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Preventing Chronic Diseases: A Vital Investment

Background
Insufficient consumption of fruits and vegetables in childhood increases the risk of future chronic diseases, including cardiovascular disease.

Objectives
To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE, Embase Classic and Embase to identify eligible trials on 30 September 2016. We searched CINAHL and PsycINFO in July 2016, Proquest Dissertations and Theses in November 2016 and three clinical trial registers in November 2016 and June 2017. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included studies to identify further potentially relevant trials.

Selection criteria
We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

Data collection and analysis
Two review authors independently extracted data and assessed the risks of bias of included studies; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures.We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures.

Main results
We included 50 trials with 137 trial arms and 10,267 participants. Thirty trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Eleven trials examined the impact of parent nutrition education in increasing child fruit and vegetable intake. Eight studies examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. One study examined the effect of a nutrition intervention delivered to children in increasing child fruit and vegetable intake.

Thirteen of the 50 included trials were judged as free from high risks of bias across all domains; performance, detection and attrition bias were the most common domains judged at high risk of bias of remaining studies.

Meta-analysis of trials examining child-feeding practices versus no intervention revealed a positive effect on child vegetable consumption (SMD 0.38, 95% CI 0.15 to 0.61; n = 1509; 11 studies; very low-quality evidence), equivalent to a mean difference of 4.03 grams of vegetables. There were no short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.11, 95% CI -0.05 to 0.28; n = 3023; 10 studies; very low-quality evidence) or multicomponent interventions versus no intervention (SMD 0.28, 95% CI -0.06 to 0.63; n = 1861; 4 studies; very low-quality evidence).

Insufficient data were available to assess long-term effectiveness, cost effectiveness and unintended adverse consequences of interventions.Studies reported receiving governmental or charitable funds, except for two studies reporting industry funding.

Authors' conclusions
Despite identifying 50 eligible trials of various intervention approaches, the evidence for how to increase fruit and vegetable consumption of children remains sparse. There was very low-quality evidence child-feeding practice interventions are effective in increasing vegetable consumption of children aged five years and younger, however the effect size was very small and long-term follow-up is required. There was very low-quality evidence that parent nutrition education and multicomponent interventions are not effective in increasing fruit and vegetable consumption of children aged five years and younger. All findings should be considered with caution, given most included trials could not be combined in meta-analyses. Given the very low-quality evidence, future research will very likely change estimates and conclusions. Such research should adopt more rigorous methods to advance the field.

This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

Policy Points: Nudges steer people toward certain options but also allow them to go their own way. "Dark nudges" aim to change consumer behavior against their best interests. "Sludge" uses cognitive biases to make behavior change more difficult. We have identified dark nudges and sludge in alcohol industry corporate social responsibility (CSR) materials. These undermine the information on alcohol harms that they disseminate, and may normalize or encourage alcohol consumption. Policymakers and practitioners should be aware of how dark nudges and sludge are used by the alcohol industry to promote misinformation about alcohol harms to the public.

CONTEXT: "Nudges" and other behavioral economic approaches exploit common cognitive biases (systematic errors in thought processes) in order to influence behavior and decision-making. Nudges that encourage the consumption of harmful products (for example, by exploiting gamblers' cognitive biases) have been termed "dark nudges." The term "sludge" has also been used to describe strategies that utilize cognitive biases to make behavior change harder. This study aimed to identify whether dark nudges and sludge are used by alcohol industry (AI)-funded corporate social responsibility (CSR) organizations, and, if so, to determine how they align with existing nudge conceptual frameworks. This information would aid their identification and mitigation by policymakers, researchers, and civil society.

METHODS: We systematically searched websites and materials of AI CSR organizations (e.g., IARD, Drinkaware, Drinkwise, Educ'alcool); examples were coded by independent raters and categorized for further analysis.

FINDINGS: Dark nudges appear to be used in AI communications about "responsible drinking." The approaches include social norming (telling consumers that "most people" are drinking) and priming drinkers by offering verbal and pictorial cues to drink, while simultaneously appearing to warn about alcohol harms. Sludge, such as the use of particular fonts, colors, and design layouts, appears to use cognitive biases to make health-related information about the harms of alcohol difficult to access, and enhances exposure to misinformation. Nudge-type mechanisms also underlie AI mixed messages, in particular alternative causation arguments, which propose nonalcohol causes of alcohol harms.

CONCLUSIONS: Alcohol industry CSR bodies use dark nudges and sludge, which utilize consumers' cognitive biases to promote mixed messages about alcohol harms and to undermine scientific evidence. Policymakers, practitioners, and the public need to be aware of how such techniques are used to nudge consumers toward industry misinformation. The revised typology presented in this article may help with the identification and further analysis of dark nudges and sludge.

/pdf/dark-nudges-and-sludge-in-big-alcohol-behavioral-economics-3ij9v6e422.pdf

Dark Nudges and Sludge in Big Alcohol: Behavioral Economics, Cognitive Biases, and Alcohol Industry Corporate Social Responsibility.

• Engages health and education officials, teachers, teachers' unions, students, parents, health providers and community leaders in efforts to make the school a healthy place. • Strives to provide a healthy environment, school health education, and school health services along with school/community projects and outreach, health promotion programs for staff, nutrition and food safety programs, opportunities for physical education and recreation, and programs for counselling, social support and mental health promotion. • Implements policies and practices that respect an individual's wellbeing and dignity, provide multiple opportunities for success, and acknowledge good efforts and intentions as well as personal achievements. • Strives to improve the health of school personnel, families and community members as well as pupils; and works with community leaders to help them understand how the community contributes to, or undermines, health and education.

/pdf/health-promoting-schoolnogai-nian-toshi-jian-1nmtfw300c.pdf

Health Promoting Schoolの概念と実践

Nudging is increasingly used in public health interventions in Western societies to produced health-promoting behavior changes; however, there is lack of clarity as to what constitutes a nudge, scant knowledge of the effectiveness of nudging techniques in public health lifestyle interventions and a number of ethical and value-based concerns. The aim of this review is to address these research lacunae and identify the characteristics of nudges in empirical research on public health interventions intended to induce healthy lifestyle changes, including whether they are effective. We conducted systematic searches for relevant articles published between January 2008 and April 2019 in three databases, PubMed, CINAHL and PsycINFO, and combined this with a metasynthesis to construct interpretative explanations. A total of 66 original studies met the inclusion criteria. The findings of the systematic review showed that most nudging interventions involved diet/nutrition, most were carried out as single experiments, and the majority had the intended effects. Specific nudging techniques were identified with respect to the broader nudging categories of accessibility, presentation, using messages and pictures, technology-supported information, financial incentives, affecting the senses, and cognitive loading; several studies included more than one nudging technique. Although many nudging techniques had the intended effects, it is unclear whether they would work outside the study setting. The synthesis revealed that the studies lacked critical reflection on the assumptions about health that were implicit in nudging interventions, the cultural acceptability of nudges, the context-free assumptions of nudging theory, and the implications of these aspects for the public health context.

Nudging in Public Health Lifestyle Interventions: A Systematic Literature Review and Metasynthesis.

Research has consistently indicated that most children do not consume sufficient fruit and vegetables to provide them with a healthy, balanced diet. This study set out to trial a simple, low-cost behavioural nudge intervention to encourage children to select and consume more fruit and vegetables with their lunchtime meal in a primary school cafeteria. Four primary schools were randomly allocated to either the control or the intervention condition and baseline data were collected over two days in each school. Following this, changes were made to the choice architecture of the school cafeterias in the intervention schools and maintained over a three-week period. The intervention included improved positioning and serving of fruit, accompanied by attractive labelling of both fruit and vegetables on offer. Next, data were collected over two days in each school, with menus matched in each instance between baseline and follow-up. We employed a validated and sensitive photographic method to estimate individual children’s (N = 176) consumption of vegetables, fruit, vitamin C, fibre, total sugars, and their overall calorie intake. Significant increases were recorded in the intervention schools for children’s consumption of fruit, vitamin C, and fibre. No significant changes were observed in the control condition. The increases in fruit consumption were recorded in a large proportion of individual children, irrespective of their baseline consumption levels. No changes in vegetable consumption were observed in either condition. These results are the first to show that modest improvements to the choice architecture of school catering, and inclusion of behavioural nudges, can significantly increase fruit consumption, rather than just selection, in primary-age children. This has implications for the development of national and international strategies to promote healthy eating in schools. AsPredicted: 3943 05/02/2017. URL: https://aspredicted.org/see_one.php?a_id=3943

/pdf/a-low-cost-behavioural-nudge-and-choice-architecture-11ut9cpan2.pdf

A low-cost Behavioural Nudge and choice architecture intervention targeting school lunches increases children’s consumption of fruit: a cluster randomised trial

OBJECTIVE The present study tested the validity of a digital image-capture measure of food consumption suitable for use in busy school cafeterias. DESIGN Lunches were photographed pre- and post-consumption, and food items were weighed pre- and post-consumption for comparison. SETTING A small research team recorded children's lunchtime consumption in one primary and one secondary school over seven working days.ParticipantsA primary-school sample of 121 children from North Wales and a secondary-school sample of 124 children from the West Midlands, UK, were utilised. Nineteen children were excluded because of incomplete data, leaving a final sample of 239 participants. RESULTS Results indicated that (i) consumption estimates based on images were accurate, yielding only small differences between the weight- and image-based judgements (median bias=0·15-1·64 g, equating to 0·45-3·42 % of consumed weight) and (ii) good levels of inter-rater agreement were achieved, ranging from moderate to near perfect (Cohen's κ=0·535-0·819). This confirmed that consumption estimates derived from digital images were accurate and could be used in lieu of objective weighed measures. CONCLUSIONS Our protocol minimised disruption to daily lunchtime routine, kept the attrition low, and enabled better agreement between measures and raters than was the case in the existing literature. Accurate measurements are a necessary tool for all those engaged in nutrition research, intervention evaluation, prevention and public health work. We conclude that our simple and practical method of assessment could be used with children across a range of settings, ages and lunch types.

/pdf/measuring-lunchtime-consumption-in-school-cafeterias-a-c0l70y1y9m.pdf

Measuring lunchtime consumption in school cafeterias: a validation study of the use of digital photography.

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A low-cost Behavioural Nudge and choice architecture intervention targeting school lunches increases children’s consumption of fruit: a cluster randomised trial

Measuring lunchtime consumption in school cafeterias: a validation study of the use of digital photography.