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The present study aimed to evaluate the effect of the school-based educational intervention “FOODcamp” on dietary habits among 6th–7th graders (aged 11–13 years), focusing on the food groups: fruits and vegetables, fish, meat, discretionary food, and sugar-sweetened beverages. In this cluster-based quasi-experimental controlled intervention study, 16 intervention classes (322 children) and 16 control classes (267 children) from nine schools were recruited during the school year 2019–2020. The children were asked to record their food intake for four consecutive days (Wednesday to Saturday) before (baseline) and after (follow-up) attending FOODcamp, using a validated self-administered web-based dietary record. Eligible dietary intake registrations from 124 and 118 children from the control and interventions classes, respectively, were included in the final statistical analysis. Hierarchical mixed model analysis was used to evaluate the effect of the intervention. No statistically significant effects of participating in FOODcamp were found on the average food intake of the food groups eaten regularly (vegetables, fruit, vegetables/fruit/juice combined, or meat) (p > 0.05). Among the food groups not eaten regularly (fish, discretionary foods, and sugar-sweetened beverages), a non-significant tendency to lower odds of consuming sugar-sweetened beverages from baseline to follow-up (OR = 0.512; 95% CI: 0.261–1.003; p = 0.0510) was seen among FOODcamp participants compared to control participants. In conclusion, this study found no effect of the educational intervention FOODcamp on the dietary intake of vegetables, fruit, vegetable/fruit/juice combined, meat, fish, or sugar-sweetened beverages. The intake frequency of sugar-sweetened beverages tended to decrease among FOODcamp participants.

Background and aimIn 2007, the Danish Food Industry Agency announced a project where Danish schools could apply for funds to establish a school food programme to provide the school children with free school meals for two months during 2008. This school food programme should be tested and evaluated. The present PhD thesis is based on evaluation of the dietary effect of this project.There is room for improvement of the dietary habits of Danish children. Dietary habits are influenced by multiple factors across different contexts. The school setting is known as a suitable arena for promotion of healthy eating. In Denmark most children eat a packed lunch brought from home.It is challenging to collect dietary data from a pediatric population where recall problems exist and estimation of portion sizes can be complicated. Thus, to measure and assess the dietary effect of an intervention, new valid methods are needed.The overall aim of this PhD thesis was to evaluate the dietary effect of a school food programme in Danish schools on the quality of lunch consumed by children aged 7-13 years compared to packed lunches brought from home. Furthermore, the aim was to develop appropriate methods to measure and assess dietary intake for evaluation of interventions, which are designed to promote credible evidence to this area. The objectives were; to evaluate the validity and reliability of a digital photographic method (DPM) to assess the quality of dietary intake from packed lunches brought from home among children aged 7-13 years (paper I); to develop and validate an index for assessment of dietary quality of school meals, either brought from home or provided by the schools (paper II); to evaluate the effect of implementing a school food programme on the dietary quality of lunches consumed by students aged 7-13 years compared to packed lunches brought from home and furthermore to investigate if a possible effect would differ between the youngest school children and the older (paper III).MethodsThe evaluation of the school food programme was conducted in 4 intervention schools and 4 control schools from all over Denmark. Data on packed lunches were collected at baseline. At 1st follow-up the children in the intervention schools were offered free school meals and at the 2nd follow-up the school meals were paid. The control group had packed lunches at all measurements. Collection of data covered 3 consecutive days during a week at each of the three measurements. In total 984 school children were invited at baseline – 493 from the 2nd -3rd grades and 491 from the 5th-6th grades. A standardized DPM was used to collect data on food intake 3 consecutive days in a week at all of the 3 measurements. To assess the dietary quality of food consumed a Meal Index of dietary Quality (Meal IQ) was developed.The validity and reliability of the DPM was tested on weighed foods of 191 packed lunches. The Meal IQ was developed and validated against calculated nutrient content of both 191 packed lunches and 63 school meals.ResultsImplementing a school food programme increased the quality of dietary intake among school children aged 7-13 years at 1st follow-up where the school meals were free, compared to the packed lunches brought from home (P=0.004). At the 2nd follow-up, where the school meals were not provided for free, only a limited number of children ate school meals and there was no difference in quality of dietary intake at lunch among children in the intervention and control schools (P=0.343). The statistical analyses demonstrated some differences in changes in dietary quality intake at lunch between school children in the 2nd-3rd grades and 5th-6th grades. This was not due to different effect of the school food programme but was mainly explained by more skipped meals in the oldest age group compared to the youngest age group.Correlation coefficients and cross-classifications between the DPM and the weighed foods showed good agreement. There were no statistical differences between fish, fat, starch, whole grains and Meal IQ using the two methods. Differences were found for fruit and vegetables. Bland-Altman analyses showed a tendency to underestimate high amounts of these variables using the DPM. For inter-rater reliability, Kappa statistics ranged from 0.59 to 0.82 across the dietary components and Meal IQ.A higher Meal IQ score was associated with a higher overall dietary quality including lower contents of fat, saturated fat and added sugars, higher contents of fiber, various vitamins and minerals, and more fruit, vegetables and fish.Conclusion and perspectivesOffering a free school meal had a positive effect on the change in dietary quality of the lunches consumed by school children aged 7-13 years compared to packed lunches brought from home. No effect was measured when the school meals were no longer provided for free. The dietary effect of the school food programme did not depend on age.The standardized DPM was shown to be valid and reliable for assessment of the dietary quality of packed lunches brought from home. Furthermore the Meal IQ was found to be valid and a useful evaluation tool for assessing the dietary quality of school meals or packed lunches brought from home.Future research has to refine the methods for dietary assessment. Utilizing the technology for dietary assessment may decrease the burden of the researcher and thereby improve the cost-effectiveness and possibly the accuracy of the DPM. Using the DPM to estimate food intake in free-living conditions among children is also a relevant perspective because data on the entire diet could be achieved.Furthermore, future research has to focus on development of multicomponent school-based interventions which take into account the multiple factors and environments which affect the dietary habits of children. The focus of such an intervention could be implementation of a sustainable school food programme. Another focus could be improvement of the packed lunches brought from home with the purpose to contribute to the shaping of a healthier dietary behaviour among Danish school children.

Fokus på madordninger i daginstitutioner og kvaliteten heraf har været stigende de seneste år. Mange nye madordninger er etableret i løbet af 2009 og 2010 især i børnehaver og i børnehavegrupper i de integrerede daginstitutioner. I 2009 opstillede Fødevarestyrelsen anbefalinger for den ernæringsmæssige kvalitet af de fælles frokostmåltider, der serveres i daginstitutionerne. Formålet med denne undersøgelse har været at evaluere, hvor stor en del af daginstitutionerne med madordninger, der opfylder disse anbefalinger. Et spørgeskema blev udarbejdet på baggrund af anbefalingerne og pilottestet blandt 13 daginstitutioner. Spørgeskemaet tog hovedsagelig udgangspunkt i den foregående uges frokostudbud. Et pointsystem blev udviklet ud fra både hvor hyppigt de enkelte fødevarer blev serveret og i forhold til fødevarernes kvalitet, fx fedtindhold og fedttype (mættet kontra umættet fedt). Jo flere anbefalinger der efterleves, jo flere point opnås (max 32 point). Spørgeskemaet blev udsendt til et repræsentativt udsnit af alle landet institutioner med madordninger. I alt 376 institutioner besvarede skemaet fyldestgørende (svarprocent 64). Flertallet af daginstitutionerne med madordninger tilberedte frokostmåltiderne intern i institutionen frem for at få maden fra en ekstern leverandør (hhv. 94 % af vuggestuerne, 91 % af de integrerede institutioner og 71 % af børnehaverne). Der blev generelt udtrykt stor tilfredshed med madordningerne blandt institutionerne med intern madordning. Langt hovedparten af respondenterne opfattede både ledelse, pædagoger, køkkenpersonale, forældre og børn som værende tilfredse eller meget tilfredse med madordningen (92 % - 97 %). Billedet var mere blandet i relation til de eksterne madordninger (34 % - 64 % tilfredse eller meget tilfredse;. køkkenpersonale ikke medtaget). Med hensyn til i hvor høj grad måltiderne opfylder de ernæringsmæssige anbefalinger viste resultaterne, at de fleste af daginstitutionerne opfyldte mindst to tredjedele af anbefalingerne (81 % med 22 point eller flere). Langt de fleste institutioner angav da også, at de anvendte adskillige ernæringsmæssige anbefalinger i relation til planlægningen af deres menuplan. Dog blev kun lidt over en tredjedel af institutionerne (36 %) vurderet til at opfylde alle eller stort set alle anbefalinger (26 point eller flere). Lidt bedre til at opfylde anbefalingerne var de daginstitutioner, der planlagde frokostmenuerne for en uge af gangen (39 %) i forhold til de institutioner, der planlagde fra dag til dag (17 %). Opsummerende viste resultaterne, at mange daginstitutioner har svært ved at opfylde alle Fødevarestyrelsens anbefalinger for det fælles frokostmåltid. Dette gælder især anbefalingerne i relation til fødevaregrupperne ”kød, kødpålæg og æg” (især kvaliteten), ”fedtstoffer” (både hyppighed og kvalitet) og ”ost” (både hyppighed og kvalitet). Dette betyder, at børnene i mange tilfælde får tilbudt mere mættet fedt end anbefalet. Fokus bør være på, at anvende produkter med en høj andel af umættet fedt frem for mættet fedt samt at servere fisk, grøntsager, kartofler, samt fuldkornsvarianter af ris, pasta og brød mere hyppigt.