/‌comfort_rooms.pdf
14. Hydon S, Wong M, Langley AK, Stein BD, Kataoka SH. Preventing secondary traumatic stress in educators. Child and Adolescent Psychiatric Clinics. 2015 Apr 1;24(2):319-33
15. The University of Minnesota Extension Children, Youth & Family. Calming Room [Internet]. Bruce Vento University of Minnesota. 2015 [cited 2021Mar31]. Available from: https://bventoumn.wixsite.com/bvento/calmingroom
16. The University of Minnesota Extension Children, Youth & Family. The Dining Hall [Internet]. Bruce Vento University of Minnesota. 2015 [cited 2021Mar31]. Available from: https://bventoumn.‌wixsite.com/‌bvento/dininghall
17. Eyewitness News. Can Design Changes Lead To Mood Changes? St. Paul Elementary School To Find Out [Internet]. KSTP. 2017 [cited 2021Mar31]. Available from: from http://kstp.com/news/mood-changes-design-changes-st-paul-elementary/4609159/
18. The University of Minnesota Extension Children, Youth & Family. Teacher Sanctuary [Internet]. Bruce Vento University of Minnesota. 2015 [cited 2021Mar31]. Available from: https://bventoumn.wixsite.com/bvento/teachersanctuary
19. Bobier C, Boon T, Downward M, Loomes B, Mountford H, Swadi H. Pilot investigation of the use and usefulness of a sensory modulation room in a child and adolescent psychiatric inpatient unit. Occup Ther Ment Heal. 2015;31(4):385-401
20. Warner E, Koomar J, Lary B, Cook A. Can the body change the score? Application of sensory modulation principles in the treatment of traumatized adolescents in residential settings. J Fam Violence. 2013;28(7):729-38
21. Asojo AO, Patel T. Community Participatory Design Process for an Autism Clinic: Role+ Pedagogy+ Reflection. Journal of Interior Design. In: Proceedings of the 2017 EDRA48 Madison Annual Conference. 31 May- 3 June 2017; Madison. p.157-163
22. Brown, J. A school's dining environment: Why is it Important? [Internet]. Ecoliteracy. 2010 [cited 2021Mar31]. Available from: https://www.ecoliteracy.org/‌article/‌school%E2%80%99s-dining-environment-why-it-important
23. Gage, L. Recreating school cafeterias: A menu of creative options [Internet]. Global Educator Institute. 2015 [cited 2021Mar31]. Available from: http://bit.ly/2kHbcFs
24. Health Promotion Agency for Northern Ireland. Improving the dining experience in schools [Internet]. Public Health. n.d. [cited 2021Mar31]. Available from: http://www.publichealth.hscni.net/sites/default/files/Dining%20Experience%2009_10.pdf
25. Kuong, P. Redesigning the school cafeteria [Internet]. HuffPost. 2013 [cited 2021Mar31]. Available from: http://bit.ly/2zgpvnC
26. The School Food Plan. Tips on improving the dining experience [Internet]. What Works Well. 2014 [cited 2021Mar31]. Available from: http://bit.ly/2zgkBXy
27. Wansin, B., Just, D. R., McKendry, J. Lunch line redesign [Internet]. The New York Times. 2010 [cited 2021Mar31]. Available from: http://nyti.ms/1NrTs5b
28. Ben-Peretz M, Schonmann S, Kupermintz H. The teachers' lounge and its role in improving learning environments in schools. School climate: Measuring, improving, and sustaining healthy learning environments. 1999 Apr 1:148e164
29. Mawhinney L. Let's lunch and learn: Professional knowledge sharing in teachers' lounges and other congregational spaces. Teaching and Teacher Education. 2010 May 1;26(4):972-8
30. Shapiro S. Revisiting the teachers' lounge: Reflections on emotional experience and teacher identity. Teaching and teacher education. 2010 Apr 1;26(3):616-21

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution 3.0 License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Healthy Nutrition for Children in Foster Care

Children entering the U.S. foster care system are a highly vulnerable population who suffer from high rates of chronic health conditions, including malnutrition and other food-related problems. One study shows that about 20% of children in foster care are of short stature, a possible sign of malnourishment due to neglect, with an additional 6% to 10% of infants and toddlers meeting criteria for failure to thrive. On the other extreme, about 15% of children in foster care meet criteria for obesity, and data indicates that this figure is continuing to rise. This paper explores malnutrition among children in foster care in the U.S. and programs and interventions that help to improve the nutritional health of children in foster care.

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In addition to physical and mental wellbeing, a well-balanced diet forms a cornerstone of good health. Consuming a healthy diet helps to prevent malnutrition in all its forms as well as a range of non-communicable diseases (NCDs) and conditions, such as diabetes, heart disease, stroke and cancer. Increased production of processed foods, rapid urbanization and changing lifestyles have led to a shift in dietary patterns across the globe. People are now consuming more foods high in energy, fats, free sugars and salt/sodium, and many people do not eat enough fruit, vegetables and other dietary fiber such as whole grains. The exact make-up of a diversified, balanced and healthy diet will vary depending on individual characteristics (for example, age, gender, lifestyle and degree of physical activity), cultural context, locally available foods and dietary customs. However, the basic principles of what constitutes a healthy and responsible diet remain the same:

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Promoting Healthy Eating among Young People—A Review of the Evidence of the Impact of School-Based Interventions

Abina chaudhary.

1 Independent Researcher, Kastrupvej 79, 2300 Copenhagen, Denmark; moc.oohay@yrahduahcaniba

František Sudzina

2 Department of Materials and Production, Faculty of Engineering and Science, Aalborg University, A. C. Meyers Vænge 15, 2450 Copenhagen, Denmark

3 Department of Systems Analysis, Faculty of Informatics and Statistics, University of Economics, nám. W. Churchilla 1938/4, 130 67 Prague, Czech Republic

Bent Egberg Mikkelsen

4 Department of Geosciences and Natural Resource Management, Faculty of Science, University of Copenhagen, Rolighedsvej 23, 1958 Frederiksberg C, Denmark; kd.uk.ngi@imeb

Intro: Globally, the prevalence of overweight and obesity is increasing among children and younger adults and is associated with unhealthy dietary habits and lack of physical activity. School food is increasingly brought forward as a policy to address the unhealthy eating patterns among young people. Aim: This study investigated the evidence for the effectiveness of school-based food and nutrition interventions on health outcomes by reviewing scientific evidence-based intervention studies amongst children at the international level. Methods: This study was based on a systematic review using the PRISMA guidelines. Three electronic databases were systematically searched, reference lists were screened for studies evaluating school-based food and nutrition interventions that promoted children’s dietary behaviour and health aiming changes in the body composition among children. Articles dating from 2014 to 2019 were selected and reported effects on anthropometry, dietary behaviour, nutritional knowledge, and attitude. Results: The review showed that school-based interventions in general were able to affect attitudes, knowledge, behaviour and anthropometry, but that the design of the intervention affects the size of the effect. In general, food focused interventions taking an environmental approach seemed to be most effective. Conclusions: School-based interventions (including multicomponent interventions) can be an effective and promising means for promoting healthy eating, improving dietary behaviour, attitude and anthropometry among young children. Thus, schools as a system have the potential to make lasting improvements, ensuring healthy school environment around the globe for the betterment of children’s short- and long-term health.

1. Introduction

Childhood is one of the critical periods for good health and development in human life [ 1 , 2 ]. During this age, the physiological need for nutrients increases and the consumption of a diet high in nutritional quality is particularly important. Evidence suggests that lifestyle, behaviour patterns and eating habits adopted during this age persist throughout adulthood and can have a significant influence on health and wellbeing in later life [ 3 , 4 ]. Furthermore, the transition from childhood into adolescence is often associated with unhealthy dietary changes. Thus, it is important to establish healthful eating behaviours early in life and specially focus on the childhood transition period. A healthy diet during the primary age of children reduces the risk of immediate nutrition-related health problems of primary concern to school children, namely, obesity, dental caries and lack of physical activity [ 5 , 6 , 7 ]. Furthermore, young people adopting these healthy habits during childhood are more likely to maintain their health and thus be at reduced risk of chronic ailments in later life [ 7 , 8 , 9 ]. Thus, healthy behaviours learnt at a young age might be instrumental in reaching the goals of good health and wellbeing of the 2030 Sustainability Agenda which has implications at the global level.

Globally, the prevalence of overweight and obesity rose by 47.1% for children and 27.5% for adults between 1980 and 2013 [ 10 ]. A recent WHO (World Health Organization) Commission report [ 10 ] stated that if these same trends were to continue, then by 2025, 70 million children are predicted to be affected [ 11 ]. Hence, the increased prevalence might negatively affect child and adult morbidity and mortality around the world [ 12 , 13 ]. Worldwide the dietary recommendations for healthy diets recommend the consumption of at least five portions of fruits and vegetables a day, reduced intake of saturated fat and salt and increased consumption of complex carbohydrates and fibres [ 14 ]. However, studies show that most children and adolescent do not meet these guidelines [ 15 , 16 ] and, thus, as a result, childhood and adolescent obesity are alarming nearly everywhere [ 17 ]. Recent figures show that the prevalence has tripled in many countries, making it the major public health issue in the 21st century [ 18 , 19 , 20 , 21 ]. According to WHO [ 4 ], 1 in 3 children aged 6–9 were overweight and obese in 2010, up from 1 in 4 children of the same age in 2008.

The increased prevalence of overweight and obesity has fuelled efforts to counteract the development, as seen for instance in the action plan on childhood obesity [ 17 ]. Increasingly policy makers have been turning their interest to the school setting as a well-suited arena for the promotion of healthier environments [ 18 ]. As a result, schools have been the target of increased attention from the research community to develop interventions and to examine the school environment to promote healthful behaviours including healthy eating habits.

Globally, interventions in the school environment to promote healthier nutrition among young people have received considerable attention from researchers over the past years. But there is far from a consensus on what are the most effective ways to make the most out of schools’ potential to contribute to better health through food-based actions. Is it the environment that makes a difference? Is it the education or is it the overall attention given to food and eating that plays the biggest role? School food and nutrition intervention strategies have witnessed a gradual change from knowledge orientation to behavioural orientation [ 22 ] and from a focus on the individual to the food environment. Research evidence has shown that adequate nutrition knowledge and positive attitudes towards nutrition do not necessarily translate to good dietary practices. Similarly, research has shown that the food environment plays a far bigger role in behaviour than originally believed [ 23 , 24 ].

School-based interventions can a priori be considered as an effective method for promoting better eating at the population level. Schools reach a large number of participants across diverse ethnic groups. It not only reaches children, but school staffs, family members as well as community members [ 8 , 25 ]. Schools can be considered a protected place where certain rules apply and where policies of public priority can be deployed relatively easily. In addition, schools are professional spaces in which learning and formation is at the heart of activities and guided by a skilled and professional staff. Schools, as such, represent a powerful social environment that hold the potential to promote and provide healthy nutrition and education. Besides the potential to create health and healthy behaviours, good nutrition at school has, according to more studies, the potential to add to educational outcomes and academic performance [ 26 , 27 , 28 ].

However, taking the growth in research studies and papers in the field into account, it is difficult for both the research community and for policy makers to stay up to date on how successful school-based interventions have been in improving dietary behaviours, nutritional knowledge and anthropometry among children. Also, the knowledge and insights into how it is possible to intervene in the different corners of the school food environment has developed which obviously has influenced over recent decades how programs and interventions can be designed. It has also become clear that food at school is more than just the food taken but includes curricular and school policy components. The findings from school-based studies on the relationship between school, family as well as community-based interventions and health impact suggest that health impacts are dependent on the context in which they have been carried out as well as the methodology. Thus, an updated overview as well as a more detailed analysis of initiatives is needed in order to develop our understanding of the nature of the mechanisms through which the school can contribute to the shaping of healthier dietary behaviour among children and adolescents before more precise policy instruments can be developed. Our study attempted to fill the need for better insight into which of the many intervention components works best. It attempted to look at school food and nutrition interventions reported in the literature that have been looking at healthy eating programmes, projects, interventions or initiatives.

School-based interventions in the Western world are traditionally targeted at addressing obesity and over-nutrition, but school food interventions are also addressing under nutrition and, as such, their role in a double burden of disease perspective should not be underestimated. Many studies have reported on micronutrient malnutrition among school-aged children in developing countries (for instance [ 29 , 30 , 31 ]) but it has also been reported in the context of developed countries [ 32 ]. Against this backdrop, the aim of this study was to provide an analysis of the evidence of the effectiveness of school-based food interventions by reviewing recent scientific, evidence-based intervention studies on healthy eating promotion at school. The specific objectives of the study were to identify which interventions had an effect on primary outcomes, such as BMI, or on secondary outcomes such as dietary behaviour, nutritional knowledge and attitude.

2. Materials and Methods

The functional unit of the review were healthy eating programmes, projects or initiatives that have been performed using the school as a setting. We included only programmes, projects or initiatives that were studied in a research context, in the sense that they were planned by researchers, carried out under controlled settings using a research protocol, and reported in the literature. School-based programmes, projects, interventions or initiatives are, per definition, cluster samples where a number of schools first were chosen for intervention followed by performing an outcome measurement before and after the intervention and, in most cases, also in one or more control schools. The outcome measurement in the studies reviewed was performed on a sample of students that was drawn from each school (cluster).For this, the systematic review and meta-analysis (PRISMA) guidelines and the standardised quality assessment tool “effective public health practice project (EPHPP) quality assessment tool for quantitative studies” were used for analysing the quality assessment of the included studies [ 33 ]. This EPHPP instrument can be used to assess the quality of quantitative studies with a variety of study designs.

2.1. Literature Search

The literature review involved searches in PubMed, Web of Science and Cochrane Library database. The search strategy was designed to be inclusive and focused on three key elements: population (e.g., children); intervention (e.g., school-based); outcome (e.g., diet and nutrition, knowledge, attitude and anthropometrics). The search terms used in PubMed database were: “effectiveness of school food AND nutrition AND primary school children”, “effectiveness of school food AND nutrition AND interventions OR programs AND among primary school children AND increase healthy consumption”, “primary school children and education and food interventions”, “Effectiveness of school-based food interventions among primary school”, “effectiveness of school-based nutrition and food interventions”, “primary school interventions and its effectiveness”, and “obesity prevention intervention among Primary schools”. Search terms such as: “effectiveness of school-based food interventions among primary school”, “effectiveness of school based food and nutrition interventions”, “primary school interventions and its effectiveness” and “obesity prevention interventions”, were used in the Web of Science database. Lastly, search terms such as: “nutrition interventions in primary schools” and “Nutrition education interventions in school” were used in the Cochrane Library database to find the articles. In addition, reference lists of all retrieved articles and review articles [ 34 ] were screened for potentially eligible articles. The search strategy was initially developed in PubMed and adapted for use in other databases. In addition, snowballing of the reference list of the selected articles was conducted.

2.2. Inclusion Criteria

Studies selected for the inclusion were studies which investigated the effectiveness of a school-based interventions targeting food and nutrition behaviour, healthy eating and nutrition education as a primary focus during the intervention. Also, to be included in this review, only articles from 2014 to 2019 were selected and of those inclusion criteria included articles targeting primary school children aged between 5 and 14 years. Participants included both boys and girls without considering their socio-economic background. Study design included randomized controlled trial “RCT”, cluster randomized controlled trial “RCCT”, controlled trial “CT”, pre-test/post-test with and without control “PP”, experimental design “Quasi”. Studies which did not meet the intervention components/exposures, such as information and teaching (mostly for the target group and parents were additional), family focus on social support and food focus (which mainly focuses on the availability of free foods including food availability from school gardening), were excluded. Systematic review papers and studies written in different language except for English were excluded as well. Studies which met the intervention criteria but had after school programs were excluded.

2.3. Age Range

Since the review covers a broad range of different countries and since school systems are quite different, the sampling principle had to include some simplification and standardisation. The goal of the review was to cover elementary (primary) and secondary education and, as a result, the age range of 5–14 was chosen to be the best fit, although it should be noted that secondary education in some countries also covers those 15–18 years of age. In most countries, elementary education/primary education is the first—and normally obligatory—phase of formal education. It begins at approximately age 5 to 7 and ends at about age 11 to 13 and in some countries 14. In the United Kingdom and some other countries, the term primary is used instead of elementary. In the United States the term primary refers to only the first three years of elementary education, i.e., grades 1 to 3. Elementary education is, in most countries, preceded by some kind of kindergarten/preschool for children aged 3 to 5 or 6 and normally followed by secondary education.

2.4. Assessment of Study Eligibility

For the selection of the relevant studies, all the titles and abstracts generated from the searches were examined. The articles were rejected on initial screening if the title and abstract did not meet the inclusion criteria or met the exclusion criteria. If abstracts did not provide enough exclusion information or were not available, then the full text was obtained for evaluation. The evaluation of full text was done to refine the results using the aforementioned inclusion and exclusion criteria. Thus, those studies that met predefined inclusion criteria were selected for this study.

2.5. Analytical Approach

The first step of data collection was aimed at organizing all studies with their key information. In the second step, we created coded columns. A coded column served as a basis for being able to do further statistical analysis. In other words, in a coded column we added a new construct not originally found in the papers as a kind of dummy variable that standardized otherwise non-standardized information, allowing us to treat otherwise un-calculable data statistically. For the impact columns, we used the following approach to construct codes where impacts where put on a 1–4-point Likert scale with 1 being “ineffective”, 2 “partially effective”, 3 “effective” and 4 “very effective”.

For the design column, the following approach was adopted as illustrated in the Table 1 . Quasi experimental/pre–post studies were labelled QED and were considered to always include a baseline and follow-up outcome measurement. As the simplest design with no comparison but just a pre/post study of the same group, we constructed a power column and assigned 1 to this for a QED design. For the controlled trial (CT), we assigned the power 2. A controlled trial is the same as QED but with a comparison/control in which no interventions are made and with no randomization. We considered a study to be of that kind if some kind of controls were made which could be, for instance, matching. All CTs in our study included 2 types of comparisons: pre and post (baseline and follow-up) as well as a comparison between intervention/no intervention. For the RCT/RCCT—a trial that is controlled through the randomization—we assigned the power 3. This “top of hierarchy” design includes the case (intervention) and a control (no intervention) and normally two types of comparisons (pre and post) as well as an intervention/no intervention. For the context of this study, we did not differentiate between RCTs and RCCTs. The latter is sometimes used to stress the fact that the school (or the class) is the sampling unit from which the subjects are recruited. But since in the context of schools RCCT is simply a variation of RCT, we coded them in the same class of power. We simply assumed that when authors spoke about an RCT, they in fact meant an RCCT since they could not have been sampling subjects without using the school as the unit.

Coding table for study designs. The table shows the types of studies examined in the review and the power assigned to them.

Code	Design	Power
PP	Pre-Test/Post-Test	1
OBS	Observational	1
CT	Controlled Trial	2
RCT	Randomized Controlled Trial	3
RCCT	Randomized Controlled Cluster Trial	3

Codes and categorization were used to standardize the information found in the papers for our statistical analysis. Categorisation of the age/class level, such as EA—Early age, EML—Early middle late, EL—Early late, was used.

For the intervention components (“what was done”) we translated all studies into three columns: information and teaching, family and social support and environmental components, food provision and availability. The latter was further expanded into three columns labelled as: focus on and provisioning of F & V; free food availability through school gardening and availability of food and healthier food environment. Our inclusion criteria were that studies should contain at least one of these components. For the environmental component—food provision and availability intervention components—we identified 2 distinct types: either a broad healthier eating focus or a narrow and more targeted fruit and vegetable focus. After the coding, we started to ask questions about the data. Most importantly, we were interested in knowing whether there existed a relationship between “what was done” and “what was the impact”. In other words, we were interested in knowing more whether there was a pattern in the way the studies intervened and the outcomes.

2.6. Queries Made

We performed queries for each intervention component (the independent variable in columns K, L and M) for each single outcome measure.

Is there a relationship between age and outcome? We used the coded column (EA, EML, etc.) to study that relationship.

In addition, we made queries regarding the relationship among study designs. For instance, would the duration of studies influence whether an effect could be found or not? Would more powerful designs result in more impact?

Furthermore, we made queries on the relationship between one intervention and a multi-interventional component and their effect on the outcome measure. Also, the queries on target groups were made. Codes such as S and NS (refer Table 4) in the column were used to study the relationship. In our analysis a distinction was made between “standard” and “extreme” (special cases). From the reviewed papers, it was clear that some studies put little emphasis on the school selected. We classified those as standard (S). However, a few papers used a stratification approach and case/cluster selection that can be classified as an “extreme” or non-standard case. We coded these as non-standard (NS). For instance, studies could be targeted to include only refugees or subjects of low socio-economic status. It can be speculated that being a “special case” or extreme case could have an influence. As a result, we reserved a code for these cases, although it became clear that they represented only a minority.

In our study, availability plays a central role, since it is used in many food-at-school intervention studies. Availability signals that food is “pushed” as opposed to being used in the “pull” mode, where individuals are expected to request food in the sense that is the behaviour of the individual that becomes the driving force rather than the “out thereness”. Availability is in most studies used in combination with the idea of a food environment. The literature shows that availability can be of two types. One is when food is made available for the individual to take where visibility, salience, product placement, etc., are used as factors. The other type of availability is when it is made free and the individual as a result does not have to pay. Free availability has been studied extensively in intervention studies but for obvious reason it is difficult to implement “post-study” since there needs to be a permanent financing present. The only exceptions to this are the collective meal models found in countries such as Sweden, Finland, Estonia and Brazil as well as in the EU scheme where the EU subsidizes the fruit.

Study design and other characteristics are provided in Table 2 , and their findings are provided in Table 3 .

The review sample: study design/characteristics. The table shows the 43 studies of the review Illustrating study design and study characteristics of the included studies.

Author	Year	Title/Reference	Main Aim (from Abstract)	Main Aim in Brief	Program Name	Location & Country	Study Design	Study Design Coded	Power	Intervention Components
					Acronym		Column I	RCT, PP, CT, RCCT, Quasi		Information and Teaching	Food Focus		Family/Social Support
					Acronym		Column I	RCT, PP, CT, RCCT, Quasi		Information and Teaching	Environmental/Food Focus on Healthy Meal Availability	Environmental/Food Focus through School Gardening	Family/Social Support
Harake et al. [ ]	2018	Impact of pilot school-based nutrition intervention on dietary knowledge, attitudes, behaviours and nutritional status of Syrian refugee children in the Bekaa, Lebanon	This study aimed to evaluate the impact of a six-month pilot school-based nutrition intervention on changes in dietary knowledge, attitude, and behavior of Syrian refugee children enrolled in informal primary schools located in the rural region of the Bekaa in Lebanon. A secondary objective of the study was to explore the effect of the intervention on the dietary intake and nutritional status of children.	Nutritional knowledge, attitude, HE & FV	GHATA	Bekaa Lebanon	Quasi experimental	QED	1	x		x
Adab P, et al. [ ]	2018	Effectiveness of a childhood obesity prevention programme delivered through schools, targeting >6 (more than 6 years) and 7 years old cluster randomised controlled trial (WAVES study)	To assess the effectiveness of a school and family based healthy lifestyle programme (WAVES intervention) compare with usual practice, in preventing childhood obesity.	Anthropometry, HE & FV	WAVES	UK primary schools from the West Midlands within 35 miles of the study centre	Randomized Controlled Cluster Trials	RCCT	3	x
Harley A, et al. [ ]	2018	Youth Chef Academy: Pilot Results From a Plant-Based Culinary and Nutrition Literacy Program for Sixth and Seventh Graders	The study aim was to examine the effectiveness of Youth Chef Academy (YCA), a classroom-based experiential culinary and nutrition literacy intervention for sixth and seventh graders (11- to 13-year-old) designed to impact healthy eating.	HE & FV, Nutritional knowledge	YCA	US (exact location is missing)	Controlled Trial (CT)	CT	2	x
Hermans R.C.J. et al. [ ]	2018	Feed the Alien! The Effects of a Nutrition Instruction Game on Children’s Nutritional Knowledge and Food Intake	The aim of this study was to test the short-term effectiveness of the Alien Health Game, a videogame designed to teach elementary school children about nutrition and healthy food choices.	HE & FV, Nutritional knowledge	AHG	Dutch, Netherland	Pre-test post-test, experimental study design	QED	1	x
Piana N., et al. [ ]	2017	An innovative school-based intervention to promote healthy lifestyles	To describe an innovative school-based intervention to promote healthy lifestyles. To evaluate its effects on children’s food habits and to highlight the key components which contribute most to the beneficial effects obtained from children’s, teachers’ and parents’ perspectives.	HE & FV, Nutritional knowledge, Physical activity	Kidmed test	Spoleto, Umbria	Pre-test post-test	PP	1	x			x
Battjes-Fries M.C.E., et al. [ ]	2017	Effectiveness of Taste Lessons with and without additional experiential learning activities on children’s willingness to taste vegetables	The aim of this study was to assess the effect of Taste Lessons with and without extra experiential learning activities on children’s willingness to taste unfamiliar vegetables, food neophobia, and vegetable consumption.	HE & FV, attitude	TLVM	Dutch province of Gelderland	Quasi experimental design	QED	1	x
Bogart L.M., et al. [ ]	2014	A Randomized Controlled Trial of Students for Nutrition and eXercise (SNaX): A Community-Based Participatory Research Study	To conduct a randomized controlled trial of Students for Nutrition and eXercise (SNaX), a 5-week middle-school-based obesity-prevention intervention combining school-wide environmental changes, multimedia, encouragement to eat healthy school cafeteria foods, and peer-led education.	HE & FV, Nutritional knowledge	SNaX	Los Angeles Unified School District	Randomized Controlled Trial	RCT	3	x
Shriqui V.K., et al. [ ]	2016	Effects of a School-Based Intervention on Nutritional Knowledge and Habits of Low-Socioeconomic School Children in Israel: A Cluster Randomized Controlled Trial	Examining the effect of a school-based comprehensive intervention on nutrition knowledge, eating habits, and behaviours among low socioeconomic status (LSES) school-aged children was performed	Anthropometry, HE & FV, Nutritional knowledge	NRI & PA	Beer Sheva, a big metropolis in southern Israel	Randomized Controlled Cluster Trial	RCCT	3	x			x
Sharma S.V. et al. [ ]	2016	Evaluating a school-based fruit and vegetable co-op in low-income children: A quasi-experimental study	The purpose of this study was to evaluate the effectiveness of a new school-based food co-op program, Brighter Bites (BB), to increase fruit and vegetable intake, and home nutrition environment among low-income 1st graders and their parents.	HE & FV, Nutritional knowledge	BB	Houston, Texas	Quasi-experimental non-randomized controlled study	QED	1	x		x	x
Lawlor A.D. et al. [ ]	2016	The Active for Life Year 5 (AFLY5) school-based cluster randomised controlled trial: effect on potential mediators	To determine the effect of the intervention on potential mediators	Anthropometry, HE & FV	AFLY5	South East of England	Cluster RCT	RCCT	3	x			x
Steyn P.N. et al. [ ]	2016	Did Health kick, a randomised controlled trial primary school nutrition intervention improve dietary quality of children in low-income settings in South Africa?	To promote healthy eating habits and regular physical activity in learners, parents and educators by means of an action planning process	HE & FV, PA	HK	Western Cape (WC) Province	Cluster RCT	RCCT	3	x
Jones M. et al. [ ]	2017	Association between Food for Life, a Whole Setting Healthy and Sustinable Food Programme, and Primary School Children’s Consumption of Fruit and Vegetables: A cross Sectional Study in England	The aim of the study was to examine the association between primary school engagement in the Food for Life programme and the consumption of fruit and vegetables by children aged 8–10 years.	HE & FV, Nutritional knowledge	FLP	England	Cross sectional school matched comparison approach	Cross-sectional study design	1	x		x
Larsen L.A. et al. [ ]	2015	RE-AIM analysis of a randomized school-based nutrition intervention among fourth-grade classrooms in California	To promote healthy eating behaviours and attitudes in children	HE & FV, Nutritional knowledge, Attitude	NPP	California	RCT with pre-, post-, and follow-up assessments	RCT	3	x			x
Shen, Hu and Sun [ ]	2015	Assessment of School-Based Quasi-Experimental Nutrition and Food Safety Health Education for Primary School Students in Two Poverty-Stricken Counties of West China	Aimed to assess the reliability of the knowledge, attitude and behaviour of nutrition and food safety questionnaire for primary school students (Grade 4 to 6) in poverty-stricken counties of China, and evaluate the effectiveness of health education through a quasi experiment, in order to promote policy establishment for child and adolescent health in the future	HE & FV, Nutritional knowledge, Attitude	NFSE	West China (Shaanxi and Yunnan provinces)	Quasi-experimental design	QED	1	x
Gallotta C.M. et al. [ ]	2016	Effects of combined physical education and nutritional programs on schoolchildren’s healthy habits	To evaluate the efficacy of three 5-month combined physical education (PE) and nutritional interventions on body composition, physical activity (PA) level, sedentary time and eating habits of schoolchildren	Anthropometry, HE & FV, Nutritional knowledge, PA	ESFS	Rome (Italy)	Randomised Controlled Cluster Trial	RCCT	3	x			x
Fairclough J.S. et al. [ ]	2013	Promoting healthy weight in primary school children through physical activity and nutrition education: a pragmatic evaluation of the CHANGE! randomised intervention study	To assess the effectiveness of the CHANGE! intervention on measures of body size, PA and food intake	Anthropometry, HE & FV, PA	CHANGE	Wigan Borough in northwest England, UK	Cluster randomised intervention	RCCT	3	x
Cunha B.D. et al. [ ]	2013	Effectiveness of a randomized school-based intervention involving families and teachers to prevent excessive weight gain among Adolescents in Brazil	To evaluate the effectiveness of a school-based intervention involving the families and teachers that aimed to promote healthy eating habits in adolescents; the ultimate aim of the intervention was to reduce the increase in body mass index (BMI) of the students	Anthropometry, HE & FV, PA	PAPPAS	Duque de Caxias, Rio de Janeiro, Brazil	Paired cluster randomized school-based trial	RCCT	3	x
Aviles O.A. et al. [ ]	2017	A school-based intervention improved dietary intake outcomes and reduced waist circumference in adolescents: a cluster randomized controlled trial	The program aimed at improving the nutritional value of dietary intake, physical activity (primary outcomes), body mass index, waist circumference and blood pressure (secondary outcomes)	Anthropometry, HE & FV, PA	ACTIVITAL	Urban area of Cuenca, Ecuador	Pair-matched cluster randomized controlled trial	RCCT	3	x			x
Muros J.J. et al. [ ]	2013	Results of a seven-week school-based physical activity and nutrition pilot program on health-related parameters in primary school children in Southern Spain	To determine the effect of nutrition education combined with sessions of vigorous extracurricular physical activity (VEPA) on the improvement of health-related parameters in children in primary education	Anthropometry, HE & FV, PA	VEPA	Southern Spain	Pilot study, PP	QED	1	x
Moss A et al. [ ]	2013	Farm to School and Nutrition Education: Positively Affecting Elementary School-Aged Children’s Nutrition Knowledge and Consumption Behavior	To introduce the CATCH nutrition curriculum and Farm to School program to assess nutrition knowledge of 3rd grade students, and increase their fruit and vegetable consumption behavior	HE & FV, Nutritional knowledge	CATCH	Southern Illinois	Quasi-experimental design	QED	1	x
Zota D. et al. [ ]	2016	Promotion of healthy nutrition among students participating in a school food aid program: a randomized trial	To evaluate the potential benefits on students’ eating habits, of incorporating healthy nutrition education as part of a school food aid program	Anthropometry, HE & FV	DIATROFI	Greece	Randomised Controlled Trial with the aspects of pre and post intervention questionnarie	RCT	3	x		x	x
Gold A. et al. [ ]	2017	Classroom Nutrition Education Combined With Fruit and Vegetable Taste Testing Improves Children’s Dietary Intake	To test the classroom curriculum, go wild with fruits & veggies! (GWWFV) effectiveness to increase FV intake of third graders in rural and urban communities in North Dakota	HE & VF	GWWFV	North Dakota	Intervention study with RCT aspects (the schools were randomized to control and intervention school)	RCT, Intervention study	3	x
Mbhatsani H.V., et al. [ ]	2017	Development and Implementation of Nutrition Education on Dietary Diversification for Primary School Children	To ensure that people consume a variety of foods that, together, provide adequate quantities of all the essential micronutrients necessary for health	HE & FV, Nutritional knowledge	NET & HBoIF	Vhembe District of Limpopo Province in South Africa	Quasi-experimental, with a one-group pre-test/post-test intervention	QED	1	x
Hutchinson J. et al. [ ]	2015	Evaluation of the impact of school gardening interventions on children’s knowledge of and attitudes towards fruit and vegetables. A cluster randomised controlled trial	To evaluate whether ongoing gardening advice and gardening involvement from the Royal Horticultural Society (RHS) gardening specialists was associated with better fruit and vegetable outcomes in children than those at teacherled schools that obtained standard advice from the RHS Campaign for School Gardening	Nutritional knowledge, Attitude	CFSG	London boroughs, Wandsworth, Tower Hamlets, Greenwich and Sutton	Randomised Controlled Cluster Trial	RCCT	3	x	x
Viggiano A et al. [ ]	2018	Healthy lifestyle promotion in primary schools through the board game Kaledo: a pilot cluster randomized trial	The board game Kaledo seems to improve knowledge in nutrition and helps to promote a healthy lifestyle in children attending middle and high schools. So, this study was conducted to investigate whether similar effects of Kaledo could be found in younger children in primary school.	Anthropometry, HE & FV, Nutritional knowledge	Kaledo	Campania, Italy	Pilot cluster randomized trial	RCCT	3	x
Waters E. et al. [ ]	2017	Cluster randomised trial of a school-community child health promotion and obesity prevention intervention: findings from the evaluation of fun ‘n healthy in Moreland!	Fun ‘n healthy in Moreland! aimed to improve child adiposity, school policies and environments, parent engagement, health behaviours and child wellbeing	Anthropometry, HE & FV	FHM	Victoria, Australia	Randomised Controlled Cluster Trial	RCCT	3	x
Xu F et al. [ ]	2015	Effectiveness of a Randomized Controlled Lifestyle Intervention to Prevent Obesity among Chinese Primary School Students: CLICK-Obesity Study	To evaluate whether the lifestyle intervention was able to reduce obesity risk and increase healthy behaviors and knowledge	Anthropometry, Nutritional knowledge	CLICK-Obesity	Mainland China	Randomised Controlled Cluster Trial	RCCT	3	x			x
Jung et al. [ ]	2018	Influence of school-based nutrition education program on healthy eating literacy and healthy food choice among primary school children	To examine the effectiveness of a school-based healthy eating intervention program, the Healthy Highway Program, for improving healthy eating knowledge and healthy food choice behavior among elementary school students	Nutritional knowledge, HE & FV	Healthy highway program	Oswego County, New York State	Pre-/post-test	QED	1	x
Jhou W et al. [ ]	2014	Effectiveness of a school-based nutrition and food safety education program among primary and junior high school students in Chongqing, China	To examine the effectiveness of a school-based nutrition and food safety education program among primary and junior high school students in China	Nutritional knowledge, attitude	school-based nutrition and food safety education	Chongqing, China	Pre-/post-test	QED	1	x
Anderson EL, et al. [ ]	2016	Long-term effects of the Active for Life Year 5 (AFLY5) school-based cluster-randomised controlled trial	To investigate the long-term effectiveness of a school-based intervention to improve physical activity and diet in children.	HE & FV, PA	AFLY5	Southwest of England	Randomised Controlled Cluster Trial	RCCT	3	x
Griffin T.L. et al. [ ]	2015	A Brief Educational Intervention Increases Knowledge of the Sugar Content of Foods and Drinks but Does Not Decrease Intakes in Scottish Children Aged 10–12 Years	To assess the effectiveness of an educational intervention to improve children’s knowledge of the sugar content of food and beverages	Nutritional knowledge, attitude	NEMS	Aberdeen, Scotland	Randomised Controlled Cluster Trial	RCCT	3	x
Kipping R.R. et al. [ ]	2014	Effect of intervention aimed at increasing physical activity, reducing sedentary behaviour, and increasing fruit and vegetable consumption in children: Active for Life Year 5 (AFLY5) school-based cluster randomised controlled trial	To investigate the effectiveness of a school-based intervention to increase physical activity, reduce sedentary behaviour, and increase fruit and vegetable consumption in children	HE & FV, PA	AFLY5	South west of England	Randomised Controlled Cluster Trial	RCCT	3	x
Gaar V.M. et al. [ ]	2014	Effects of an intervention aimed at reducing the intake of sugar-sweetened beverages in primary school children: a controlled trial	Aimed at reducing children’s SSB consumption by promoting the intake of water	Nutritional knowledge, attitude	Water campaign	Rotterdam, Netherland	Controlled trial	CT	2	x
Moore GF et al. [ ]	2014	Impacts of the Primary School Free Breakfast Initiative on socio-economic inequalities in breakfast consumption among 9–11-year-old schoolchildren in Wales	To examine the impacts of the Primary School Free Breakfast Initiative in Wales on inequalities in children’s dietary behaviours and cognitive functioning	HE & FV	FSM	Wales, UK	Randomised Controlled Cluster Trial	RCCT	3			x
Nyberg G. et al. [ ]	2016	Effectiveness of a universal parental support programme to promote health behaviours and prevent overweight and obesity in 6-year-old children in disadvantaged areas, the Healthy School Start Study II, a cluster-randomised controlled trial	To develop and evaluate the effectiveness of a parental support programme to promote healthy dietary and physical activity habits and to prevent overweight and obesity in six-year-old children in disadvantaged areas	Anthropometry, HE & FV	A Healthy School Start	Stockholm, Sweden	Randomised Controlled Cluster Trial	RCCT	3	x
Mittmann S., Austel A., and Ellrott T. [ ]	2016	Behavioural effects of a short school-based fruit and vegetable promotion programme: 5-a-Day for kids	To evaluate the acceptance of the scheme as well as the short- and intermediate-term effects of the German “5-a-day for kids” project	HE & FV	5-a-day for kids	Hannover, Germany	Pre-/post-test	PP	1	x		x
Huys N. et al. [ ]	2019	Effect and process evaluation of a real-world school garden program on vegetable consumption and its determinants in primary schoolchildren	To investigate the effectiveness of a school garden program on children’s vegetable consumption and determinants and to gain insight into the process of the program	HE & FV, Nutritional knowledge	Taste Garden	Ghent, Belgium	Non-equivalent pre-test. Post–test control group design	PP	1	x	x
Weber K.S. et al. [ ]	2017	Positive effects of promoting physical activity and balanced diet in a primary school setting with a high proportion of migrant school children	To evaluate the effects of a school-based intervention offering additional hours of supervised physical activity and dietary education for 3rd and 4th graders in primary schools	HE & FV, Nutritional knowledge	‘Be smart. Join in. Be fit.’	Düsseldorf, Germany	Controlled trial	CT	2	x
Llargue’s E. et al. [ ]	2016	Four-year outcomes of an educational intervention in healthy habits in schoolchildren: the Avall 3 Trial	To investigate the impact of the intervention on physical activity, BMI and prevalence of overweight and obesity after 4 years	Anthropometry	The Avall project	Granollers, Spain	Randomised Controlled Cluster Trial	RCCT	3	x
Martins M.L. et al. [ ]	2015	Strategies to reduce plate waste in primary schools—experimental evaluation	To determine and compare the effect of two interventions in reducing the plate waste of school lunches	Nutritional Knowledge	Reduce plate waste	City of Porto, Portugal	Controlled trial	CT	2	x		x
Rosario R. et al. [ ]	2016	Impact of a school-based intervention to promote fruit intake: a cluster randomized controlled trial	To examine the effects of a six-month dietary education intervention programme, delivered and taught by trained teachers, on the consumption of fruit as a dessert in children aged 6–12 years	HE & FV	Dietary education intervention programme	City in north of Portugal	Randomised Controlled Cluser Trial	RCCT	3	x
Zafiropulos V. et al. [ ]	2015	Preliminary results of a dietary intervention among primary school children	To evaluate the effectiveness of the dietary intervention by measuring body composition and dietary behavior of children prior to and after the intervention	Anthropometry, HE & FV	WBDI	central/eastern Crete Greece	RCT with the aspects of pre and post intervention	RCT	3	x

The review sample-findings. The table shows the findings from the 43 studies of the review.

Author	Year	Age	Age Coded			Sample Size, n	Time Duration/Month	Outcome Measures				Effectiveness Among Children				Target Group	Target Group Coded
		Years	EA	EML	EL			Anthropometry	HE/FV	Nutritional Knowledge	Attitude	Anthropometry	HE/FV	Nutritional Knowledge	Attitude		S	NS
Harake et al. [ ]	2018	6–14 years	x	x	x	183	6	x	x	x	x	3	3	4	2	Syrian refugee children in grade 4 to 6 from three informal primary schools (2 intervention and one control)		x
Adab P, et al. [ ]	2018	6–7 years	x			1392	12	x	x			1	1			UK primary schools	x
Harley A, et al. [ ]	2018	11–13 years			x	248	1 and half		x	x			4	4		8 public kindergarten		x
Hermans R.C.J. et al. [ ]	2018	10–13 years		x	x	108	N.A.		x	x			1	1		Dutch children (elementary school children)—3 primary school in the souther part of Netherland	x
Piana N., et al. [ ]	2017	7–9 years	x	x		190	4		x	x			4	4		11 primary school classes in five schools	x
Battjes-Fries M.C.E., et al. [ ]	2017	10–11 years		x	x	1010	3		X		X		1		1	children of 34 elementary school grade 6 and 7	x
Bogart L.M., et al. [ ]	2014	N.A.				2997	41		x	x			4	4		10 schools	x
Shriqui V.K., et al. [ ]	2016	4–7 years	x			240	10	x	x	x		2	4	4		Children attending LSES school classes	x
Sharma S.V. et al. [ ]	2016	N.A. (first grade students)	x			172	24		x	x			3	3		Public or charter schools 1st grade students and their family members		x
Lawlor A.D. et al. [ ]	2016	9–10 years		x		2221 (valid data for the 10 mediators were available for 87% to 96% of participants	36	x	x			1	1			primary school children	x
Steyn P.N. et al. [ ]	2016	Mean age 9.9 years	x			500 intervention and 498 control	36		x				1			primary school children from low income settings	x
Jones M. et al. [ ]	2017	8–10 years		x		2411	24		x	x			4	4		schools engaged with the Food for Life programme	x
Larsen L.A. et al. [ ]	2015	(fourth grade students) average 9 years	x			1713	2		x	x	x		4	4	3	47 fourth-grade California classrooms	x
Shen, Hu and Sun [ ]	2015	10.80 ± 1.14		x		478	8		x	x	x		4	4	1	Twelve primary schools in west China	x
Gallotta C.M. et al. [ ]	2016	8–11 years		x	x	230	5	x	x	x		3	4	3		three primary schools in the rural area in the north of the city of Rome (Italy)	x
Fairclough J.S. et al. [ ]	2013	10–11 years		x	x	318	6	x	x			3	1			12 primary schools	x
Cunha B.D. et al. [ ]	2013	10–11 years		x	x	574	9	x		x		1		3		20 schools with fifth grade classes	x
Aviles O.A. et al. [ ]	2017	12–14 years			x	1430	28	x	x			2	3			20 schools	x
Muros J.J. et al. [ ]	2013	10–11 years		x	x	54	2	x	x			2	2			2 schools from rular environment with same socio economic status	x
Moss A et al. [ ]	2013	N.A. 3rd grade students				65	1		x	x			3	4		3rd grade students	x
Zota D. et al. [ ]	2016	4–11 years	x	x	x	21261	12	x	x	x		3	4	3		students attending both elementary and secondary schools in areas of low socioeconomic status (SES)	x
Gold A. et al. [ ]	2017	8–9 years		x		662	12		x				4			3rd grade children from 26 schools	x
Mbhatsani H.V., et al. [ ]	2017	9–14 years		x	x	172	6		x	x			3	3		2 rural primary schools with similar socioeconomic backgrounds	x
Hutchinson J. et al. [ ]	2015	7–10 years	x	x		1256	12		x	x	x		3	3	2	21 London schools	x
Viggiano A et al. [ ]	2018	7–11 years	x	x	x	1313	2.5	x	x	x		2	3	3		10 primary schools	x
Waters E. et al. [ ]	2017	5–12 years	x	x	x	2965	42	x	x	x		1	3	3		24 schools of Moreland municipality	x
Xu F et al. [ ]	2015	Mean age 10.2		x		1182	10	x		x		2		3		4th grade students from 8 schools of Nanjing, China	x
Jung et al. [ ]	2018	NA (elementry school-kindergarden, 2nd, 3rd, 4th, 5th and 6th graders)	x	x	x	646	12		x	x	x		2	3	2	2 elementary schools	x

The information from abstracts were organized in a table with the following information:

Column A: Authors. The column lists the researchers/authors conducting the study.

Column B: Year. The column shows the year of the publication of the article.

Column C: Title/Reference. The column lists the title of the article.

Column D: Main aim. The column lists the main aim presented by authors in the abstract of each article.

Column E: Main aim in brief. This column is a constructed variable that refers to the main aim of each study. The idea was to give in brief the study idea and which outcome measures was focused on in the study.

Column F: Program name. The column gives the name of the project, program or intervention reported in in the article.

Column G: Location and Country. The column lists the specific place or location where the study was performed.

Column H: Study design. The column shows research design of the study according to authors.

Column I: Study design coded. This column is a constructed variable to capture the research design of the study and used to make an analysis of power possible, see Column J.

Column J: Power. The column was constructed to express the strength of the design. It is a dummy variable that was assigned a numerical value that allowed for a quantitative analytical approach.

Column K, L and M: Intervention components. The column shows which intervention components that was used in the study. We used a model that categorizes components into three different mechanisms of influence: cognitive (K), environmental (L, M, N) and social (O).

The environmental component includes actions where availability of meals—or fruit and vegetable (F & V)—were increased. Either through passive provision (F & V and meals) or through active participation such as gardening. The social category included actions where families and/or peers were actively influencing the participants. The cognitive category included teaching and learning.

Column L: Environmental/food focus on F & V. In this column, interventions which were targeted towards fruits and vegetables were flagged. This includes interventions whose focus was providing cooking lessons and maintaining healthy cafeterias during the intervention periods. Also, maintaining healthy cafeteria here refers to school canteens providing healthy options to its menu where children’s while buying food have healthier options to choose.

Column M: Environmental/food focus on increasing availability through school gardening. In this column, interventions which provided free foods among participants through gardening within the school were listed.

Column N: Environmental/food interventions focused on healthy meal availability. Interventions which provided healthy meals, breakfast, snacks during the school hours and distributed fresh fruits among the participants were listed in this column.

Column O: Family/social support. In this column interventions that included social components were flagged. These interventions included peer and family influence mechanisms.

Column P: Age. The column lists the age of the targeted groups of the intervention expressed in years according to the primary article data provided by authors.

Column Q: Age construct EA. This column shows a constructed variable for the age categorization based on the primary data given by authors. The constructed code was made to make statistical analyses possible. The construct Early Age (EA) was assigned if intervention were carried out in early school.

Column R: Age construct EML. This column shows a constructed variable for the age categorization based on the primary data given by authors. The code Early Middle Late (EML) was assigned if intervention was targeted all age groups.

Column S: Age construct EL. This column shows a constructed variable for the age categorization based on the primary data given by authors. The code EL refers to Early late and was assigned if the intervention was targeted early and early and late school.

Column T: Sample size. The number of young people enrolled in the intervention was listed in this column.

Column U: Time duration. This column shows the length of the intervention expressed in months. It is a constructed variable based on the primary data given by authors and was made to standardize duration and make it ready for cross study analysis.

Columns V, W, X, Y: Outcome measures. In Columns T, U, V, W, the outcome measures named as Anthropometry, HE/FV (healthy eating fruits and vegetables), Nutritional knowledge, and Attitude, respectively, were listed according to our outcome model shown in Figure 1 . Only a few include all outcome measures, but all studies included at least one of them.

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Outcome measures model. The figure illustrates the four types of outcome measures found in the interventions.

Columns X, AA, AB, AC: Effectiveness. The effectiveness as measured by the outcomes measured are listed in this column. Each outcome measure was rated using a Likert scale from 0–4. The effectiveness of outcome measures among participants as measured by the measures in our model ( Figure 1 ): attitude, anthropometry, HE/FV, nutritional knowledge and attitude were listed in the Columns X, Y, Z, AA, respectively.

Column AD: Target group. This column provides information on the target group of interventions such as information on grades of subjects and municipalities.

Columns AE, AF: Target group. This column is a constructed variable created to capture if the intervention had a special ethnic or socio-economic focus. Columns AC and AD consisted of coded target group named as Standard (S) and Non-Standard (NS). The “NS” here represents the target group either from refugees or immigrants or lower socio-economic classes.

Column AG: Keywords. This column lists the keywords found in the interventions.

Ordinary least squares regression was applied in this study; specifically, we used the linear regression function in IBM SPSS 22. We opted for a multi-variate approach; i.e., multiple linear regression was used. Anthropometry, behaviour (healthy eating and food focus), attitude and nutritional knowledge were used as dependent variables. In order to better account for control variables, such as sample size and study length, a dummy variable was introduced for study length of one year and more; and a logarithm of the sample size was used instead of the actual sample size to eliminate scaling effects. We grouped countries by continents (while splitting Europe into North and South as there were enough studies and no countries in between) and introduced related dummy variables. The remaining variables were used as independent variables without any additional manipulations.

Since the aim was to create models consisting only of independent variables that significantly influence the dependent variables, we used the backwards function. Because there were too many independent variables for the backwards function for the attitude model (with only eight observations), the stepwise function was used instead.

Information and teaching was present in all but one study. Free food was found only in two studies and focus on fruit and vegetables in three studies. Therefore, it is not surprising that neither of the three variables were found to be significant in any of the models.

2.7. Study Sample

The search strategy resulted in 1826 titles which were screened for duplicates and potential relevance. After this initial screening, 345 titles and abstracts were assessed against the inclusion and exclusion criteria. Articles that studied school interventions after school hours were excluded. In addition, articles which studied interventions among children in out of school context such as at community level were excluded. The justification is that both “after school” and “out of school” since can be regarded as non-typical school environments. We aimed to study the “school” as an artefact that can be considered as a “standard” across countries despite some national differences. For both “after school” and “out of school”, we argue that there are considerable differences among countries and that an inclusion of such studies would negatively influence our analytical approach. In total, 42 articles were identified as relevant and full papers were obtained as the final sample. Figure 2 below illustrates the search terms and selection process of articles.

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Review flow chart. The figure shows the progress of the literature review process following the PRISMA 2009 approach.

2.8. Intervention Study Characteristics

For all 43 items in our sample, Table 2 provides the information about the study, intervention methodologies, characteristics strategies, etc. In our extract of studies, the sample size ranged from 65-2997 subjects/participants, and the intervention duration ranged from 1 and half month to 36 months. The systematic review locations identified by the author were: 26 from Europe [ 21 , 36 , 38 , 39 , 40 , 44 , 46 , 49 , 52 , 54 , 57 , 58 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 ], six from Asia [ 35 , 42 , 48 , 59 , 60 , 62 ], 10 from America [ 37 , 41 , 43 , 45 , 47 , 50 , 51 , 53 , 55 , 61 ] and one from Africa [ 56 ]. We categorized all interventions according to their intervention components. To this end, we had constructed three classes: Information and Teaching, Food Focus and Family/Social support as illustrated. The interventions characteristics of each included study are shown in Table 2 .

Of the total study sample, the majority of studies ( n = 41) involved “Information and Teaching” components consisting mainly of classroom-based activities (e.g., an adapted curriculum and distribution of educational materials, health and nutrition education program). Another 12 studies along with “Information and Teaching” involved a food focus and availability component. These food and availability components which consisted mainly of supervised school gardening, environmental modifications to stimulate a more healthful diet, such as increased availability and accessibility of healthy foods, distributions free food programmes, school provided free breakfast, school lunch modifications and incentives. Only two studies combined all the three intervention components of this study. Family/social support intervention was clearly focused on in nine study. In other studies, even though their interventions were not primarily or secondarily focused on family/social support component, they indirectly acknowledged the importance of parents and included them in their studies.

All of the reviewed studies included intervention components that were delivered in school settings and within school hours. Our sample showed that consumption of fruit and vegetables was the most used intervention component and was include in more than half of the interventions. Most studies were designed and carried in a way where a research assistant was trained by senior researchers/co-authors to ensure that each members of the research team followed same procedures for data collection. Since all studies were “in situ” studies included a close researcher/school staff cooperation component. In most of the listed studies, teachers being the responsible person to implement the interventions were trained beforehand.

2.9. Types of Interventions

Table 2 shows an overview of the programmes and their intervention components. From the table, it can be seen that studies differed according to how broadly they intervened. Some studies have included a narrow intervention (i.e., only one intervention components which targeted behavioural components), whereas others included multicomponent approaches where all three intervention components were used in the study.

Finding the right approach to intervening for healthier eating at school is a major challenge. In other words, which interventions create which impacts and how should the public best invest in new policies, strategies, and practices at school if long term health is the intended end point?

The purpose of this review was to compile the evidence regarding the effectiveness of successful school-based interventions in improving dietary behaviours, nutritional knowledge, attitudes and anthropometry among children. The analysis of the data showed a number of relationships between outcome effect and a number of other characteristics of the intervention (i.e., age, location/region, intervention type, duration). Descriptive statistics are provided in Table 4 .

Descriptive statistics.

		Minimum	Maximum	Mean	Standard Deviation
Power	42	1.00	3.00	2.2619	0.91223
InfoAndTeach	42	0.00	1.00	0.9762	0.15430
FandV	42	0.00	1.00	0.0714	0.26066
FreeFood	42	0.00	1.00	0.0476	0.21554
AvailFood	42	0.00	1.00	0.1667	0.37720
FamilySocialSupport	42	0.00	1.00	0.2143	0.41530
EA—early age	42	0.00	1.00	0.3810	0.49151
EML—early middle late age	42	0.00	1.00	0.7381	0.44500
EL—early late age	42	0.00	1.00	0.5476	0.50376
SampleSize	42	54.00	21261.00	1464.2619	3277.18184
log10SampleSize	42	1.73	4.33	2.7904	0.54986
Months	41	1.00	112.00	14.6585	19.00245
YearOrMore01	41	0.00	1.00	0.4390	0.50243
AnthropometryScale	18	0.00	4.00	2.0000	1.13759
HEFVScale	36	1.00	4.00	2.5556	1.27491
NutritionalKnowledgeScale	26	1.00	4.00	3.1923	0.89529
AttitudeScale	9	1.00	3.00	1.7778	0.66667

The linear regression models carried out for each intervention component is added in the text and the tables have been referred to each associated result. Out of 42 studies, 36 studies reported the outcome on HE/FV behaviour scale while anthropometry and attitude impacts were observed in 18 and six studies, respectively. The item one of the results in this article presents the most general finding from the literature review, item two describes the variable found significant in two cases, while the remaining variables were significant in once case each. Additionally, item four, five and six are related “design” phenomena effects in the sense that they are not related to intervention components but to the study was designed your study. The rest is related to (intervention components rather than designs. In Table 5 , the outcome measures for which an effect could be seen has been listed. The linear regression model describing what influences the attitude is provided in Table 6 .

Linear regression model for attitude.

Model	Unstandardized Coefficients		Standardized Coefficients	t	Significance
Model	B	SE	Beta	t	Significance
(Constant) FamilySocialSupport EA—early age	1.250	0.177		7.071	0.000
	1.000	0.395	0.500	2.530	0.045
	0.750	0.250	0.593	3.000	0.024

Linear regression model for anthropometry.

Model	Unstandardized Coefficients		Standardized Coefficients	t	Significance
Model	B	SE	Beta	t	Significance
(Constant) Power AvailFood YearOrMore log10SampleSize	4.140	1.008		4.109	0.001
	1.511	0.468	0.859	3.231	0.007
	3.432	0.804	0.976	4.267	0.001
	0.870	0.403	0.384	2.161	0.050
	−2.437	0.503	−1.267	−4.846	0.000

With regards to the explanatory power of the model, R 2 = 0.789, R 2 adj. = 0.719, and significance = 0.009.

The linear regression model describing what influences the anthropometry is provided in Table 6 .

With regards to the explanatory power of the model, R 2 = 0.683, R 2 adj. = 0.586, and significance = 0.003.

The linear regression model describing what influences the behaviour is provided in Table 7 .

Linear regression model for behaviour.

Model	Unstandardized Coefficients		Standardized Coefficients		t	Significance
Model	B	SE	Beta		t	Significance
(Constant) FamilySocialSupport	2.321	0.229		10.131	0.000
(Constant) FamilySocialSupport	1.054	0.486	0.348	2.168	0.037

With regards to the explanatory power of the model, R 2 = 0.121, R 2 adj. = 0.096, and significance = 0.037.

An alternative linear regression model describing what influences the behaviour is provided in Table 8 .

Alternative linear regression model for behaviour.

Model	Unstandardized Coefficients		Standardized Coefficients	t	Significance
Model	B	SE	Beta	t	Significance
(Constant) Neurope	3.227	0.205		15.761	0.000
(Constant) Neurope	−1.727	0.328	−0.670	−5.260	0.000

With regards to the explanatory power of the model, R 2 = 0.449, R 2 adj. = 0.432, and significance < 0.001.

3.1. School-Based Interventions in General Create Impact

Looking across the whole study sample, it can be seen that in general the interventions created an impact in one or more ways either on knowledge, intentions, eating habits and/or anthropometry. In other words, it was hard to find studies that created no impact. This finding adds to the body of evidence that suggests that food-based interventions are a well-suited and effective policy tool when it comes to promoting healthier eating among young people.

3.2. Family Support Affects Healthier Eating Behaviour and Attitude

Out of all the included studies, nine studies focused on family support as an intervention component. But out of those, our analysis showed that the family involvement was impactful among participants when it comes to promoting healthier food choices. Parents being influencers and role models in the family in these studies seemed to help to influence children’s dietary habits. Studies which involved participants’ parents in the intervention and provided them with nutritional knowledge and healthy cooking skills (i.e., knowledge about the importance of healthy food and nutrition during the early age of their children), seemed to be able to help young people prepare more healthy and nutritious food at home. As studies showed, this seemed to increase children’s intentions towards eating more fruits and vegetables and eventually resulted in consumption of more healthy foods. However, this did not seem to be the case for all ages. Intention to eat more fruits and vegetables was seen among early age participants (EA) either alone or with family support. It should be noted that the regression models did not include interactions, since the number of analysed studies was only ~40. It was not possible to include age as a continuous variable in the models because (as it can be seen in Table 5 ) age was a range, and sometimes even a wide range, e.g., 8–11 or 4–11. Family support increases the outcome measure by approximately 1 in both cases. Please refer to Table 5 and Table 7 for detailed linear regression model used for attitude and behaviour.

3.3. Interventions Done in Northern Europe (7 Studies) Had a Smaller Impact on Behaviour than the Studies Conducted in the Rest of the World (22 Studies)

The results from the models which was created to measure the efficiency of HE/FV highlighted the fact that HE/FV scale depends only on region where the intervention was done. The behaviour outcome for Northern Europe was on average 1.5 while the average for the rest was 3.2 (please refer to Table 8 ).

3.4. Effect of Anthropometry Measures Increases with Study Power

The results suggested that the design of the study plays a role when it comes to be able to show impact of interventions. From the findings, it was clear that the anthropometry measured among the participants were increasing with the power of the study. That is, the stronger the design the greater the likelihood of being able to measure impact on anthropometric outcomes—a unit increase in the design power is associated with an outcome increase of approximately 1.5 (please refer to Table 6 ). To examine the influence of study design we used the score that was constructed for the purpose (please refer to Table 1 ). This score assigns a higher power to randomized designs than non-randomized ones.

3.5. Study Duration Impacts Anthropometric Outcomes

It was also clear that the intervention duration does have impact on the outcome, i.e., the longer the duration better the anthropometric results among the children. Interventions that lasted a year or more, had the outcome measure on average almost one unit higher than shorter studies (please refer to Table 6 ).

3.6. Larger Samples Impacts Anthropometry Measures

Results showed that anthropometric outcome decreased within the sample size. Increasing the sample size by a factor of 10, from approximately 100 to 1000, decreased the outcome measure by almost 2.5 (please refer to Table 6 ). Thus, bigger the sample size a reverse effect on outcome was obtained. The studies whose intervention was done for long period of time (i.e., couple of months or year and among small participants) were found to be effective in the outcome. It might be the case that it was hard to administer the same thing to large sample size post intervention and thus could have decreased the anthropometry outcome among the participants.

3.7. Food Availability Interventions Influence Anthropometric Outcomes

Our analyses showed that a food focus, specifically healthy meal availability had an impact on the children’s anthropometric outcomes—increasing it by almost 3.5 on average (please refer to Table 6 ).

3.8. Interventions among Younger Students Influence Attitude Among Participants

Results showed that the younger the study subjects were, the more influence interventions had on attitudes (the outcome was on average 0.75 higher than for other age groups). Thus, the result suggests that the participants’ attitude increases when they are in their early age (EA) i.e., 4–7 years old. Furthermore, results suggest that increased family support associated with participants’ attitude towards healthy eating helps in changing the behaviour among them. Early age (EA) and family support seemed to impact positively both alone and together. Meaning that the intervention had positive impacts on participants (i.e., EA participants) attitudes towards healthy eating either with the involvement of their family support or without the involvement of family support. Please refer to Table 5 for detail linear regression model for attitude.

3.9. No Effect of School Based Interventions on Nutritional Knowledge

Findings showed that nutritional knowledge among participants (i.e., of all age group) does not depend on school-based interventions. Thus, none of the collected variables have influences on nutritional knowledge.

4. Discussion

4.1. discussion of results of this review in relation to others.

In the discussion we aim to relate our findings with what has been found in previous studies, discuss our methodological approach and reflect on what are the policy implications. Since the discussion on how to counteract the unhealthy eating pattern and the worrying increase in nutrition related disorders among young people is attracting much attention and since the discussion on how the school could contribute we aim to give policy makers and practitioners an up to date insight into the potentials of the school to act as a hub for promotion of healthier eating and provide inspiration for the development of new types of school-based interventions and strategies.

The huge interest in using the infrastructure of the school to initiate and promote healthier eating among young people has resulted in a large number of interventions studies over the past decades. This research interest per definition as the same time creates a need for syntheses of the findings in order to make them feed into the public health and school policy cycle and to “send the results to work”. Taken the huge investment that better food at school strategies at school will cost for states it is worth appreciating that the Evidence-Informs-Policy pathway seems to be working. At the same time the conceptual approaches and the understanding of what intervention components might work better than others, which age groups might benefit the most etc. as developed considerably which again adds to the rationale for synthesis of intervention study findings. Most recent reviews by Julie et al. [ 76 ], Noguera el al. [ 77 ], Evans et al. [ 78 ], Cauwenberghe et al. [ 34 ] and Brown et al. [ 79 ] has created a time gap of almost five years. Covering the last five years of research our review makes a needed contribution and in addition we argue it makes a needed contribution to a standardization and conceptualization of both sampling and intervention design methodologies.

Overall, the findings from this review suggest that school-based interventions that include intervention components such as information and teaching, food focus and family support are effective in improving the HE/FV, anthropometric measurements and attitude towards healthy dietary behaviour among the participants. On the other hand, nutritional knowledge among participants did not seem to be influenced much by any of the intervention components used.

Impacts on HE/FV behaviours were observed, but mostly among early age children revealing a distinct age pattern in the findings. Thus, age was seen as a significant factor in determining effectiveness in several study [ 35 , 37 , 39 , 42 ]. Impact was greater on young children in the 4–7 year old age range, suggesting that dietary influences may vary with age.

Multicomponent approaches that includes good quality instruction and programs, a supportive social environment both at school and home, family support has been effective in addressing childhood related diseases through focusing on diet and physical activity. Most of the studies in this review implemented with combination of school staff and intervention specialists provide evidence for the effectiveness of the program. Thus, evidence supports that family involvement and nutrition education curriculum delivered by the teacher under supervision of intervention specialists can alter the intake of fruit and vegetables while impacting positively on anthropometric measurements. Teacher led interventions have been effective and can be the most sustainable approach for long term impact of the program. The same conclusion was found in a review done in investigating the effectiveness of school-based interventions in Europe which provided the effectiveness of multicomponent intervention promoting a healthy diet in school aged children in Europe [ 34 ].Studies with a food focus in their intervention approaches showed significant improvements in BMI [ 35 , 54 , 58 ]. Significant improvements in BMI here refers to the studies whose probability value was less or equal to 0.05. This means that the interventions in that case showed reduction in body mass of participants. We looked at studies whose aim was to focus on interventions of obesity prevention or reduction among primary school children’s. Thus, search term such as: “obesity prevention intervention among primary schools”, was used as explained in the methods section. When performing the search for school-based interventions we did not encounter any studies that were focusing on underweight. Making the options for healthy choices of food in the school cafeterias and having the option of free food from the school gardens decreases the sugar sweetened beverages and junk options among the children’s and thus resulting in improvements in BMI. This review evidence further highlights that duration of the intervention, i.e., a year or more has an impact on anthropometric measurements. This is in contrast to reviews of Julie et al. [ 76 ] and Cauwenberghe et al. [ 34 ] review that found that making the better options of food choices and duration of the studies were effective in reducing the sedentary behaviour and noting improvements in BMI. This study also found that larger sample sizes reverse the outcome of anthropometric measurements (i.e., sample size negatively influences the outcome). This might be the case because it might be harder to administer the same thing to more individual. Thus, more studies are needed to examine the effects of bigger sample sizes.

Our study is far from being the first to create overview of the large number of studies that are studying interventions that can promote healthier eating habits and that can counteract the worrying increase in obesity and overweight among young people the general. The huge interest is reflected in the number of studies trying to assess the impact and effectiveness of school-based interventions as well as in the number of reviews aiming to synthesize the findings from the growing body of evidence of the effect of school-based food interventions into actionable school food policies. Our study adds to this body of knowledge and fills a gap since our study looks at the most recent studies.

Comparing our review with others we find that the majority of the studies on school food-based interventions have been conducted in high income countries. This is also the case in our study and this fact is important to keep in mind since it introduces a bias in the insight created from school food effectiveness reviews. It is also important to keep in mind that studies—and as a result also reviews-covers different types of school food cultures. These cultures can roughly be divided in collective, semi collective and non-collective types. In the collective type found in countries such as Sweden, Finland, Estonia and Brazil school food provision is an integrated—and mainly free—part of the school day. In semi-collective approaches food is in most cases traditionally a part of what is offered at school, but due to payment. In the non-collective approach found in countries such as Denmark, Norway and the Netherlands there is little infrastructure and tradition for school organized foodservice. In this approach parents organized lunch boxes as well as competitive foods traditionally play a bigger role.

A further important note to make is the distinction between narrow F & V approaches and broader healthier eating intervention approaches. This classification can also be seen in previous studies and in more recent reviews. The first type of interventions that follow the six-a-day tradition that to some extent has been fuelled by the European School Fruit program introduced by the EU in 2009 was reviewed by Noguera et al. [ 77 ] and by Evans et al. [ 78 ]. In a study by Noguera el al. [ 77 ] a meta-analysis on F&V interventions was done but limited to educational interventions in the sense that it only looked at computer-based interventions and covering mostly European research. The study showed that this targeted but narrowed approach was effective in increasing FV consumption but that broader multicomponent types of interventions including free/subsidized FV interventions were not effective. In the review paper from 2012 by Evans et al. [ 78 ] examined studies done in United Kingdom, United States, Canada, Denmark, New Zealand, Norway and the Netherlands. Evans and co-workers [ 78 ] found that school-based interventions were able to moderately improve fruit intake but that they had only minimal impact on vegetable intake. These reviews and previous ones generally conclude that F&V targeted interventions are able to improve young people’s eating patterns towards higher intake of fruit.

In the category of reviews taking a broader approach to healthier lifestyle promotion we find studies and reviews that looks at promotion of healthier eating in general—and that in some cases include physical activity. A review by Julie et al. [ 76 ] covered studies from United States, United Kingdom, Australia, Spain and the Netherlands. This review also included physical activity as part of broader school-based obesity prevention interventions. In particular, interventions should focus on extending physical education classes, incorporating activity breaks, and reducing sedentary behaviours to improve anthropometric measures. Julie et al. concluded that interventions taking a broader approach should include employing a combination of school staff and intervention specialists to implement programs; that they should include psychosocial/psychoeducational components; involve peer leaders; use incentives to increase fruit and vegetable consumption and should involve family. In a study by Cauwenberghe et al. [ 34 ] intervention studies done in a European union studies were reviewed. This review—as our study do—made an age distinction in the sense that a categorization was done between children and adolescents. Among children the authors found a strong evidence of effect for multicomponent interventions on fruit and vegetable intake. For educational type of interventions Cauwenberghe et al. [ 34 ] found limited evidence of effect as found when looking at behaviour and fruit and vegetable intakes. The study found limited evidence on effectiveness of interventions that specifically targeted children from lower socio-economic status groups. For adolescents Cauwenberghe et al. [ 34 ] found moderate evidence of effect was found for educational interventions on behaviour and limited evidence of effect for multicomponent programmes on behaviour. In the same way as our review authors distinguished between behaviour and anthropometrics and found that effects on anthropometrics were often not measured in their sample. Therefore, evidence was lacking and resulted in inconclusive evidence. Cauwenberghe et al. [ 34 ] concluded that there was evidence was found for the effectiveness of especially multicomponent interventions promoting a healthy diet but that evidence for effectiveness on anthropometrical obesity-related measures was lacking. In a review by Brown et al. [ 79 ] studies mostly from Europe but also covering United States, New Zealand, Canada and Chile it was found that intervention components most likely to influence BMI positively included increased physical activity, decreased sugar sweetened beverages intake, and increased fruit intake.

Our review adds to the increasing support for the idea that school should play a role in promoting healthier eating habits among young people. As such the school can be seen as an important actor when it comes to the promotion of human rights. In particular; the right to adequate food, the right to the highest attainable standard of health and right to the education, school plays an integral part which has also been highlighted in the “United Nations System Standing Committee on Nutrition” new statement for school-based and nutrition interventions [ 25 ]. Furthermore, Mikkelsen and colleagues [ 80 ] in their study have also suggested the fact that the international framework of human rights should invoke its strategies, policies, and regulations in the context of school and that national, regional, and local level actors has important roles to play. Additionally, they have highlighted that ensuring healthy eating in school environment can be a good investment in children short- and long-term health and education achievements. Thus, schools, as a system have the potential to make lasting improvements in students nutrition both in terms of quality and quantity and simultaneously contribute to realization of human rights around the globe [ 25 ].

4.2. Discussion of Methods

Strengths and limitations.

All attempts to reduce complexity of research studies in a research field suffers from in built weaknesses. Standardising the work of others in attempts to make generalizations is always difficult. As per definition a review includes attempts to standardize its study material in order to create an overview of “what works” and what “this that works” depends on. For obvious reasons research protocols depends very much on the context of the study: What is doable in one study setting on one country might not work on other settings. Additionally, reporting procedures vary among authors. The aim of a review is to standardize this heterogeneity to something that is homogenous and computable. So, in our case our constructs represent an attempt to make different studies with similar but slightly different approaches and methodologies comparable by making them computable. This has obviously some disadvantages.

Another limitation is that our review restricted itself to cover only published English language articles. Therefore, publication bias cannot be excluded, as it is possible that the inclusion of unpublished articles written in other languages than English will have affected the results of this review. Second, most of the studies included in the present were carried out in countries from Southern and Northern parts of Europe. This raises questions about the generalisability of these results to other countries in Europe, especially because contextual variables were often lacking in the included studies. And the same questions about the generalisability could be raise in other parts of the world i.e., in Latin America, North America, Asia and Africa, as very few studies were reported from this part of the world.

On the other hand, large dropouts were reported in many listed studies and the study follow up were reported in few studies and was for short time period. Among these studies which did follow up, was right after the end of the intervention period and thus this could have affected the effectiveness among this study outcomes. Long-term follows-up post-interventions would help to study the retention of behaviour change and effect on the body composition among the participants. Thus, long terms studies post interventions are needed to draw the conclusion about the sustainability of an intervention. Additionally, in future studies to improve the quality of the evidence of effectiveness in this kind of interventions, studies with high quality, rigorous design, appropriate sample size, post interventions long term follow up, assessment of implementation issues and cost effectiveness of the intervention should be executed.

On the strength side the standardisation approach helps to find patterns and to create overview of a large material within a given field of research. The strength of this study is that it provides a broad up to date overview of what is known about the relationship between school-based intervention and policies and healthy eating outcomes among children and that it contributes to the deeper understanding of the fact that current research findings are quite limited. This is among the very few recent reviews which evaluated the effect of school-based food at nutrition interventions among children only. A systematic review approach of this study attempted efficiently to integrate existing information and provide data for researchers’ rationale in the decision making of future research. Furthermore, the applied explicit methods used in this limited bias and, contributed to improved reliability and accuracy of drawn conclusions. Other advantages are that this study looks specifically at the evidence available in Northern and Southern Europe. Statistical analyses of pooled data have facilitated a more through synthesis of the result is one of the biggest strengths of this study.

4.3. Policy Implications

The evidence of the impact of school intervention derived from our review suggests several topics to be dealt with in future research not only in Europe but also the other part of the world. First, this review highlights the need for researchers to recognize the importance of further investigations on the measures of anthropometrics, nutritional knowledge, and attitude. Among these 42 studies carried out in different regions very few looked upon the effects on participants’ attitudes and anthropometrics measures. And of those showed positive impact if family support was provided, if started at early age and lastly if food focus was part of the intervention. Additionally, most of the included studies were not aiming to contribute to obesity prevention. Thus, it is highly recommendable that there is urgent need for more studies to be done that includes more measures of efficiency of participants’ attitude towards the healthy behaviour and healthy lifestyle and measures for anthropometrics. Second, to increase the comparability between studies and to facilitate the assessment of effectiveness, more agreement is needed for best measures of the diet and questionnaires. Third, more research is needed to be done among specific groups like low socio-economic group, immigrants or minorities. As mention earlier, only few listed studies included this specific group in their studies. Furthermore, evidence suggest that health inequalities such as prevalence of overweight are as a result of dietary habits and ethnicity and socio-economic status are identified as determinants of health eating. Thus, future research should not exclude these specific groups as European countries have become ethnically diverse.

To improve or decrease childhood diseases such as overweight and obesity and other aspects of health, many policy documents have been calling for the development of the effective strategies among children’s and adolescents. Even though the limited to moderate impact and evidence was found among these school-based interventions, it should be noted that interventions were not primarily targeting obesity prevention but, in many cases, had a broader scope. Thus, in order to deliver these evidence-based recommendations to policy makers factors such as sustainability of intervention, context and cost effectiveness should be considered. Additionally, the policy makers should ensure school policies and the environment that encourage physical activity and a healthy diet.

5. Conclusions

Findings from this systematised review suggest that applying multicomponent interventions (environmental, educational, and physical strategies) along with parental involvement and of long-term initiatives may be promising for improving dietary habits and other childhood related diseases among primary school children. Despite being challenging to find experimental studies done in related fields, those studies found showed positive trend. Thus, to conclude, evidence of the effect was found among school-based food and nutrition initiatives among primary school children. However, to strengthen the perspectives of this study, further systematic review targeting the more long-term studies assessing the long-term sustainability of the interventions should be considered. Also, studies with goal to increase efficiency of anthropometric measurements in their future school-based interventions could include increasing PA, increasing fruit and vegetable intake and decreasing sedentary behaviour. This study has provided fundamentals background on which further research could be done in this area of school-based food and nutrition interventions. Thus, the findings from this systematic review can be used as guidelines for future interventions in school settings related to food and nutrition. Also, the categorization of intervention components we see as useful for the planning of future interventions.

Author Contributions

Conceptualization, B.E.M. and A.C.; methodology, B.E.M., A.C. and F.S.; validation B.E.M.; formal analysis, F.S.; investigation, A.C.; resources B.E.M. and A.C.; data curation, A.C. and F.S.; writing—original draft preparation, B.E.M., A.C. and F.S.; writing—review and editing, B.E.M., A.C. and F.S.; project administration, B.E.M. All authors have read and agreed to the published version of the manuscript.

This research received no external funding.

Conflicts of Interest

The authors declare no conflict of interest.

Health, Safety and Nutrition for the Young Child Essay

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Healthy food ensures the growth of children, their physical and psychological development. It should be balanced and meet all the needs of the child taking into account his age as well as individual peculiarities. Unfortunately, sometimes it is difficult to make children eat healthy food. In this regard, this paper examines how parents are struggling for the healthy food, tips they could apply, and essential nutrients that their body needs.

During the first two years of life, children are developing very quickly. The child begins life as a helpless newborn baby completely depending on his parents. After that, he turns into a person trying to show his parents that he can be very independent. Toddlers could already understand a lot and begin experimenting with words frequently saying the word “no”. By the age of two, the child forms his inclination and rejection of things, especially in relation to food. Therefore, it seems appropriate to consider healthy toddlers’ healthy feeding.

First of all, the majority of parents make the following mistake: they pamper their child by means of food. In other words, the child is eating only what he wants. At that time, it does not matter for parents whether it is useful or harmful. As a result, when the child acquires some digestive problems, it becomes challenging to get him switch to healthy food and limit his favorite sweets. A variety of chronic diseases of the digestive system appears in that age (Brown 277). Moreover, junk food influences the overall physical development and reduced learning ability. Therefore, parents should pay the increased attention to the quantity, quality, composition, and diet of their children.

Second, parents should try to get the child to eat together with the whole family. It is not always easy to implement, in particular, if the child is active and wayward. However, if parents show the child the example of helpfulness of the healthy nutrition, they do a lot of good as it contributes to child’s awareness at the very beginning of his life. Best of all, if eating with family would be a good tradition. It is the time when everyone gathers to eat and talk, a time when everyone could speak and be heard.

Family dinnertime should not leave an unpleasant residue. During the family meal, the child would see what his parents eat and how they act to adopt their demeanor. Children accustomed eating healthy food get a huge benefit. Healthy food provides them with the building blocks of the body, through which they will grow. Proper nutrition helps children to maintain harmony and good health, strengthen their immune system, reduce the risk of different diseases, and even improve their ability to learn (Marotz 516). Therefore, preparation and consumption of healthy food should be an integral part of every family.

What if you want your child’s food to be healthy, but the child refuses to eat it? In order to resolve this problem, one could try various tips. For example, tell your child that his favorite cartoon character always eats healthy food, that is why he is such a strong, courageous, and brave. If the child is old enough and does not believe your story, you can talk to him as with adult carefully explaining why it is important to eat the appropriate food. In the case your daughter refuses to eat worrying about the overweight, make it clear that the proper and healthy eating contributes to the perfect body.

As a matter of fact, it is parents of the toddler who control his feeding as they decide what products should be an essential part of his everyday menu. In order to attract his attention, they might use different strategies. For example, they could garnish healthy food with berries, funny faces made of that food, and your toddler would undoubtedly eat the whole portion. Thus, it is necessary that the dish should be not only tasty and healthy, but also colorfully decorated. Moreover, children like to view products. Hence, you could hang a picture of “healthy food pyramid” in your kitchen. It would describe in detail, what food should make up the daily diet of the toddler. Probably, it would stimulate the child to eat something that is useful.

In addition, parents should not encourage their child to eat more than he wants to. There is no need to feed him forcibly even if you think that he eats little. He eats as much as he needs. Wanting to feed the child to eat properly it must be remembered that the pressure could lead to opposite results (Leung, Marchand and Sauve 455). Consequently, child’s taste preferences should be respected and taken into account.

Tastes of children of this age are not completely predictable. Year-old child, who devoured boiled potatoes with an appetite last week could inexplicably withdraw it this week. Additionally, some children refuse to eat any vegetables for a long period of time. In that case, parents should continue to feed their child with vegetables he likes remembering about fruits, grain products, and lentils that supply the deficiency of vitamins and minerals (“Feeding Toddlers” par. 7). During this period, it is necessary to choose a flexible strategy of communication.

It goes without saying that parents should avoid fast food. Even if you want to eat hamburgers or French fries on weekends or vacation, try not to tempt children. Instead, make sure that the child could always easily take the food that you consider useful for him. Here are a few examples of how to implement it in practice. A tray or dish with fresh or cooked vegetables should always be stored in the refrigerator on child’s eye level. In addition, during breakfast, lunch or dinner, it should be on the table.

It is also very important to point out the fact that planning child’s diet should take into account certain features of his body and behavior. The main difference between children and adults nutrition is the growth of his body. For example, it is obvious that the toddler needs more protein than the adult does.

Products for nutrition of children should be fresh, high quality, delicious, and highly nutritious. As children get older, their food becomes more diverse, denser products replace semi-liquid and liquid food. The original product processing, in particular, removal of defective parts thorough washing and cleaning influences the quality and taste of ready meals. Failure to comply with rules for processing products might contain bacteria that cause food poisoning. In its turn, it might create some hostility to the healthy food.

Speaking of essential nutrients of the child, it seems important to mention milk, fish, meat, fruits, and vegetables. Milk is a valuable product because it saturates the body with animal protein; it is a source of fats, salts, and vitamins. Meat and fish contain complete proteins, vitamins, trace elements along with phosphorus compounds necessary for proper development of the central nervous system. Fish contains very valuable fish oil. Besides, the healthy diet of children making their first steps should include a variety of fresh vegetables, fruits, beans, and whole grains. It is important to include in their diet some sources of vitamin B12 (such as cereals or soy milk, for example) (“Feeding Toddlers” par. 10). Besides, calcium-rich large-leafy green vegetables and beans fortified with calcium are also essential.

In order to structure the paper, it seems appropriate to consider characteristics of adequate children nutrition in relation to their body and activities.

High mobility. In contrast to adults, children are very mobile. The high mobility of the body of the child helps to normalize his or her metabolism. The limitation of movements of the child would provoke insufficient secretion of growth hormone and, as a result, the development gap. Carbohydrates are the main supplier of energy for muscles and other organs (Samela 14). The more the child is active, the more energy is consumed by his organism. Various cereals, vegetables, honey, and milk contains the essential carbohydrates.
Eating sweets. Due to the high metabolism intensity, children could absorb more sweets than adults without much harm. However, there should be some restrictions. Although, sweet products of natural origin such as dates or raisins are very useful for the child. The child might appeal some sweet vegetables such as carrots or baked beets as well.
Cholesterol . As a major component of the membrane that surrounds the cells of the whole organism, it is extremely important for the health of the child. The child grows up, and his organism produces plenty of new cells. It should also be mentioned that fat cells formed during the first years of life influence the perspective possibility of overweight. Therefore, adult’s health in many respects is connected with nutrition in childhood.
Water . Because of their high mobility, children loss noticeable amount of water, so they cannot be restricted to drink. Nevertheless, parents should not compensate the lack of water by means of sweet compotes or juices, as it leads to the appetite suppression.
Regulatory mechanisms . It is the most important feature of child food. In the body of the child, there are perfectly functioning regulatory mechanisms that control power consumption. However, if there is an abundance of spiced, fried, fatty, and sweet dishes, the physiological function might be disrupted.
General development. This feature requires an adequate nutrition, too. The lack of adequate nutrition might cause “poor mental health and lower IQ in children” (Parletta par. 3). It is important for the child to receive sufficient unsaturated fatty acids many of which are found in olive, linseed, and sunflower oil.

Thus, the healthy nutrition of children requires taking into account features of the body of the child as well as the knowledge of some rules and principles of healthy eating. It should be stressed that providing a healthy diet for children, parents ensure the all-round development, strengthen the immune system of the child, and protect him from diseases generally improving his quality of life.

Works Cited

Brown, Judith E. Nutrition through the Life Cycle . 5th ed. New York: Cengage Learning, 2013. Print.

“Feeding Toddlers.” Parenting and Child Health . n.d.

Leung, Alexander, Valérie Marchand, and Reginald Sauve. “The ‘picky Eater’: The Toddler or Preschooler Who Does Not Eat.” Paediatr Child Health 17.8 (2012): 455-57. Print.

Marotz, Lynn R. Health, Safety, and Nutrition for the Young Child . 9th ed. New York: Cengage Learning, 2015. Print.

Parletta, Natalie. “ Health Check: How to Get Kids to Eat Healthy Food. ” The Conversation . Web.

Samela, Kate. Give Peas a Chance: A Foolproof Guide to Feeding Your Picky Toddler , New York: Cengage Learning, 2013. Print.

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