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. 2022 Sep 2;14(17):3640. doi: 10.3390/nu14173640

Table 2.

Characteristics of the studies included in the systematic review.

# Author,
Year of Publication		 Study Design, Study Duration + (Dates) Setting Sample Characteristics Study Aims Intervention Duration + (Dates), Components * Intervention Detail
1 Askelson et al., 2019 [117] Before-after
Pilot
1 y (2016)		 USA, Iowa, rural and urban areas 6 middle schools (5 rural and 1 urban); 1 intervention
Grades served by schools K-12; 5–8; 6–8 and 7–8
Enrolment across all schools, n = 3326, range n = 341–1140 per school; all students exposed to intervention; age NR; eligible for FRP lunch, range 18% to 42%		 To improve the lunchroom environment to promote healthy food choices and empower food service staff with the knowledge, skills, and ability to communicate with students about making healthy choices in the lunchroom 1 y (2016)

  1. Food service operations

  2. BE: accessibility, availability, presentation

  3. Stakeholder engagement: staff, students

  4. BE: promotion

  5. Staff training

  6. Student training

  1. Changing how students move through the lunch line to improve food service

  2. Offering pre-sliced fruit, re-arranging milk coolers, adding bowls, bins and stand-alone carts for whole fruit to the lunch line, adding menu boards

  3. Student lunchroom assessment conducted by students to inform nudge strategies; student groups assisted with planning and implementation of lunchroom changes; meetings between staff and students

  4. Visual cues at lunch line for staff communication prompts, food naming, table signage with menu and fruit/veg facts

  5. Webinars for food service staff including nutrition for adolescents, communication strategies

  6. Research team trained students on principles of behavioural economics and how it can be applied in the lunchroom
2 Bean et al., 2019 [102] Before-after
2 y (2014–2016)		 USA,
Virginia		 16 schools: 8 middle, 8 high; 1 intervention
Demographic data: student sample size or age NR
School district demographics: 75% African American, 13% Hispanic, 9% white, 1% Asian, 2% other ethnicity; 83% of schools with >90% NSLP participation rate		 To examine the impact of food service staff training on Smarter Lunchroom adherence in school cafés 2 y (2014–2016)

  1. BE: accessibility, availability, presentation

  2. BE: promotion

  3. Staff training

  1. Smarter Lunchroom changes: strategic placement of healthy foods, low-cost/no-cost solutions to promote healthier school lunches (varied between schools)

  2. Signage/marketing materials and suggestive selling strategies

  3. Train-the-trainer model to teach cafeteria staff Smarter Lunchroom principles to promote student healthy food selections
3 Bhatia et al., 2011 [44] Before-after
Pilot
2 y (2008–2010)		 USA,
San Francisco, California		 3 schools: 1 middle school, 2 high schools; 1 intervention
Demographic data: enrolment across all schools, n = 4304; student age NR		 To examine the impact of removing competitive a la carte lunch offerings and providing greater diversity of meal offerings for all students, on NSLP participation rates 5 m (January–May 2010)

  1. Food service operations

  2. BE: availability, acceptability, presentation

  3. Stakeholder engagement: staff, students

  4. BE: promotion

  5. Staff training

  1. New point-of-service system, additional staff for line control, a la carte line removed and re-purposed for NSLP

  2. A la carte options removed, expanded NSLP options, add salad bars and refrigerators, student taste testing, installation of student-designed mural, designed and posted new menus

  3. Students engaged for taste testing, surveys and mural design; staff consultation for design and implementation of initiatives

  4. Branded and marketed former a la carte locations; student taste testing

  5. Training on NSLP rules
4 Boehm et al., 2020 [96] Controlled before-after
(random allocation of schools)
Pilot
9 m (September 2013–May 2014)		 USA,
Northeast USA, urban area		 3 high schools; 2 interventions
2 I-schools: (1) Choices school, n = 1177 enrolled students, (2) Nudging school, n = 2140 enrolled students
1 C-school: n = 1297 enrolled students
Demographics: student age NR; ethnic diversity (NS differences across schools); >95% students eligible for FRP meals, therefore free meals provided to all students		 To compare federally reimbursable meals served when competitive foods are removed and when marketing and nudging strategies are used in school cafeteria operating the NSLP 4 w (April–May 2014)

  1. Choices school: food service operations

  2. Choices school, BE: availability

  3. Nudging school, BE: accessibility, availability, presentation

  4. Nudging school, BE: promotion

  1. Choices school: competitive foods removed and line re-purposed as NSLP cold lunch line

  2. Choices school: competitive food options removed

  3. Nudging school: fruit and milk placement in high traffic areas, whole fruit in colourful bowls, pre-sliced fruit in grab-n-go containers

  4. Nudging school: meal of the day promotional signage, posters of celebrities and athletes drinking milk
5 Bogart et al., 2011 [109] Controlled before-after (non-random allocation of schools)
Pilot
15 w (dates NR)		 USA
Los Angeles, California		 2 middle schools, 1 intervention
1 I-school, 1 C-school
Similar demographic data for ethnicity and 77% students eligible for FRP lunch
I-school: n = 399 7th grade students completed pre and post surveys (50% female, mean age 13, SD 0.5);
n = 140 7th grade student advocates; enrolled students or student sample size NR		 To pilot a community-based intervention for adolescents, Students for Nutrition and eXercise (SNaX) to translate school obesity-prevention policies into practice through peer leader advocacy of healthy eating and school cafeteria changes 5 w (dates NR)

  1. BE: nutrition labelling

  2. BE: availability, accessibility

  3. Stakeholder engagement: students

  4. BE: promotion

  5. Student training

  1. POS signage with nutritional information

  2. Introduction of pre-sliced fruit

  3. Formative research results from students

  4. Handouts to students; SNaX related cafeteria changes publicised during a 7th grade assembly; posters explaining how to read nutritional information

  5. Peer leader training
6 Bogart et al., 2014 [88] Cluster randomised trial
(controlled)
3.5 y (January 2009–June 2012)		 USA
Los Angeles, California		 10 middle schools, 1 intervention Similar demographic data for ethnicity; >83% students eligible for FRP lunch; student age and gender NR
5 I-schools, n = 1515 mean number of students enrolled per school (SD = 323)
5 C-schools, n = 1524 mean number of students enrolled per school (SD = 266)
n = 2997 7th grade students from I-school completed B and FU surveys		 To conduct an RCT of SNaX, and examine effect on cafeteria participation, student eating behaviours and cafeteria attitudes 5 w per school (during spring semester each y; January to June)

  1. BE: nutrition labelling

  2. BE: availability, accessibility

  3. Stakeholder engagement: students

  4. BE: promotion

  5. Student training

  1. POS signage with nutritional information

  2. ↑ variety of sliced/bite-sized fruit and veg, water stations with free chilled water, pre-sliced fruit and veg

  3. Lunchtime peer leader activities (wearing T-shirts, taste tests, distribution of promotional material)

  4. Posters marketing cafeteria changes; student taste testing

  5. Peer leader training to communicate SNaX messages
7 Bogart et al., 2018 [110] Cluster non-randomised trial
(controlled)
2 y (2013–2015)		 USA
Los Angeles, California		 65 middle schools, 1 intervention
n = 17 I-schools, n = 22311 enrolled students, 70% students in NSLP; n = 47 C-schools, n = 56,120 enrolled students, 86% students in NSLP
n = 242 student advocates at end of I-year (student grade NR)
n = 187 students completed student advocate surveys
n = 154 student advocates participated in post-I focus groups		 To disseminate an evidence-based middle-school obesity-prevention program, SNaX 5 w per school (1 y across all schools; 2014–2015)

  1. BE: availability, accessibility, acceptability

  2. Stakeholder engagement: students

  3. BE: promotion

  4. Student training

  1. Introduction of pre-sliced fruit, water stations with free chilled water; student taste tests of food reformulated to be healthier

  2. Lunchtime activities including taste tests, distribution of promotional items (e.g., bookmarks), videos, lessons, kick-off assembly

  3. Cafeteria food focussed school-wide announcements and posters; student promotion of SNaX at lunchtime; student taste testing

  4. Student training to promote SNaX
8 Chu et al., 2011 [118] Non-randomised trial
(controlled, crossover)
1 y (spring and fall semesters 2009)		 USA, Minnesota, Texas, urban and suburban areas 5 schools, 2 interventions
3 middle schools (1 Minnesota, 2 Texas), 2 high schools (1 Minnesota, 1 Texas)
Demographics: Hispanic students, Texas range 25.7% to 54.5%, Minnesota range 1.4% to 35.6%; non-Hispanic, Texas range 1.7% to 47.3%, Minnesota range 26% to 94.7%; students eligible for FRP meals, range 30.5% to 100% across all schools; student age not reported		 To compare student acceptance of whole-wheat vs. refined tortillas in school meals according to sensory attribute ratings 30 w (2 school semesters, 2009)

  1. Recipe changes

  2. Procurement

  1. 2 interventions to ↑ wholegrains and fibre intake. Replace refined tortillas in soft-taco entrée dish with (1) 66% white whole wheat tortilla, and (2) 100% white whole wheat tortilla

  2. Food supplier sourced for whole wheat tortillas
9 Cohen et al.
2012 [89]
2013 [119]		 Cluster non-randomised trial
(controlled, parallel arm)
Pilot
2 y (2007–2009)		 USA, MA, Boston 4 middle schools, 1 intervention
2 I-schools: 88% eligible for FRP meals, 78% participation in NSLP, n = 1609 student participants
2 C-schools, 86% eligible for FRP meals, 70% participation in NSLP, n = 1440 student participants
Students in grades 6–8, most aged 12–14 years		 2012: To evaluate the impact of chef-based model on student’s selection and consumption of school lunches
2013: To assess the impact of food waste on nutrient consumption, if school foods served could be valid proxies for food consumed, and costs associated with food waste		 2 y (2007–2009)

  1. BE: acceptability

  2. Recipe changes

  3. Staff training

  1. Meals modified to enhance palatability using sauces, seasoning, salad dressings

  2. Replace trans and saturated fats with unsaturated fats; ↓ added sugar and salt, ↑ wholegrains and fibre

  3. Professional chef engaged to train cafeteria staff to improve menu diet quality and cooking techniques
10 Cullen et al., 2007 [114] Before-after
Pilot
1 y (spring 2003–spring 2004)		 USA, California, North Carolina, Texas 6 middle schools, 1 intervention
2 California, n = 2873 students
2 North Carolina, n = 1565 students
2 Texas, n = 1810 students
Student age NR; baseline differences in ethnicity and eligibility for FRP meals (range, 55–97%) between schools		 To examine the feasibility of instituting school food environment changes during a 6-week pilot in school foodservice programs 6 w (winter/spring 2004)

  1. BE: availability

  2. Stakeholder engagement: staff, students

  3. Staff training

  1. Expand healthy menu options to meet goals: (1) serve ≥3 fruit and veg items/day, (2) include ≥10 different fruit and veg items/3-week period, (3) serve ≥2 lower-fat entrees/week

  2. Focus groups with students and school staff to inform the development of school foodservice changes

  3. Dietitian facilitated staff training to implement menu change goals
11 Cullen et al., 2008 [103]
Mendoza et al., 2010 [104]		 Before-after
5 y (2001–2006)		 USA, Texas 3 middle schools, 1 intervention Students in grades 6–8; n = 2690 enrolled students across all schools (2001–2002 school year), and n = 3306 (2005–2006 school year)
FRP eligibility, range 26–68% in 2001–2002, and 38–75% in 2005–2006		 To assess the effect of the Texas Public School Nutrition Policy on middle school student lunchtime food consumption 2 y (2004–2006)

  1. Food standards implementation

  1. Statewide policy that applied to all school food sources (NSLP, snack bars, vending): restrict portion size of high-fat and sugar snacks, SSBs and the fat content of all foods served; limit frequency of serving high-fat veg
12 Cullen et al., 2015 [90] Cluster randomised trial
(controlled, parallel arm)
Pilot
15 w (fall 2011)		 USA, TX, Houston 4 intermediate schools, 1 intervention
2 I-schools, 2 C-schools
Student age or enrolment numbers NR;
Sample size for observations, n = 427 students (I-schools, n = 212; C-schools, n = 215)		 To investigate changes in student food selection and consumption in response to the new NSLP meal patterns during fall 2011 15 w (fall 2011)

  1. Food standards implementation

  2. BE: promotion

  1. New regulations for allowable food serves for reimbursable meal: 1 fruit, 2 veg, 1 protein, 2 grain, 1 milk

  2. Colour displays of food at cafeteria entrance, signage with instructions for food selections, supporting materials for class teachers and parents
13 D’Adamo et al., 2021 [113] Non-randomised trial
(controlled, crossover)
2 y (dates NR)		 USA, Maryland, Baltimore, urban area 1 high school, 1 intervention
I-group (herbs and spices), C-group (typical recipe)
n = 273 enrolled students
Demographics: 57% female, African American 76% Hispanic 10%, ≥2 races 10%, White 4%, Asian < 1%, 100% eligible for FRP meals
All students provided lunch trays for veg plate waste assessment		 To determine whether stakeholder-informed addition of spices and herbs to NSLP veg would increase intake 4 school semesters (dates NR)

  1. Recipe changes, BE: acceptability

  2. Stakeholder engagement: staff, students

  3. BE: promotion

  1. Addition of a variety of spices and herbs to 7 different NSLP veg recipes; student taste testing to inform recipe changes

  2. Engagement with school staff, teachers, food service staff and students to assess needs, attitudes and preferences for NSLP veg; health educators and professional chef led after-school student nutrition education and veg recipe sensory-testing; ‘Lunch Bunch’ student-led advocacy group

  3. ‘Lunch Bunch’ promoted veg recipes with spices and herbs (year 2 only); student created signage for display around the school; school announcements
14 Elbel et al., 2015 [107] Cluster non-randomised trial
(controlled)
11 m (November 2010–September 2011)		 USA, New York, NYC 17 schools (includes elementary, middle and high schools; split between school type unknown), 1 intervention
8 I-schools, 9 C-schools
I-schools: n = 1091 mean number of students/school, 55% female, 54% eligible for FRP meals, 21% African American, 41% Hispanic, 25% White, 11% Asian
C-schools: n = 1175 mean number of students/school, 52% female, 47.1% eligible for FRP meals, 13% African American, 33% Hispanic, 33% White, 20% Asian
Sub-set of larger study separated survey data for middle and high school (8th and 11th grade; n = 1759 students).		 To determine the influence of water-jets on observed water and milk taking and self-reported fluid consumption in NYC public schools 10 m (December 2010–September 2011)

  1. Food service operations

  2. BE: accessibility, availability

  1. Water jet installation near lunch line in cafeterias; water jets in place throughout post-I period of study; no other parallel interventions such as activities to promote water drinking

  2. Increased water access and availability
15 Ellison et al.
1989 a [115]
1989 b [100]
1990 [116]		 Controlled before-after
(non-randomised)
4 y (1984–1988)		 USA, NH and MA 2 boarding high schools, 2 interventions (phase 1 and 2)
Student mean age 15 years, almost none obese, 77% white
1989a: Sodium intake from food diary assessment, at B n = 674 (I-group n = 340, C-group n = 334), at FU n = 431 (I-group n = 221, C-group n = 210); 1700 ballots for food acceptability rating
1989b: BP assessment, n = 650 students (I-group n = 309, C-group n = 341)
1990: Fat intake from food diary assessment, at B n = 774 (I-group n = 389, C-group n = 385), at FU n = 467 (I-group n = 228, C-group n = 239)		 To measure the effects of changes in food purchasing and preparation practices on student acceptability of modified foods, sodium and fat intake, and BP 6 m/phase (phase 1: reduced sodium; phase 2: modified fat; years unclear)

  1. Recipe changes, BE: acceptability

  2. Stakeholder engagement: staff

  3. Procurement

  4. Staff training

  1. Phase 1 and 2: collaboration with nutritionist to revise menus and recipes: ↓ sodium in preparation, ingredient swaps to enhance flavour, modified fat in recipes (reduced saturated fat, increase polyunsaturated fat)

  2. Phase 1 and 2: meetings with production staff to develop modified recipes, food service staff taste testing of modified recipes

  3. Phase 1 and 2: procurement of alternate products with ↓ sodium, ↓ SFA and ↑ PUFA

  4. Phase 1 and 2: collaboration with nutritionist for staff training, 4 components: (1) healthy diet in early life, staff’s essential role, (2) recipe testing (3) serving-line staff training because of their direct interaction with students
16 Fritts et al., 2019 [120] Phase 1: Non-randomised trial
(controlled, crossover)
Phase 2:
Before-after
10 m (March–December 2017)		 USA, Pennsylvania, rural area 1 middle/high school, 2 interventions (phase 1 and 2)
I-group (herb and spice veg), C-group (lightly salted veg);
approx. 75% students participate in the NSLP, and 44% received FRP lunch; 600–700 students aged 11–18 years were served lunch daily across 3 lunch periods
School district demographics: 97% Caucasian		 To test whether adding herbs and spices to school lunch veg increases selection and consumption compared with lightly salted veg among rural adolescents 10 m (March–December 2017)

  1. Recipe changes, BE: acceptability

  2. BE: presentation

  3. Stakeholder engagement: staff

  4. Staff training

  1. Phase 1 (March–May 2017): addition of a variety of spices and herbs to 8 different NSLP veg recipes to enhance palatability compared to lightly salted versions (C-group); phase 2 (October–December 2017): repeated exposure of 2 modified veg recipes with herbs and spices

  2. Phase 2: black plastic containers used to present 2 veg dishes on offer and improve visual appeal

  3. Phase 1: staff taste testing of new recipes; Phase 2: collaboration between school foodservice director, cafeteria staff and researchers to select 2 most appropriate recipes to incorporate into regular menu

  4. Phase 1 and 2: Industry partner who developed recipes conducted a half-day training session with cafeteria staff to demonstrate recipe preparation
17 Greene et al., 2017 [91] Cluster randomised trial
(controlled)
9 w (February–April 2014)		 USA, New York, urban and rural districts 7 middle schools, 1 intervention
4 I-schools (2 urban, 2 rural) and 3 C-schools (2 urban, 1 rural)
I-schools: n = 1258 enrolled students, 1–97% white, 55–92% economic disadvantage
C-schools: n = 850 enrolled students, 5–90% white, 49–92% economic disadvantage
All students in grades 5–8, age NR		 To evaluate the impact of fruit-promoting Smarter Lunchroom interventions on middle school students’ selection and consumption of fruit 6 w (March–April 2014)

  1. BE: accessibility, availability, presentation

  2. Stakeholder engagement: students

  3. Staff training

  4. BE: promotion

  1. Smarter Lunchroom changes: fruit placed first on the line, at least two varieties offered in at least two locations, pre-sliced fruit in small attractive cups, whole fruit in large attractive bowls at eye level

  2. Student focus groups to generate creative names

  3. 30–60 min session for cafeteria staff and food service managers on how to make fruit-promoting changes

  4. Creative names for fruit labels and display on menus
18 Hackett et al., 1990 [121] Controlled before-after
(non-randomised)
1 y (July 1987–July 1988)		 UK,
Northum-berland county		 4 middle schools, 2 interventions
2 ‘dish of day free-choice’ I-schools; 2 ‘2 course fixed price’ I-schools
2 ‘affluent’ and 2 ‘less well-off’ schools (each allocated 1 free-choice I-school and 1 fixed-price I-school);
Approx. n = 830 students aged 11–12 years across all schools
Completion of surveys with school meal participation data: survey 1, n = 674 (n = 301 from free-choice I-schools, n = 373 from fixed-price I-schools); survey 2, n = 692 students (n = 333 from free-choice I-schools, n = 359 from fixed-price I-schools)		 To improve the quality of school meals and their up-take via a healthy eating campaign 10 m (October–December 1987)

  1. Recipe changes

  2. BE: availability (price targets)

  3. BE: promotion

  1. Modified menus to improve nutritional quality; 2 interventions: (1) ‘dish of day free-choice’ I-schools, and (2) ‘2 course meal fixed price’ I-schools

  2. ‘2 course meal fixed price’ initiative

  3. Both interventions: campaign pack per student to take home with healthy eating guidelines, new menus, ‘champion eater’ report card
19 Hanks et al., 2012 [122] Before-after
4 m (February–May 2011)		 USA, New York, Corning 1 high school, 1 intervention To examine the application of the principle that healthier foods are more likely to be consumed if they were more convenient than less convenient less healthy foods 2 m (April–May 2011)

  1. BE: accessibility

  2. Food service operations

  1. More convenient access to healthier food options (sub-sandwich bar, salad bar, veg, whole fruit, fruit parfait)

  2. Conversion of 1 of 2 service lines to a ‘convenience line’ that only offered healthier food options (as above) and flavoured milk
20 Hanks et al., 2013 [97] Before-after
Pilot
4 m (March–June 2011)		 USA, New York 2 high schools, 1 intervention
Grades 7–12, student numbers, age and other demographics NR		 To investigate how small changes to school cafeterias can influence the choice and consumption of healthy foods 2 m (May–June 2011)

  1. BE: presentation, accessibility

  2. Food service operations

  3. Stakeholder engagement: staff

  4. BE: promotion

  1. Fruit displayed in bowls and tiered stands, salad served in see-through to-go containers, fresh fruit located next to cash register, 100% fruit juice boxes in freezer next to ice cream

  2. ‘Healthy convenience’ line with only sub-sandwiches and healthier sides

  3. Cafeteria staff engaged to implement verbal prompts

  4. Cafeteria staff verbal prompts to promote healthy choices, lunch menu posted with colour photos of fruit and veg served, veg labelled with descriptive names
21 Hunsberger et al., 2015 [123] Before-after
4 m (January–April 2010)		 USA, Oregon, rural area 1 middle school, 1 intervention
Students in grades 6–8, aged 11–15 years, 64.6% of ethnic minority, 32.5% have BMI >95th percentile (obese), 79% eligible for FRP meals, n = 531 average number of students/day that participated in the NSLP (78%) during study period		 To investigate the impact of POS calorie information 17 d (February 2010)

  1. BE: nutrition labelling

  1. POS signage with calorie labels; consultation with Mountain View Community Health Improvement and Research Partnership for program development
22 Just et al., 2014 [93] Before-after
Pilot
3 m (February–April 2012)		 USA, New York 1 high school, 1 intervention
n = 370 enrolled students, aged 13–18 years;
School district demographics: ethnicity primarily white (93.9%), eligibility for FRP meals 19.8%		 To conduct a pilot test to gauge the feasibility of the Chef Moves To School program, and measure student response through lunch selection and consumption 2 d (April 2012)

  1. BE: acceptability

  2. Recipe changes

  3. Stakeholder engagement: students

  4. BE: promotion

  1. Student taste testing of new pizzas

  2. Professional chef engaged to use ingredients available in school cafeteria to develop 3 types of pizza (meat taco, bean taco, garlic spinach) and a ranch flavoured burger; new chefs lunch items available in cafeteria on 1 d

  3. Engaging students during after-school event

  4. After-school event for students to taste the chef’s lunch on offer the following day, meet the chef, talk about her profession and new recipes created
23 Koch et al., 2020 [124] Before-after
2 y (2017–2018)		 USA, New York City, NY 7 high schools, 1 intervention
All students eligible to participate; n = 5719 enrolled students across all schools, 74% eligible for FRP lunch, age NR		 To measure the effects of major changes to school cafeterias (STARCafe) on school lunch consumption and factors that may influence consumption (i.e., seated time, attitudes towards school lunch, perception of cafeteria noise, school lunch participation) 1 y per school (2017–2018)

  1. BE: availability

  2. BE: presentation

  3. Food service operations

  4. Stakeholder engagement: staff

  5. BE: promotion

  1. Increased frequency and prominence of deli sandwiches (turkey and cheese), entrée salads, popcorn chicken salad, chicken dumplings and veg fried rice with zucchini, and fast-food options (popcorn chicken and pizza; both served with fries); new menu items included tuna wrap, popcorn chicken wrap, and tuna salad

  2. Dining area changes included comfortable seating options, planters, other dividers, and garbage can enclosures that matched tables. Wall décor included addition of school name, mascot or theme, and school mission

  3. Service line changed to an open-choice line

  4. School principals worked with New York City Department of Education to create a table layout with variety of social arrangements.

  5. Posters and signage promoting education messages to inspire healthy choices, menu options, dining room directions, instructions
24 Madden et al., 2013 [105] Before-after
3 w (2005)		 UK, London 1 secondary school, 1 intervention
Student participants aged 12–16 years, n = 378 lunch observations, pre-I n = 180 (38.9% female), post-I n = 198 (26.3% female)
63% students eligible for free school lunch		 To examine the effect of a short, low-budget kitchen-based intervention on energy, nutrient, and fruit and veg intakes 1 w (2005)

  1. BE: availability (including price targets)

  2. Recipe changes

  3. Stakeholder engagement: staff

  4. Procurement

  5. Staff training

  1. ↑ fruit and veg offered with price targets to attract choice (salad bowls at no cost, variety of fresh fruit at cost), ↓ availability of less healthy options (larger packets of chips removed, only small chocolate bars) replaced with healthier alternative (reduced-fat cereal bars)

  2. Collaboration with dietitian to modify lunch ingredients: ↓ total fat and saturated fat, (salad added to baguettes, veg topped pizza, variety of fresh fruit, side salad)

  3. Collaboration with kitchen staff to develop menu changes

  4. Procurement of ↓ fat mayonnaise and cheese, trimmed bacon, new hot chip variety

  5. Dietitian facilitated 2hr education session with kitchen staff based around Eatwell Plate (UK guidelines)
25 McCool et al., 2005 [108] Non-randomised trial (controlled, crossover)
Pilot
12 w (dates NR)		 USA, metropolitan area 1 middle school, 3 interventions (phase 1–3)
Enrolled students, n = 1234, age NR, 87.4% eligible for FRP meals 		To compare the amount of apple consumed by students when they were offered whole versus sliced ready-to-eat packaged apples 12 w (dates NR; phase 1 = 6 weeks, phase 2 = 4 weeks, phase 3 = 2 weeks)

  1. BE: accessibility, availability (price targets)

  1. Apples offered to all students for free in addition to the regular lunch meal as (1) phase 1, whole apples, (2) phase 2, pre-sliced apples, and (3) phase 3, whole and pre-sliced apples; for all interventions fruit placed at the end of lunch line for students to take as many whole and/or pre-sliced apples as they wanted
26 Pope et al., 2018 [94] Before-after
Pilot
3 m (September–November 2015)		 USA, Vermont, rural area 1 middle school, 1 intervention
n = 587 eligible students in grades 4–8 eligible to participate; average NSLP participation rate = 66%
Student age NR; numbers who participated in taste-testing NR		 To investigate whether providing samples of a veg-focused lunch entrée the day before it appeared on the lunch menu ↑ NSLP participation 1 m (October 2015)

  1. Recipe changes

  2. BE: availability, acceptability

  3. Stakeholder engagement: students

  4. BE: promotion

  1. 4 new entrées developed by the research team, including 2 registered dietitians, and prepared by school food service staff: (1) chicken and broccoli alfredo, (2) root veg stew, (3) savoury turkey loaf, (4) eggplant parmesan. 1 new entrée offered/week

  2. Increased veg variety, students sample new entrée the day before offered in the cafeteria

  3. Students engaged for taste testing

  4. Students were invited to taste a sample of the new entrée the day before it was served
27 Prell et al., 2005 [101] Controlled before-after
(randomised)
5 w (1998–1999 school year)		 Sweden, Göteborg 3 secondary schools: 2 interventions
(1) C-group, no intervention, n = 83 students (63% participation)
(2) SL-group (school lunch intervention), n = 58 students (51% participation)
Grade 8, aged approx. 14 years
(3) SLHE-group (SL + home economics intervention), n = 87 students (60% participation)		 To examine the effectiveness of 2 school-based interventions aimed at increasing adolescents’ intake of fish at school 5 w

  1. Both groups, BE: acceptability, presentation

  2. Both groups: stakeholder engagement: students

  3. SLHE-group, student education

  4. Both groups: Staff training

  5. BE: promotion

  1. Alternative fish dish served, improved accompaniments (choice of 2 sauces, freshly boiled potatoes), fish dish garnish, lunchroom decorated with fish-related objects

  2. Students voted for a fish dish for school lunch

  3. Modifications to curricula with 5 lessons about fish including a slide show of fish preparation in school kitchen

  4. 1 day staff training in fish preparation

  5. Fish dish on display
28 Prescott et al., 2019 [99] Controlled before-after
(non-random allocation of schools)
6 m (November 2017–April 2018)		 USA, Colorado 2 middle schools, 1 intervention
(1) I-group (poster + education), n = 268 grade 6 students across 2 schools
(2) C-group (poster only), n = 426 students in grades 7–8 across 2 schools		 To examine the impact of a student-driven sustainable food systems education and promotion intervention on adolescent school lunch selection, consumption and waste behaviours, particularly for fruit and veg, during school lunch 12–16 classes (from December 2017) + 2 weeks (April 2018)

  1. BE: presentation

  2. Stakeholder engagement: students

  3. Student education

  4. BE: promotion (2 weeks, April 2018)

  1. Waste reduction posters displayed in cafeteria

  2. Grade 6 students consulted for development of promotional posters; grade 6–8 students voted for best posters for display in school cafeteria

  3. Teachers implemented a standards-based curriculum on sustainable food systems

  4. Posters promoting waste reduction displayed in school cafeteria
29 Quinn et al., 2018 [98] Controlled before-after
(non-random allocation of schools)
1 y (2013–2014 school year)		 USA, Washington, King County 11 schools, 1 intervention
6 I-schools (3 middle and 3 high schools; n = 1026 mean number students enrolled per school), 5 C-schools (3 middle and 2 high schools; n = 1219 mean number students per school)
n = 2309 tray observations across all schools and time points
Student age not reported		 To evaluate whether a year-long choice architecture intervention implemented by school cafeteria managers changed student selection and consumption of healthy foods 1 y (2013–2014)

  1. BE: presentation, availability, accessibility

  2. Stakeholder engagement: staff

  3. BE: promotion

  4. Staff training

  1. Attractive containers, pre-sliced fruit, strategic placement

  2. Kitchen manager a member of the technical team (includes dietitian, school nutrition specialist and project lead) that provided implementation support

  3. Staff verbal prompts, creative naming and signage to promote healthy foods

  4. Training and support throughout school year to implement BE strategies based on Smarter Lunchroom principles
30 Schwartz et al., 2015 [92] Before-after
3 y (2012–2014)		 USA, Connecticut, New Haven, low-income urban area 12 middle schools, 1 intervention
Approx. n = 680 enrolled students in grade 5 (all schools); Sample population followed over 3 years, n = 502 in grade 5 (2012), n = 465 in grade 6 (2013) and n = 373 in grade 7 (2014)
School district demographics: >70% eligible for free-lunch, 13% for reduced-price; 47% African American, 38% Hispanic, 15% white		 To examine food component selection and consumption data pre- and post- revisions to the NSLP nutrition standards and policies 2 y (2012–2014)

  1. Food standards implementation

  1. Updated nutrition standards for the NSLP implemented in the 2012–2013 school year: ↑ wholegrains, new calorie limits by age group, ↓ sodium, different veg served each week, ↑ fruit and veg portion size
31 Sharma et al., 2018 [106] Non-randomised trial
(controlled, parallel arm)
4 w (November–December, y NR)		 USA 1 middle-high school, 1 intervention I-group, 1 fast service lane (FSL)
C-group, 2 regular service lanes (RSL)
Approx. n = 650 enrolled students in grades 6–12		 To investigate whether middle and high school students are averse to loss of time and to assess feasibility of a fast food service lane intervention that would serve limited choices of pre-plated lunch meals 4 w (November–December, year NR)

  1. Food service operations (includes BE: accessibility, availability)

  2. BE: promotion

  1. Re-configure 1 of 3 lunch service lanes into a pre-plated FSL that offered pre-plated fruit, veg sides; students allowed 1 of 2 entrees on offer that day

  2. Promotional posters to alert students to the new FSL were strategically placed in the school a week prior to the start of the field experiment
32 Turnin et al., 2016 [112] Before-after
1 y (dates NR)		 France, Toulouse, suburban and urban areas 3 middle schools (1 suburban, 2 urban), 1 intervention
n = 350 students for analysis, mean age 13.3 years (range, 11.5 to 16.4 years)
School A, B and C; n = 84, 88 and 178 students respectively		 To evaluate the impact of interactive Nutri-Advice kiosks on children’s nutritional skills and their ability to apply it to food choices in a middle school cafeteria menu (food choice competencies) 6 m (November–May, year NR)

  1. Food service operations

  1. Installation of kiosk stations with Nutri-Advice software for children to assess and select a well-balanced meal from daily food available on cafeteria menu
33 Wansink et al., 2015 [95] Before-after
Pilot
2 m (March–April 2012)		 USA, New York, Lansing 1 high school, 1 intervention
n = 370 enrolled students in grades 9–12; age not reported
School district demographics: 93.9% white, 2% African American; 19% students eligible for FRP lunch 		To examine the potential impact that a school garden intervention, independent of corresponding educational materials, has on students veg selection and intake 1 d (24 April 2012)

  1. Recipe changes

  2. BE: presentation, acceptability

  3. Procurement

  4. BE: promotion

  1. School garden leafy greens were harvested and included for service at the salad bar

  2. Salad garnish (raspberries) and raspberry vinaigrette dressing

  3. Sourcing school garden produce

  4. School announcements, colourful signage advertising salads served that day included school garden leafy greens
34 Wansink et al., 2013 [111] Cluster randomised trial
(controlled)
Duration unclear (2011)		 USA, New York, Wayne County 6 middle schools, 1 intervention
3 I-schools, 3 C-schools
n = 2150 enrolled students across all schools		 To determine the effect of offering pre-sliced fruit in schools on selection and intake 1 m (November 2011)

  1. BE: accessibility

  1. Cafeteria staff provided pre-sliced apple upon student apple request
35 Witschi et al.
1985 [125]		 Before-after
Pilot
9 w (Oct-Nov 1982)		 USA, New Hampshire 1 boarding high school, 1 intervention
Approx. n = 1000 enrolled students;
To monitor sodium intake: n = 228 students aged 15–18 years
Palatability survey responses: n = 1036 (pre-I) and 748 (during-I)		 To test the effects of dietary modification on total sodium intake of students and assess palatability for adolescents 5 w (October–November 1982)

  1. Recipe changes

  2. Procurement

  3. Stakeholder engagement: staff

  1. Recipes modified to ↓ sodium, replace with non-sodium containing spices; frequently consumed commercially produced items (for example, meat products, cheese, potato chips) were replaced with ↓ sodium alternatives; foods obviously high in sodium omitted; students advised not to modify other aspects of lifestyle during study period, and encouraged not to add salt to food at the table

  2. Procurement of alternate products with ↓ sodium

  3. Modified recipes sampled by food service staff to assess palatability

* NOURISHING frameworks’ domains, denoted by shade colour: blue = food environment domain; green = food system domain; orange = behaviour change communication domain. + Duration: y: year/s; m: month/s; w: week/s; d: day/s. B: baseline; BE: behavioural economics; BP: blood pressure; C: control or comparison; CBPR: community-based participatory research; FU: follow-up; I: intervention; FRP: free or reduced-price; NR: not reported; NSLP: National School Lunch Program; POS: point of selection; SD: standard deviation; SSB: sugar sweetened beverages; Veg: vegetables; #: number; RCT: randomized controlled trial; SFA: saturated fatty acids; PUFA: polyunsaturated fatty acids; BMI: body mass index; ↑: increase; ↓: decrease; NYC: New York city.