[MUSIC] My name is Camilla Damsgaard, I'm an assistant professor and a PhD in Child Nutrition. I work at the Department of Nutrition, Exercise and Sports at the Faculty of Science at University of Copenhagen. I have been the daily project manager of the OPUS School Meal Study. So, the question is how can we investigate, if school children become healthier and more concentrated. When we replace lunch packs with school meals based on the New Nordic Diet. This is what we're going to talk about today. And I will tell you, about the design, the rationale, and the concept of the OPUS School Meal Study. We've made some intended learning outcomes for this session. So, after this week you should be able to describe the rationale for and the aim of the OPUS School Meal Study. You should be able to describe the concept of the New Nordic Diet in the context of the school meals. To explain approaches used to facilitate acceptance of the New Nordic Diet school meals. And to give an overview of methods used to measure health and developmental outcomes in the study. So why did we conduct the OPUS School Meal Study? Well, as in many other countries, Danish children consume too much sugar and fat and too little fish and vegetables. School meals are potential way of improving diet early in life, and also a way of reaching children of various socioeconomic backgrounds. Although school meal programs are well-established in the UK, the US, and in Sweden. Some studies indicate that the nutritional standards of these school meals are not always met. We lack scientific evidence on how diet and school meals affect learning abilities, academic performance and health in childhood. There's been some earlier school based interventions, but they have mainly modified existing school menus or worked at increasing the availability of fruits and vegetables, mainly with focus on obesity. No studies have investigated the impact of introducing a full school meal program In schools with no existing school meals. During the school day [COUGH] most Danish children consume lunch packs and snacks they bring from home. That is most Danish schools have no school meal program. There has been some studies in adults that have indicated that intervention with diets rich in fish, berries, rapeseed oil and whole grain. Can improve models of cardiovascular disease risk. But we lack evidence of, whether such effects would be seen in children as well. So the aim of the OPUS School Meal Study, was to investigate, the impact of serving Nordic school meals on: dietary intake and nutrient status. Food acceptance and costs, the growth of the children, their body composition, their academic performance, their attention and well-being. Their sleep and physical activity, and a number of early markers of lifestyle diseases such as the metabolic syndrome and cardiovascular disease. And this was investigated in Danish children aged eight to eleven years. So, how was the OPUS School Meal Study designed? Well, it was conducted during the school year 2011 to 2012. We included nine schools at Zealand and Foster. That is the southeastern part of Denmark. Schools in order to participate, had to be highly motivated to, for participation. They had to be able to provide their school kitchen for seven months for the food production. And we included third and fourth grade children only. Also, we tried to include schools with a broad socioeconomic distribution. So what was the study flow? Well, the nine schools, had forty six classes at third and fourth grade, and all one thousand and twenty one children in these classes, were invited. And they received written information about the study together with their parents. We held a number of information meetings for parents and children at each school, where we explained the study to them. Eight hundred and thirty four children participated, that corresponds to 82% of those invited. And their parents, gave written in full consent, for participation. We explained to the children and to their parents, that they could withdraw from the study at any time without giving any explanations. These procedures are mandatory when conducting this type of research with blood samples and it's regulated by the Regional Ethics Committee. The dropout from the study, or the proportion of those children who decided to, to leave the study, was 8.3%, and that is quite low compared to other school interventions. The participants were mainly normal weight; 76% of them were normal weight. 14% were overweight and obese, and 10% were actually underweight. These numbers corresponds to earlier published Danish numbers. But in our population, we had a lower degree of overweight compared to for example, American populations. About 12% of the children were immigrants or descendants. And 12% corresponds to the national numbers from statistics Denmark. Although our study population was a bit skewed towards, higher education than the general Danish population with children. All educational levels were represented among the participating families. So, all in all, we could say that study population was highly representative for the Danish population. So, what was the study design? Well, the study had, what we call a randomized control to cross over design. Hm, as you can see in the figure children with the, the year groups were assigned to New Nordic Diet. School meals, or lunch packs, control, in random order for three months each. So let's say third grade at one school, if they started with New Nordic Diet, Then for three months, then the fourth graders at the same school would consume, consume lunch packs, a control meal, for the same three months. And after three months, they would switch over, so that the third graders received lunch packs, and the fourth graders received the New Nordic Diet school meals. The year groups were randomly assigned to the order of the diets. and the measurements we conducted were conducted before the study started. After the first three months and when the study finished after six months. and this way subsequent measurements from the same child can be compared. So why did we choose this study design? Why didn't we just give school meals to half of the schools and then let the other half continue with lunch packs. And then compare the schools, the two types of schools. That would be called a Parallel Design. Well, we judged that the motivation to give blood samples and participate in a number of measurements and tests. Would be quite low in those, schools that would then just receive control. Which would be, just ordinary lunch pack and they would receive no free food. Moreover, a Parallel Design would have required a much higher number of schools, to dissect, to detect the same difference in the health outcomes. Since in the design we chose, the crossover design, children serve as their own comparison persons. So what was on the menu in the, OPUS School Meal Study? Well, the meals of the study were characterized by ten principles. Eat more fruit and vegetables. Eat more wholegrain, especially oat, rye, and barley. Eat more food from the sea. Eat meat of high quality, but less quantity. Eat more food from the wild landscapes. Eat organic whenever possible. Avoid additives. Eat according to season. Eat more homemade food. And made less waste from production. The meals of the school meal study were based, on these principles and the overall principles of the New Nordic Diet. But, particularly for the School Meal Study, we had a lot of focus on Nordic fruits and vegetables. We served a lot of fish. A lot of whole grain, and also quite a big amount of nuts and seeds and kernels. These children were served, a morning snack, a hot lunch, and an afternoon snack every day. In the NND, or in the New Nordic Diet period. Lunch, was [CROSSTALK] eaten in the classroom or in a common eating area. And it [CROSSTALK] was served as buffet on trays. The children were allowed to have more than one serving [CROSSTALK], but they were asked to keep a reasonable plate distribution. Where the [CROSSTALK] majority of the plate is filled with starchy fruits and vegetables. Monday was soup day. Tuesday was meat day. Wednesday was vegetarian day. Thursday was fish day. And Friday was buffet day. And on Fridays, calculated leftovers from the, former four days were served again, and this was both to reduce waste from the kitchen and from the plates. But also to serve things two times in a week, in order to make it more familiar to the children to improve acceptance of the diet. The recipes were developed by chefs to maximize taste. There was developed three week seasonal menus for each seasons. And these, three week menus were repeated three times per season. The recipes were nutritionally calculated for energy and nutrients at DTU food, at the Technical University of Denmark. And they were designed to follow, the official Nordic nutrition recommendations. the total energy amounts were calculated or the amounts for the servings of the food, were calculated based on the energy requirement for an 11 year old boy. And this would correspond to the most hungry of the children, you could say. What, though the, the child with the most, the highest energy requirement. And this was to assure that all children would get full. Recipes were entered in a database, to use for measuring what children actually ate. And I'll tell you more about that later. So, what did the meals consist of? Well, the morning snack could be a piece of whole grain rye bread, with fresh fruit, like an apple or some fresh carrot sticks or raw carrots or raw cooked cucumber or something else. It could also be a high protein dairy with home made mostly and some, some berries on it. Lunch could be, Danish fish cakes with potatoes vegetables. And the afternoo, noon snack was was packed in a paper bag in order to be taken on the go. So the children could, could grab it when they were leaving school or going to after school activities. It would typically, typically contain, a wholegrain bowl or muesli bar some dried nuts or seeds or, or dried berries and typically a piece of fresh fruit like a pear or something. So what did they eat in the control period? Were they served lunch packs? Well they just Received their normal lunch packs that their parents made. typically, Danish lunch packs would be open faced rye bread whole grain sandwiches with, for example, liver pate. some children have fruit in their lunch packs, and a bit of vegetables and, and so on. So, many of the dishes and the foods that where served in the Open School Meal Study. We're new to the children, or at least to some of the children. So what did we do to motivate the children to eat the New Nordic Diet school meals? Well, we wanted the food to be produced locally at each school, so we hired one or two chefs for each school. And they would cook and prepare and present. The food to the children. But we also every day had children participating in the cooking. And they also tasted it, and presented it to their peers. During these cooking lessons, the children would smell the food, they would taste the food, they would talk about the ingredients. And this created ownership and made them more likely to taste it afterwards. And when they presented it to their peers, it, it would also make the peers more likely to eat the food, rather than it was just some stranger coming with the food. All children in the participating classes were offered the school meal, regardless of their participation in the measurements. And in the story in general this was also to make sure that no children will sit alone in the classroom without being offered to be part of the meal. During these NND period, we agreed with the principals and with the school childrens. That they would set aside 25 minutes for eating rather than the 15 minutes that is normally set aside for eating lunch in Danish schools. The table was set nicely with a knife and fork, in order to create a positive meal situation. But the snacks, the mid-morning snack and the afternoon snack. Were designed to be eaten on the go and to bring when you were going out to play in order to facile, facilitate the eat, the eating of the snacks. Although the meals had to be standardized and every, everything has been, had to be served the same way in all the schools at the same time. We were able to do, some adaptations to the local taste of the children at each school. For example, if some children liked their carrots raw instead of steamed, they could have that, because it didn't effect the nutritional value of the carrots. And in the same way, the fish could be cut out in, in, in different ways without it effecting the standardization of the study. As I said, all this was done to create ambassadorship and a positive peer effect among the children. It was done to create ownership and self efficacy, which can be simplified by some children. may not be the best at reading in the classroom, but it really gave them something when they were really good at chopping vegetables or chopping up nuts in the school kitchen. So again, the belief that you are able to do something, that is self efficacy. and also. In the way we produce the food, we try to make the new foods and dishes more familiar to the children. Moreover, we sort of had an OPUS School Meal universe, where we produced different kinds of material for the children and for the schools. We made a teaching materials. And the teaching material about Nordic foods, about taste, about the body. We also designed some aprons that the children were to wear in the school kitchen. They look like this [SOUND]. and in that way. Everybody knew who were the OPUS chefs of the day and the children were quite proud when they, when they wore this and when they were cooking. We also did a, the recipe booklet that the children had, received as a gift after the study. And together with, to the science students. we developed a graphical universe or graphical design which was based on eggheads and that design was used on posters. all the material we handed out and also was used to decorate the laboratory truck where we did a lot, lot of our measurements. In all this. together. Was to signal that participation is fun and it's also safe. So what did we measure in the OPUS School Meal Study? Well, we conducted a number of measurements in our two-story laboratory truck. Which was specially designed to perform this type of measurements. Measurements were conducted three times: before the start of the study, after the new Nordic diet period and after the control period, when the study ended. The measurements were performed in the morning, after an overnight fast. And approximately one school class was examined per day. So, the truck was parked at the school's parking lot for about a week in each row. In the two-story truck we measured height, weight, waist circumference. We made a DXA scan, this is a scan that can measure. fat mass, lean body mass, and also the bone density of the child's body. We measured blood pressure and we also took a blood sample. And, the children were really courageous with the blood samples. Most of the children were able to provide a blood sample. And we sent local anesthetic patches to the parents and to the children before the meas, measurements. So that they could put it on here, on the forearm where the blood sample was to be taken. And that way, they couldn't really feel the blood sampling. After all these measurements, the children received a simple breakfast. Because they had been fasting and some of them until the mid-morning. So, what did we actually measure in these blood samples? Well, the blood samples were processed and then they were frozen at minus 80 degrees, for later analysis. And, in these blood samples we measured, markers of nutrient status and nutrient intake. For example, we measured vitamin D in the blood. This can be used as a marker of vitamin D intake and how much vitamin D you get from the sun. We also measured omega-3 fatty acids in the blood. This is a really good biomarker of the intake of fatty fish, but also measures the intake of fish oil. We measured also a number of cardiovascular and metabolic syndrome markers in the blood, for example, cholesterol and insulin. We measured a number of inflammatory markers, that could be cytokines, C-reative proteins. And then we measured markers of growth, and also appetite hormones. During the study, a number of other measurements were, were, collected also from some of our collaborators at baseline before the study started. The families underwent an in depth two hour interview, where they were asked about socioeconomic variables, demographics, ethnic origin, dietary habits, and so on. three times during the study, as mentioned the children were asked to record their dietary intake. For seven days and to record their physical activity and sleep for the same seven days and nights. And these types of recordings were done in the evening of all of the seven days. And based on a web-based program that was specially developed for the OPUS School Meal Study. And here, in the web program, an armadillo guided the children and, and told them to record everything they had eaten that day and everything they had been drinking. And of course the parents had to help them do that during the evening. And you can read more about that method in the paper by [INAUDIBLE] from 2012. the, the physical activity recordings were performed by ActiGraph. Which is an accelerometer which can also measure sleep. And the children had to wear, this little monitor around their waist. Or, and some of them also around the wrist for 7 days. We also measured academic performance and attention. So, using standard tests for the h group. they, they were tested in reading and math and concentration in the classroom. we measured well being and illnessess, either self rated or parent rated. And we also had a group of sociologists who looked at food culture and the social impact of the study. They did this through surveys, through focus group, groups, interviews, both with the children and with many of the other people involved in the study, and through classroom observations. Finally, at two schools, food waste both from the plates and from the kitchens were measured. We had two primary outcomes in the study. First of all, we had a metabolic syndrome score, which was based on waist circumference, blood pressure, blood lipids and cholesterol, and an index of insulin resistance. And this is a composite scroll, which in adult is thought to be related to the later risk of the metabolic syndrome and cardiovascular disease. We also had another primary outcome. And this was concentration performance, which was measured bye the D2 Test of Attention in the classroom. So, what questions can we actually answer with these data that we have collected? Well, first of all we can answer, did the school meals improve the diet and nutritional status of the children compared to lunch packs? Did the school meals affect early markers of metabolic syndrome and cardiovascular risk in the children? Did the school meals improve school performance and attention in the children? And many other questions we'll be able to answer. However, the results are not ready yet. We are currently working hard on the statistical analyses, and also with writing up the results and the scientific papers. We expect that the first scientific papers will be out in the press from the beginning of 2014. So, finally I'd like to talk a bit about some of the challenges that we met when we conducted this huge study, that involved so many different stakeholders and collaborators. We from the beginning we thought it would be a big challenge to try to motivate the school staff and the principals to invest time and effort in the study. But actually, this turned out to be a quite easy task. Because we had some really strong personalities among the teachers and, and they invested so much time and effort, and were really keen on this story. So, this was really a huge asset for us. It was a real challenge to make all our activities fit class schedules. The many measurements had to be fitted in. and also another challenge was to hire and train the chefs that were that had to be positioned geographically spread out and, and, and work out at the different schools. Another challenge was cooking at the schools. We had to use normal school kitchens just made for cooking classes, and at some schools the chefs had to cook for 200 students or pupils every day. So that was quite a challenge, and we had to. Buy some equipment as well for some of them. Also an other challenge was cleaning the school kitchens, getting rid of all the garbage. And also, making sure that the naughty foods would get out and be supplied to all the school kitchens during the study. An other thing was communication and coordination in the study, since it was so big and involved so many people. It involved 9 school principals, about 100 teachers, 1600 parents and their children, 30 chefs. And in the truck there was 20 daily members of the investigator team, doing the measurements, and also 15 to 20 other investigators. In all these, persons had to sort of act in a coordinated way during the study. every, everyone had to know what everyone was doing at the same time, so that was quite a challenge. But everyone, everyone worked really hard during the study, and in the end, everything worked so well we think. You can read more about the way we designed the study and all the thinking behind it, in a paper that we published in 2012 in the Scandinavian Journal of Public Health. Thank you. [MUSIC]
