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Savovic J.,University of Bristol | Jones H.E.,University of Bristol | Altman D.G.,University of Oxford | Harris R.J.,Public Health England | And 14 more authors.
Annals of Internal Medicine | Year: 2012

Published evidence suggests that aspects of trial design lead to biased intervention effect estimates, but findings from different studies are inconsistent. This study combined data from 7 metaepidemiologic studies and removed overlaps to derive a final data set of 234 unique meta-analyses containing 1973 trials. Outcome measures were classified as 'mortality,' 'other objective,' 'or subjective,' and Bayesian hierarchical models were used to estimate associations of trial characteristics with average bias and betweentrial heterogeneity. Intervention effect estimates seemed to be exaggerated in trials with inadequate or unclear (vs. adequate) random-sequence generation (ratio of odds ratios, 0.89 [95% credible interval {CrI}, 0.82 to 0.96]) and with inadequate or unclear (vs. adequate) allocation concealment (ratio of odds ratios, 0.93 [CrI, 0.87 to 0.99]). Lack of or unclear double-blinding (vs. doubleblinding) was associated with an average of 13% exaggeration of intervention effects (ratio of odds ratios, 0.87 [CrI, 0.79 to 0.96]), and between-trial heterogeneity was increased for such studies (SD increase in heterogeneity, 0.14 [CrI, 0.02 to 0.30]). For each characteristic, average bias and increases in between-trial heterogeneity were driven primarily by trials with subjective outcomes, with little evidence of bias in trials with objective and mortality outcomes. This study is limited by incomplete trial reporting, and findings may be confounded by other study design characteristics. Bias associated with study design characteristics may lead to exaggeration of intervention effect estimates and increases in between-trial heterogeneity in trials reporting subjectively assessed outcomes. © 2012 American College of Physicians.

Nelson M.,Childrens Food Trust | Breda J.,World Health Organization
Public Health Nutrition | Year: 2013

Objective Following an international workshop on developing the evidence base for policy relating to school food held in London, UK, in January 2012, the objectives of the present paper were (i) to outline a rationale for school food research, monitoring and evaluation in relation to policy and (ii) to identify ways forward for future working. Design The authors analysed presentations, summaries of evidence, and notes from discussions held at the international workshop in London in 2012 to distil common themes and make recommendations for the development of coherent research programmes relating to food and nutrition in schools. Setting International, with an emphasis on middle- and high-income countries. Results Overviews of existing school food and nutrition programmes from the UK, Hungary, Sweden, the USA, Australia, Brazil, China, Mexico and other countries were presented, along with information on monitoring, evaluation and other research to demonstrate the impact of school feeding on health, attainment, food sourcing, procurement and finances, in the context of interactions between the evidence base and policy decisions. This provided the material which, together with summaries and notes of discussions, was used to develop recommendations for the development and dissemination of robust approaches to sustainable and effective school food and nutrition programmes in middle- and high-income countries, including policy guidelines, standards, cost-effectiveness measures and the terms of political engagement. Conclusions School food and nutrition can provide a cohesive core for health, education and agricultural improvement provided: (i) policy is appropriately framed and includes robust monitoring and evaluation; and (ii) all stakeholders are adequately engaged in the process. International exchange of information will be used to develop a comprehensive guide to the assessment of the impact of school food and nutrition policy and supporting infrastructure. Copyright © The Authors 2013.

Adamson A.,Northumbria University | Spence S.,Northumbria University | Reed L.,Welsh Assembly Government | Conway R.,Welsh Assembly Government | And 5 more authors.
Public Health Nutrition | Year: 2013

Objective To outline the evolution of school food standards and their implementation and evaluation in each of the four countries of the UK since 2000. Design Review of relevant policies, surveys and evaluations, including country-specific surveys and regional evaluations. Setting UK: England, Wales, Scotland and Northern Ireland. Subjects Primary and secondary schools and schoolchildren. Results By September 2013 standards will have been introduced in all primary and secondary schools in the UK. Evaluations have varied in their scope and timing, relating to government forward planning, appropriate baselines and funding. Where standards have been implemented, the quality and nutritional value of food provided have improved. Emerging evidence shows improved overall diet and nutrient intake by school-aged children as a result. Conclusions The re-introduction of school food standards in the UK has not been centrally coordinated, but by September 2013 will be compulsory across all four countries in the UK, except in England where academies are now exempt. Provision of improved school food has had a demonstrable impact on diet and nutrition beyond the school dining room and the school gate, benefiting children from all socio-economic groups. Improved school food and dining environments are associated with higher levels of school lunch take up. Implementation of school food standards requires investment. It is critical to policy development that the value of this investment is measured and protected using planned, appropriate, robust and timely evaluations. Where appropriate, evaluations should be carried out across government departments and between countries. Copyright © The Authors 2013A.

Nicholas J.,Childrens Food Trust | Wood L.,Childrens Food Trust | Harper C.,Childrens Food Trust | Nelson M.,Childrens Food Trust
Public Health Nutrition | Year: 2013

Objectives To assess lunchtime provision of food and drink in English secondary schools and the choices and consumption of food and drink by pupils having school lunches, and to compare provision in 2011 with that in 2004. Design Cross-sectional data collected between October 2010 and April 2011. In each school, food and drink provision, including portion weights and number of portions of each item served at lunchtime, were recorded over five consecutive days. Caterers provided recipe information. Setting England. Subjects A random selection of 5969 pupils having school lunches in a nationally representative sample of eighty secondary schools in England. Results Compared with 2004, significantly more schools in 2011 provided main dishes, vegetables and salads, water, fruit juice and other drinks on 4 or 5 d/week (P < 0·005). The number of schools offering items not permitted under the food-based standards for school food on 4 or 5 d/week fell significantly over time (P < 0·005), while the number not offering these items on any day increased significantly (P < 0·005). Meals eaten by pupils were well-balanced in relation to macronutrients. Conclusions Lunchtime food provision and consumption in secondary schools have improved considerably since 2004, following the introduction of new compulsory standards for school food in 2009. To maximise their energy and nutrient intake at lunchtime, pupils should be encouraged to select a full meal, and to take and eat more fruit and vegetables. Schools also need continued support to increase the micronutrient content of menus and recipes. Copyright © The Authors 2013.

Pearce J.,Childrens Food Trust | Wood L.,Childrens Food Trust | Nelson M.,Childrens Food Trust
Public Health Nutrition | Year: 2013

Objective To compare the key differences between school lunches and packed lunches as eaten in eleven secondary schools in England, 21 months after the food-based standards for school lunch became mandatory, but before the introduction of nutrient-based standards. Design Data on 358 school lunches and 139 packed lunches were collected in May and June 2008 from pupils attending secondary schools in Sheffield, Manchester, Leicester City and Essex. Fieldwork was conducted over five consecutive school days at each school. Fieldworkers randomly selected five pupils taking a school lunch and five pupils bringing a packed lunch each day. All food and drink items chosen by pupils were weighed and recorded. Leftovers were also weighed. Setting Eleven state-maintained, co-educational secondary schools from four local authorities in England. Subjects Four hundred and ninety-seven pupils aged 11-16 years. Results Pupils taking school lunches, on average, had significantly higher intakes of energy, protein, carbohydrate, NSP, vitamin C, folate, Fe and Zn than pupils bringing a packed lunch to school. Mean intakes of protein, fat and vitamin C from both types of lunch met the nutrient-based standards and school lunches also met standards for carbohydrate, NSP and energy. Conclusions Nutrient intakes from school lunches were more favourable than those from packed lunches, but typically failed to meet nutrient-based standards for school food. A combination of continued improvements to school food, educating pupils to make healthier choices and policies to encourage pupils to eat at school or bring healthier packed lunches is needed. Copyright © The Authors 2012.

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