Nia Dotson
HLTH 698-A
References
1. Adams E, Raynor H, Thornton L, et al. Using digital imagery to quantify students’ added
sugar intake at lunch in Title I schools with universal free meals. Preventative Medicine
Reports. 2020;20. doi: 10.1016/j.pmedr.2020.101253
2. Blakeslee S, Vieler K, Horak I. Planting seeds for the future: scoping review of child
health promotion apps for parents. JMIR mHealth and uHealth. 2023.20(11). doi:
10.2196/39929
3. Bunten A, Porter L, Burgess-Allen J, et al. Using behavioral insights to reduce sugar in
primary school children's packed lunches in derby; a cluster randomized controlled trial.
Appetite. 2021; 157: 104987. doi: 10.1016/j.appet.2020.104987
4. Cohen J, Hecht A, McLoughlin G, et al. Universal school meals and associations with
student participation, attendance, academic performance, diet quality, food security, and
body mass index: a systematic review. Nutrients. 2021;13(3):911. doi:
10.3390/nu13030911
5. Earl L, Lalli, G. Healthy meals, better learners? debating the focus of school food policy
in England. British Journal of Sociology of Education. 2020;41(4):476-489. doi:
10.1080/01425692.2020.1735999
6. Elliot S, McCloskey M, Johnson S, et al. Food photography as a tool to assess type,
quantity, and quality of foods in parent-packed lunches for preschoolers. Journal of
Nutrition Education and Behavior. 2021; 53(2):164-173. Doi:
10.1016/j.jneb.2020.10.007
7. Haney E, Parnham J, Chang K, et al. Dietary quality of school meals and packed lunches:
a national study of primary and secondary schoolchildren in the UK. Public Health
Nutrition. 2023;26(2):425-436. doi:10.1017/S1368980022001355
8. Johnson D, Podrabsky M, Rocha A, et al. Effect of the healthy hunger-free kids act on the
nutritional quality of meals selected by students and school lunch participation rates.
JAMA Pediatr. 2016;170(1):e153918. doi:10.1001/jamapediatrics.2015.3918
9. Lindquist K, Mann G, Farris A, et al. Parent perspectives of packing school lunches.
Journal of Hunger & Environmental Nutrition. 2023; 18(5): 713-730. doi:
10.1080/19320248.2021.1994081
10. Lucas P, Patterson E, Sacks G, et al. Preschool and school meal policies: an overview of
what we know about regulation, implementation, and impact on diet in the UK, Sweden,
and Australia. Nutrients. 2017; 9(7):736. doi: 10.3390/nu9070736
11. Lundbord P, Rooth D, Alex-Peterson J. Long-term effects of childhood nutrition:
evidence from a school lunch reform. The Review of Economic Studies. 2022;89(2): doi:
10.1093/restud/rdab028
12. Melnick E, Thomas K, Farewell C, et al. Impact of a nutrition education programme on
preschool children’s willingness to consume fruits and vegetables. Public Health
Nutrition. 2020;23(10):1846-1853. doi:10.1017/S1368980019005032
13. Merlo C, Smarsh B, Xiao X. School nutrition environment and services: policies and
practices that promote healthy eating among k-12 students. Journal of School
Health.2023;93(9):762-777. doi: 10.1111/josh.13365
14. Nathan N, Janssen L, Sutherland R, et al. The effectiveness of lunchbox interventions on
improving the foods and beverages packed and consumed by children at centre-based
care or school: a systematic review and meta-analysis. International Journal of
Behavioral Nutrition and Physical Activity. 2019;16(38). doi: 10.1186/s12966-019-0798-
1
15. O’Rourke B, Shwed A, Bruner B, et al. What's for lunch? Investigating the experiences,
perceptions, and habits of parents and school lunches: a scoping review. Journal of
School Health. 2020;90(10):812-819. doi: 10.1111/josh.12944
16. Parnham J, Chang K, Rauber F, et al. The ultra-processed food content of school meals
and packed lunches in the UK, 2008-17: a pooled cross-sectional study. Lancet.
2022;400(S12). doi: 10.1016/S0140-6736(22)02222-X
17. Shukaitis J, Elnakib S, Cuite C. Yumbox: A tool to improve the quality of preschoolers’
packed lunches. Journal of Nutrition Education and Behavior. 2021;53(8):719-723. doi:
10.1016/j.jneb.2021.04.007
18. Sutherland R, Nathan N, Brown A, et al. A randomized controlled trial to assess the
potential efficacy, feasibility and acceptability of an m-health intervention targeting
parents of school aged children to improve the nutritional quality of foods packed in the
lunchbox 'SWAP IT'. International Journal of Behavioral Nutrition and Physical
Activity.2019;16(54). doi: 10.1186/s12966-019-0812-7
19. Sutter C, Taylor J, Nishina A, et al. Parental and family predictors of fruits and
vegetables in elementary school children's home-packed lunches across a school week.
Appetite. 2019;133:423-432. doi: 10.1016/j.appet.2018.12.003
20. Watson-Mackie K, McKenzie H, McKay F. Are mothers under lunchbox pressure? An
exploration of the experiences of Victorian mothers preparing lunchboxes for their
children. Health Promotion Journal of Australia. 2022;34(1): 91-99. doi:
10.1002/hpja.681
Nia Dotson
HLTH 698-A
Annotated Bibliography
1. Adams E, Raynor H, Thornton L, et al. Using digital imagery to quantify students’ added
sugar intake at lunch in Title I schools with universal free meals. Preventative Medicine Reports.
2020;20. doi: 10.1016/j.pmedr.2020.101253
Sugar, sweets, and sweetened beverages continue to be a focus for policymakers and
researchers, as they contribute to undesirable effects in young children. 2103 students
between the first and fifth grader’s meals were provided and recorded based on their
consumption to understand the amount of sugars that are ingested in school lunches. It
was found that students in the sample consumed around 2.5% of their recommended daily
calorie intake from added sugars at school lunch, which was lower than researchers had
intended prior to implementation. It is implied that school lunches are not the root cause
of the excessive sugar intake reported in young children. Future studies should focus on
the increase in other nutritional food groups.
2. Blakeslee S, Vieler K, Horak I. Planting seeds for the future: scoping review of child health
promotion apps for parents. JMIR mHealth and uHealth. 2023.20(11). doi: 10.2196/39929
A scoping review was done with 39 studies to understand the guidelines, identification
and implementation of web-based apps and how these apps can influence health
promotion among school children. Qualitative and quantitative methodologies were
utilized to discover eight core topics, such as: parental feeding and nutrition, physical
activity, maternal-child health, parent-child health, healthy environment, dental health,
mental health, and sleep. Child health apps were discovered to focus on a strong
theoretical groundwork before implementation to support the adoption of desired
behaviors. Tailored content, adaptive features and well-researched parameters are
components that will be essential to successful implementation of this intervention.
3. Bunten A, Porter L, Burgess-Allen J, et al. Using behavioral insights to reduce sugar in
primary school children's packed lunches in derby; a cluster randomized controlled trial.
Appetite. 2021; 157: 104987. doi: 10.1016/j.appet.2020.104987
Monitoring sugar intake, specifically, in children’s packed lunches has been a focus when
discussing the overall comparisons between home-packed lunches and school-provided
lunches. Researchers have found difficulty in implementing successful interventions to
improve healthy packed lunches. Previous studies showed that interventions such as the
“SMART lunchbox” and an intervention using educational videos and incentives had a
positive effect on the overall quality of packed lunches, but did not effectively reduce the
provision of sweets and sweetened beverages. Thus came a need to tailor the focus to
develop planning to reduce the overall rates of sweets provided in packed lunches, which
is where this study has found itself examining. A cluster randomized controlled trial
involving 27 schools utilized methods such as a review of packed lunch contents, parental
survey, and the implementation of informational items were provided. The intervention
had a positive impact on parents choosing to swap for healthier items, but did not prove
to stick, as the effect disappeared at the three month check in. Future studies should note
the educational materials and resources, alone, were not strong enough to create a long
standing behavioral change and more investigation should be done to discover the
barriers to success.
4. Cohen J, Hecht A, McLoughlin G, et al. Universal school meals and associations with student
participation, attendance, academic performance, diet quality, food security, and body mass
index: a systematic review. Nutrients. 2021;13(3):911. doi: 10.3390/nu13030911
A total of 47 articles were carefully identified and ran through the Newcastle-Ottawa
Scale to assess bias, to understand the association between universal free school meals
and school meal participation rates, diets, attendance, academic performance, body mass
index, and school finances; all of which contribute to the overall well being of school
children. Overall, the studies reviewed found support for a strong, positive association
between universal free school meals and increased rates of meal participation. The results
of universal free meals on school attendance was varied, but suggested that universal free
meals improved food security among students. Positive correlations were found with the
categories of diet quality and academic performance, specifically when high nutrition
standards were met with the provided meals. In terms of BMI, while more research and
review is needed, it was found that students who had universal free lunch available were
more likely (1.2%) to be a healthy weight and 0.7% less likely to be obese. The effect of
universal free meals showed that both low income and high income benefitted both
academically and physically.
5. Earl L, Lalli, G. Healthy meals, better learners? debating the focus of school food policy in
England. British Journal of Sociology of Education. 2020;41(4):476-489. doi:
10.1080/01425692.2020.1735999
Physical health is often a main focus of the implementation of healthy school lunches, but
researchers within this article shift the focus to an emphasis on important social,
wellbeing, and cultural development. The article dives into the complex nature of the
culture surrounding food and why it is important to provide ample opportunity and
options to school children to develop, both physically and mentally, in ways such as
social learnings in dining halls, food identities and food choices, a point of formal and
informal learning spaces. Qualitative methodology was utilized to identify these main
points to strengthen the argument the researchers have presented.
6. Elliot S, McCloskey M, Johnson S, et al. Food photography as a tool to assess type, quantity,
and quality of foods in parent-packed lunches for preschoolers. Journal of Nutrition Education
and Behavior. 2021; 53(2):164-173. Doi: 10.1016/j.jneb.2020.10.007
Young children spend an ample amount of time in an early care or school environment,
so the meals offered in these programs are essential to the overall health and nutrition of
many students. This study focuses on the ideology of food photography to provide an
understanding of the ratio of food provided to students versus food consumed. At young
ages, parental figures are the decision makers, so an opportunity was found to implement
a food photography program to measure the types of foods offered, the quantity of foods
offered and consumed, and the quality of foods offered. Qualitatively, parental interviews
were utilized to review the approaches to packed lunches. Results showed that most
parent packed lunches failed to provide the recommended amounts of nutrients, with only
16.2% of lunches meeting national requirements. There was a wide variety of foods
offered but it was noted that many lunches included an overserving of grains (limited in
whole grains) and a low rate of vegetables. Overall, children consumed fewer amounts of
vegetables. Through parental interviews, it was shown that parents struggled with
wanting to pack healthy lunch items while balancing the knowledge of if their child
would consume the healthier options they packed, despite quantitative results showing
that food left uneaten was even across all food groups. Overall, food photography showed
to be an effective and low-burden method to capture information on home-packed
lunches through a clear and visual lens. The study suggested that further studies should
attempt to utilize this method as a tool to understand further barriers and educational
programming surrounding childhood nutrition.
7. Haney E, Parnham J, Chang K, et al. Dietary quality of school meals and packed lunches: a
national study of primary and secondary schoolchildren in the UK. Public Health Nutrition.
2023;26(2):425-436. doi:10.1017/S1368980022001355
A gap was found when reviewing comparing the nutritional gap between school meals
and packed lunches, highlighting a need to understand the nuance and difference between
primary and secondary schoolchildren in the UK as a whole. Cross sectional data
provided via the National Diet and Nutrition Survey was used to draw a stratified sample,
to create a representative sample for the study. Overall, the sample of children ran even
keel when looking at ethnicity patterns and gender, but differed in economic status,
finding the students in the low income bracket were more likely to consume a school
provided meal across all ages. Packed lunches were associated with a higher amount of
vegetables and protein rich foods, and less rates of fruit overall. On average, the
proportion of meals with fruits, vegetables, protein-rich foods, and dairy consumed
decreased across both school provided lunches and home lunches, among older students.
Overall, children who consumed school provided meals were more likely to meet
nutritional guidelines, especially when it comes to the amount of vegetables consumed
and the limitation of sweet and savory snacks.
8. Johnson D, Podrabsky M, Rocha A, et al. Effect of the healthy hunger-free kids act on the
nutritional quality of meals selected by students and school lunch participation rates. JAMA
Pediatr. 2016;170(1):e153918. doi:10.1001/jamapediatrics.2015.3918
Reviewing and understanding the results of program implementation is essential to
understand their effects on the overall nutrition of students and are needed for future
research so there is consistent improvement within this field. The Healthy Hunger-Free
Kids Act was fully implemented during the 2012-2013 school year with a mission to
align school meal programs with national dietary guidelines. The study aimed to
understand changes in nutrition quality of school meals after the implementation of the
Healthy Hunger-Free Kids Act. Using a longitudinal study, it was found that nutrient
density increased after program implementation, while energy density decreased with the
new program, suggesting that increase of variety, portion size, and number of servings of
fruits and vegetables was successful in behavior changes. Programming did not have a
significant effect on school lunch participation, which continues to be an area of
improvement among researchers. Future studies should focus on the data surrounding the
actual ingestion of nutrients among students and utilizing a time series analysis to
understand the effects of programming over time.
9. Lindquist K, Mann G, Farris A, et al. Parent perspectives of packing school lunches. Journal
of Hunger & Environmental Nutrition. 2023; 18(5): 713-730. doi:
10.1080/19320248.2021.1994081
Far more of the studies of childhood nutrition focus on school provided lunches rather
than packed school lunches. There is a need for more research on packed school lunches
where they are seen to be less nutritious than the government issued school meals. The
focus group obtained was a group of third grade children through the course of five
consecutive days, with 118 total students being followed. There was an intentional focus
on comparing the contents of the lunches packed, while also monitoring the rate of food
waste in determining what the true amount of food eaten was. Results showed that as
compared to water, sugar-sweetened beverages were present in more of the lunches by
17% and were consumed at a higher rate (92% consumption of water, 94.6%
consumption of sugar-sweetened beverages). Overall, children who consumed the packed
school lunches, fell within calorie recommendations and met the requirements for healthy
macronutrient intake, but were insufficient in maintaining healthy levels of sugar intake
and a below average intake of fiber. The study suggests that future investigations
highlight plate waste measurement when determining overall nutrition of students.
10. Lucas P, Patterson E, Sacks G, et al. Preschool and school meal policies: an overview of
what we know about regulation, implementation, and impact on diet in the UK, Sweden, and
Australia. Nutrients. 2017; 9(7):736. doi: 10.3390/nu9070736
A comparison was completed of the approaches to the provision and improvement of
preschool and primary school meals across the United Kingdom, Sweden, and Australia
to have a comprehensive sample of three different degrees of regulations in each location.
All locations were shown to attempt to provide healthy provisions to its students, but
most were loosely enforced or not comprehensive in implementation. It was found that
school lunches were only a portion of food noted to be offered and consumed by students,
excluding snacks, vending machines, extracurricular activities, bake sales, etc.
Monitoring and compliance was also an area of concern as across all locations,
monitoring and compliance were lacking in information. The study suggests that future
research focuses on stricter implementation and monitoring to ensure the application of
interventions to the target populations.
11. Lundbord P, Rooth D, Alex-Peterson J. Long-term effects of childhood nutrition: evidence
from a school lunch reform. The Review of Economic Studies. 2022;89(2): doi:
10.1093/restud/rdab028
Packed lunches are often an alternative to provided school lunches that can be costly over
the course of the school year. Using historical data and a difference-in-differences
specification of a Swedish free lunch program implemented between 1959 to 1969,
researchers found substantial long term economic benefits to this program to include:
increased lifetime income by 3% for those who were exposed to this program for their
entire primary school tenure. Researchers found the effects were greater for children from
low income households and suggested that earlier and longer exposure to this program
would reduce socioeconomic inequalities in adulthood. The school lunch program was
also shown to lead to large and positive effects on height for both girls and boys, due to
the increase of protein and vitamin intake, early adult health as shown through an 8%
reduction of probability of being diagnosed with a condition at the time of military
enlistment, and educational attainment shown by an increased likelihood of entering
university by 1.5 percentage points, for those who had 9 years of exposure. Overall, the
program was shown to improve a plethora of life-determining factors for the children
who were exposed to this program.
12. Melnick E, Thomas K, Farewell C, et al. Impact of a nutrition education programme on
preschool children’s willingness to consume fruits and vegetables. Public Health Nutrition.
2020;23(10):1846-1853. doi:10.1017/S1368980019005032
Previous research suggests that the more preschool children are presented with the
opportunities to try different foods, the more likely they are to become familiar with these
foods, and thus, more likely to be willing to try them. The study utilized a stratified
randomized sampling method to gather thirty-three classrooms to participate, which were
then split into two groups, one to participate in the program implementation and the other
to be the control group. It was shown that, over time, students who participated in the
programming had a greater change in the odds of consumption of the three vegetables
provided. Results showed the program was successful in increasing the likelihood of
consuming unfamiliar foods by increasing exposure through hands-on educational
lessons. The changes were seen more specifically with the vegetables rather than the
fruits within the sample.
13. Merlo C, Smarsh B, Xiao X. School nutrition environment and services: policies and
practices that promote healthy eating among k-12 students. Journal of School
Health.2023;93(9):762-777. doi: 10.1111/josh.13365
Within the space of school nutrition among school children, researchers are constantly
looking for factors that can hinder or support the consumption of healthy school meals. A
2023 systematic review of 97 articles, representing 121 different interventions were
studied to understand various interventions to improve school meal programming,
improve the school nutrition environment, and the effect they have had on the population.
In terms of the improvement of school meal programs, the review concluded that
improving access and quality of foods is not enough to drive change among student
behaviors. More effective methods included increasing the number of menu choices, taste
testing, incentives/rewarding, and adjusting the timing of school meals. For the
improvement of the school nutrition environment, it was found that limiting access to less
healthy food was not directly effective in changing behaviors. Future research should
focus on utilizing multiple intervention methods to effectively improve attitudes
surrounding better food and beverage choices.
14. Nathan N, Janssen L, Sutherland R, et al. The effectiveness of lunchbox interventions on
improving the foods and beverages packed and consumed by children at centre-based care or
school: a systematic review and meta-analysis. International Journal of Behavioral Nutrition and
Physical Activity. 2019;16(38). doi: 10.1186/s12966-019-0798-1
When researching the effect of home-packed lunch on child nutrition, lunch interventions
are often utilized to improve the health of lunches packed and consumed by children. A
systematic review and analysis of thirteen papers with ten trials included revealed that
there needs to be a specific focus on interventions to reduce the rate of sugary drinks and
other sweet and savory snacks, as the results were most inconsistent in these categories.
The provision and consumption of vegetables was the most affected by interventions. The
study highlighted the parental figures should be the main target for interventions and
should focus on active and sustainable interventions that consider socioeconomic status.
15. O’Rourke B, Shwed A, Bruner B, et al. What's for lunch? Investigating the experiences,
perceptions, and habits of parents and school lunches: a scoping review. Journal of School
Health. 2020;90(10):812-819. doi: 10.1111/josh.12944
Previous research indicates home-packed school lunches are lower in nutritional value as
compared to school provided meals. Home packed lunches are highly reliant on parents
and caregivers. The article works to review the decisions that influence what parents and
caregivers pack in a school lunch to gather information to determine interventions to
overcome found barriers and encourage positive facilitators to impact the healthiness of
school lunches. Articles were screened and selected through specific search criteria and
charted in Excel to compile data provided into corresponding categories. This data was
synthesized and converted into a data chart for ease of interpretation. Six themes were
found, to include: school environment, food as fuel, convenience, child’s influence, cost,
and the lunch experience.
16. Parnham J, Chang K, Rauber F, et al. The ultra-processed food content of school meals and
packed lunches in the UK, 2008-17: a pooled cross-sectional study. Lancet. 2022;400(S12). doi:
10.1016/S0140-6736(22)02222-X
A cross sectional analysis of 1895 primary aged school children and 1408 secondary
school children discovered to understand the relation between ultra processed food in the
United Kingdom and children’s household income. Regression models were utilized to
identify the relationship to provide a comparison between the provided data. The study
was significant as it gathered data from both school provided lunches as well as home-
packed lunches. It was found that school meals contained a lower rate of ultra processed
foods for both primary and secondary school children. Variables such as lower income
households and secondary school children were more likely to provide ultra processed
foods. Future research should focus on understanding barriers for lower income
households and the relation of age to the provision of more unhealthy food choices.
17. Shukaitis J, Elnakib S, Cuite C. Yumbox: A tool to improve the quality of preschoolers’
packed lunches. Journal of Nutrition Education and Behavior. 2021;53(8):719-723. doi:
10.1016/j.jneb.2021.04.007
Yumbox was a pilot program intervention, targeting preschool aged children to improve
nutritional health among this population, using the visibility principles of behavior
economics theory. Bento-style boxes were provided to 30 participants, with contents
being photographed and recorded to understand the effects of this method to increase the
nutritional value of packed lunches. On average, the intervention showed to improve the
variety of foods provided to students and parental figures were more likely to provide
more health conscious foods to their students, indicating a positive impact from the
intervention. The study reiterated the positive effects of food photography as an effective
tool for parental education on school lunch packing.
18. Sutherland R, Nathan N, Brown A, et al. A randomized controlled trial to assess the potential
efficacy, feasibility and acceptability of an m-health intervention targeting parents of school aged
children to improve the nutritional quality of foods packed in the lunchbox 'SWAP IT'.
International Journal of Behavioral Nutrition and Physical Activity.2019;16(54). doi:
10.1186/s12966-019-0812-7
When programming interventions to impact parent lunch packing behavior, it is
important to address intervention ease of use and ability to become an ingrained behavior.
The ‘SWAP IT’ intervention utilizes mobile app usage to improve the nutritional quality
of foods packed into school lunches. 55% parents and caregivers reported that this
method, provided through a school communication app, effectively changed what they
packed in their childrens’ lunches. SWAP IT was successful in increasing the overall
packing of recommended foods and was an accessible, effective method that parents and
caregivers could adopt into learned behaviors. Results show that this intervention can be
effective for school systems to adopt.
19. Sutter C, Taylor J, Nishina A, et al. Parental and family predictors of fruits and vegetables in
elementary school children's home-packed lunches across a school week. Appetite.
2019;133:423-432. doi: 10.1016/j.appet.2018.12.003
Researchers found that parental and familial factors are highly associated with the
number of days that fruits and vegetables are packed, as well as the quantity of fruits and
vegetables packed in school lunches. There was a higher rate of fruits packed everyday of
the week as compared to the rate vegetables packed everyday of the week. When fruits
and vegetables were packed in the same lunch, a higher serving of fruits were provided as
compared to the serving of vegetables. A sample size of ninety parent-child dyads were
examined over the course of 5 consecutive school days, using digital imaging to capture
the contents of the lunch, specifically noting the number of days a fruit or vegetable was
packed and the corresponding servings of both fruits and vegetables. In terms of familial
influence, an authoritative parenting style was associated with packing fewer vegetables
on a Monday but increased servings across the week. Financial stress negatively
correlated with the frequency and serving size of vegetables packed, and child
involvement in school lunch packing showed a higher likelihood of more fruits being
packed, as well as an increase of serving size and frequency of vegetables packed.
20. Watson-Mackie K, McKenzie H, McKay F. Are mothers under lunchbox pressure? An
exploration of the experiences of Victorian mothers preparing lunchboxes for their children.
Health Promotion Journal of Australia. 2022;34(1): 91-99. doi: 10.1002/hpja.681
Using qualitative methodology, 10 mothers were interviewed to understand their
viewpoint when preparing home lunches for their primary school children. As young
children are unable to prepare their own meals, it was imperative for researchers to
understand potential barriers and limitations to ensuring healthy options for young
children. It was found that mothers work to emphasize nutritional value, but a variety of
barriers such as cost and time had a profound effect on the contents provided in lunches.
Employment status was a major variable when determining whether time or cost was the
main barrier to mothers, highlighting that mothers with less time to prepare often were
likely to have a lower concern about financial barriers, and those who did have financial
barriers, seemed to have more time. There were also social and emotional influences
when packing meals, with most mothers reporting pressure to provide a “good” meal
through self-reflection and through the lens of social media. The study concluded that
mothers involved in the study had the knowledge surrounding nutritional meals but faced
a variety of factors that affect their decision making on a daily basis. Future researchers
should look into societal, emotional, and socioeconomic barriers to home packed lunches.
