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Table 1 Summary of included studies

From: 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

Study name (First author, year published, country) (Reference) Study Design and Aim Number Randomised and Sample Size (Age range of sample Intervention duration: intervention components, theoretical framework. Follow-up period from baseline data collection Measures Primary Outcome/s Results
SCHOOL INTERVENTIONS
Nutritional Intervention to Improve the Quality of Lunchboxes Among Mexican School Children (Diaz-Ramirez, 2016, Mexico) Cluster randomised controlled trial Evaluate the effects of an intervention program to improve the quality of the foods in the lunchboxes. 4 schools (2 IG, 2 CG) 973 students (8–14 years) 8 weeks: written information to parents, classroom posters for children Standalone intervention No theoretical framework identified. CONTROL: Comparison condition not described 6 months Lunchbox registry for three non-consecutive days, using a pre-validated comparison list. Proportion of lunchboxes with ≤276 kcal, fruits and/or vegetables, no unhealthy prepared foods, no unhealthy solids and liquids, meeting the established guidelines of an adequate lunchbox and a healthy lunchbox. Provision only. Total fat and sugar were lower in int (p = 0.003 and 0.002); Increase in the number of students who met the criteria of an adequate lunchbox (19% IG vs 10% CG (p = 0.002).
SMART lunch box (Evans, 2010, UK) Cluster randomised controlled trial (RCT) Conduct the first known cluster randomised controlled trial to improve the contents of packed lunches using an intervention named the “SMART” lunch box, thereby bringing packed lunches more in line with school meals using current guidelines. 89 schools (44 IG, 44 CG)a 1294 students (8–9 years) 5 months: lunch bag and two food boxes together with supporting materials for parents and children. Standalone intervention No theoretical framework identified. CONTROL: Usual practice. 12 months Weighed food record using specifically designed assessment tool. Assessed before and after lunch. Weights of food groups provided (sandwiches, fruit, vegetables, dairy foods, savoury snacks and confectionery). Levels of 14 nutrients provided. Provision and consumptionb Higher weights of food types in IG (fruits, vegetables, dairy foods and starchy foods other than bread in lunchboxes. Weights of savoury snacks was lower in IG. Higher levels of Vit A and folate in IG.
Great Taste, Less Waste (GTLW) (Goldberg, 2015, US) Cluster randomised controlled trial (RCT) – 3 arm trial GTLW (a communication campaign, capitalized on the synergy between healthy eating and eco-friendly behaviours) would improve the quality of foods from home more than a nutrition-only campaign (F2C) or a control. 15 schools (3 IG-GTLW, 3 IG-F2C, 3 CG) 582 students (8–10 years) 22 weeks: curriculum lessons and workbook, campaign kit, monthly parent newsletters, poster contest, monthly email to teachers. With a nutrition-eco approach Standalone intervention. The Theory of Reasoned Action (TRA) and Social Cognitive Theory IG-F2C: same as GTLW, with a nutrition only focus. CONTROL: Waitlist control. 7 months Digital photography of lunch and snacks supplemented by a checklist. Mean servings of fruits, vegetables and SSDs; mean prevalence of packaged items; prevalence of food items of interest. Provision only No significant differences were observed between groups in mean servings of fruit, vegetables or SSDs or mean prevalence of packaged items.
Food Dudes Ireland (Horne, 2009, UK) Cluster randomised controlled trial Evaluate the effectiveness of the Food Dudes intervention in the context of the Irish school system. Two schools (1 IG, 1 CG) 435 students (4–11 years) 12 months (16 day intervention and 12 months maintenance): videos featuring Food Dudes, small rewards for eating fruits and vegetables, Food dudes homepack Standalone intervention. No theoretical framework identified. CONTROL: No intervention. 12 months Visual estimation of fruit and vegetable portions in lunchbox. Assessed before and after lunch. Parental provision and consumption of fruits and vegetables (in grams) in the lunchbox. Provision and consumption Parents from intervention schools provided and their children consumed more fruit, vegetables and juice relative to baseline and control. Provision of FJV 103 g vs 71 g; consumption of FJV 71 g vs 47 g.
Food Dudes England (Upton, 2014, UK) (Upton, 2012, UK) Quasi-experimental Investigate the effectiveness of the Food Dudes Program in increasing primary-school children’s fruit and vegetable consumption for both home- and school-supplied meals; and to establish the extent to which the programme is able to influence the long-term maintenance of any behaviour changes which were observed. 15 schools (8 IG, 7 CG) 2443 students (4–11 years) 16 day intervention plus 12 month maintenance phase: series of DVD episodes of the Food Dudes’ adventures, letters to students from Food Dudes, rewards for tasting fruit and vegetables and then for consumption, Food Dudes home pack. (Maintenance phase – consumption is encouraged but with less intensity than intervention phase). Standalone intervention. No theoretical framework identified. CONTROL: No intervention. 12 months Visual estimation from digital photography of lunchbox using previously validated guidelines. Assessed before and after lunch. Average daily consumption of fruits, vegetables and high fat/sugar foods (in portions) for children who consumed home-supplied lunches. Consumption No significant difference in in the consumption of fruits and vegetables and high fat/sugar foods from home supplied lunches in the intervention group.
School based intervention on Nutritional Knowledge and Habits of LSES Children in Israel (Kaufman-Shriqui, 2016, Israel) Cluster-randomized trial Examine the effects of a school-based comprehensive intervention on nutrition knowledge, eating habits, and behaviours among low socioeconomic status (LSES) school-aged children. 11 schools (7 IG, 4 CG) 238 children (4–7 years) 3 months: 10 weekly nutrition lessons for children; weekly newsletters for parents; 3 meetings for parents; training for teachers. Broader nutrition and PA intervention. Ecological Model. CONTROL: PA only. 6 months Observation to calculate a lunchbox score based on five categories (a score of 0 or 1 for each category and then added together to calculate a total score out of 5). Quality score of packed lunch from 0 to 5. Provision Significant change in the overall packed lunch score over time between the IG and CG (1.16 vs 0.41; p < 0.0001)
CENTRE-BASED CARE INTERVENTIONS
Munch and Move (Hardy, 2008, Australia) Cluster randomized controlled trial Evaluate “Munch and Move”, a low-intensity, state-wide, professional development program designed to support early childhood professionals to promote healthy eating and physical activity among children in their care. 29 preschools (15 IG, 14 CG) 430 children (3–5 years)c 20 weeks: professional development for staff, resource provision (manual, fact sheets, games and small grant), project officer support visits. Broader nutrition and PA intervention. No theoretical framework identified. CONTROL: Waitlist control (During intervention, received health information on non-related topics). 20 weeks Weighed food record of all food and beverages provided. Mean serves of fruits, vegetables, snacks and sweetened drinks; Lunchboxes with > 1 serve of extra food / drinks; Proportion of lunchboxes meeting categories of balanced, overloaded with extras, unbalanced. Provision Significant reduction in sweetened drinks by 0.13 serves (p = 0.05).
Lunch is in the Bag (Roberts-Gray, 2016, United States) Cluster randomised controlled trial Assess the efficacy of the “Lunch is in the Bag” intervention to increase parents’ packing of healthy bag lunches for young children. 30 Early Care and Education Centres (15 IG, 15CG) 633 parent-child dyads (3–5 years) 5 week (plus 1 week booster): parent handouts/newsletters, teacher/child classroom activities, parent/child activity stations, calendar, workshop and materials. Standalone intervention. Social Cognitive Theory, Theory of Reasoned Action and Ecological Approach. CONTROL: Waitlist control. 28 weeks Direct observation of contents of lunchboxes using a structured food record. Servings of fruit, vegetables, whole grains, refined grains, protein foods and dairy in the children’s parent-packed bag lunches. Provision Increased the number of servings of fruit and of whole grains.
Lunch is in the Bag (Sweitzer, 2010, United States) (Briley, 2012, United States) (Sweitzer, 2014, United States) Quasi-experimental controlled trial Pilot test of a centre-based program to encourage parents of preschool aged children to pack one serving of fruits, vegetables, and wholegrains every day in sack lunches sent from home. Six childcare centres (3 IG, 3CG) 132 parent-child dyads (3–5 years) 5 weeks: parent handouts, classroom activities, educational stations, teacher training. Standalone intervention. Intervention Mapping, Theory of Planned Behaviour, Social Cognitive Theory. CONTROL: Comparison condition not described. 6 weeks Direct observation of packed food items using a Food Observation Record. Number of servings of fruits, vegetables, and whole grains in lunches children brought from home. Provision Increased the number of servings of vegetables and whole grains
Tooty Fruity Vegie (Zask, 2012, Australia) Cluster randomised controlled trial Decrease overweight and obesity prevalence among children by improving fundamental movement skills, increasing fruit and vegetable intake and decreasing unhealthy food intake. 31 preschools (18 IG, 13 CG) 560 children (29–73 months) 10 months: Food and nutrition policy, parent workshops and resources, consistent messages for children through puppets, stories, role plays, cooking, staff as role models and positive reinforcement, increase accessibility to water. Broader nutrition and PA intervention. CONTROL: Waitlist control 21 months Visual estimation of fruits, vegetables and EDNP foods and drinks. Number of fruit and vegetable serves, proportion of children with 0, 1, 2+ EDNP food items in lunchbox. Provision Significant increase in the mean number of Fruits and vegies.
  1. aOne school withdrew before randomisation. bPaper only reports on provision but consumption data obtained from author. c259 students in lunchbox analysis. IG Intervention Group, CG Control Group, SSD sugar-sweetened drinks, EDNP energy dense nutrient poor