Network spillover effects associated with the ChooseWell 365 workplace randomized controlled trial to promote healthy food choices.

Food choices are closely linked to culture, social relationships, and health. Because many adults spend up to half their time at work, the workplace provides a venue for changing population health-related behaviors and norms. It is unknown whether the effects of a workplace intervention to improve health behaviors might spread beyond participating employees due to social influence. ChooseWell 365 was a randomized controlled trial testing a 12-month healthy eating intervention grounded in principles of behavioral economics. This intervention leveraged an existing cafeteria traffic-light labeling system (green = healthy; red = unhealthy) in a large hospital workplace and demonstrated significant improvements in healthy food choices by employees in the intervention vs. control group. The current study used data from over 29 million dyadic purchasing events during the trial to test whether social ties to a trial participant co-worker (n = 299 intervention, n = 302 control) influenced the workplace food choices of non-participants (n = 7900). There was robust evidence that non-participants who were socially tied to more intervention group participants made healthier workplace food purchases overall, and purchased a greater proportion of healthy (i.e., green) food and beverages, and fewer unhealthy (i.e., red) beverages and modest evidence that the benefit of being tied to intervention participants was greater than being tied to control participants. Although individual-level effect sizes were small, a range of consistent findings indicated that this light-touch intervention yielded spillover effects of healthy eating behaviors on non-participants. Results suggest that workplace healthy eating interventions could have population benefits extending beyond participants.

Disentangling associations between pubertal development, healthy activity behaviors, and sex in adolescent social networks.

With the onset of puberty, youth begin to choose their social environments and develop health-promoting habits, making it a vital period to study social and biological factors contextually. An important question is how pubertal development and behaviors such as physical activity and sleep may be differentially linked with youths' friendships. Cross-sectional statistical network models that account for interpersonal dependence were used to estimate associations between three measures of pubertal development and youth friendships at two large US schools drawn from the National Longitudinal Study of Adolescent to Adult Health. Whole-network models suggest that friendships are more likely between youth with similar levels of pubertal development, physical activity, and sleep. Sex-stratified models suggest that girls' friendships are more likely given a similar age at menarche. Attention to similar pubertal timing within friendship groups may offer inclusive opportunities for tailored developmental puberty education in ways that reduce stigma and improve health behaviors.

Social isolation and depression as risk factors for weight loss of 5kg or more among older Korean adults.

Given a well-known overlapping prevalence of social isolation with loneliness and depression among older adults, this study aimed to contextually investigate the relationship of these constructs with weight loss of more than 5kg in a year, with a special focus on the intersection of living alone and marital dissolution as key dimensions of isolation. The data were obtained from the Korean Longitudinal Study of Aging (KLoSA) from 2006, 2008, 2010, 2012, 2014, 2016, and 2018, with an adult sample of those aged 65 and older (n = 5,481). The study evaluated several critical dimensions of social isolation: living alone, transition to living alone, infrequent social contact with children or friends, and infrequent social participation. These dimensions were examined individually and as a composite scale, along with loneliness and depressive symptoms, to determine their association with weight loss of 5kg or greater among older men and women. Generalized Estimating Equation (GEE) regression models enabled investigation of whether socially isolated men and women tended to lose 5kg or more in weight, given other confounding factors. Surprisingly, the results showed no evidence of such a trend. However, significant associations were found between weight loss and changes in living alone and marital status. For older men, transitioning to living alone without a change in marital status was linked to significant weight loss. For older women, transitioning to living alone following widowhood or divorce was the risk factor. These relationships remained significant even after adjusting for depression and a wide range of covariates. Additional analysis testing a cumulative effect revealed that only depression was a risk factor for being underweight at the last observation. Therefore, to prevent a clinically risky extent of weight loss, health policies for older Koreans should focus on those who transition to living alone, especially due to spousal bereavement or divorce (among women) and separation from living with children (among men).

Evaluation of Family and Community Social Network Characteristics Among High-Risk Family Members to Improve Cancer-Related Health Behaviors.

OBJECTIVES: To evaluate the effects of social network characteristics of individuals with a family history of cancer on the use of cancer-related services (e.g., screening, genetic counseling/testing). SAMPLE & SETTING: 170 family members of individuals with the most common hereditary or familial cancers. METHODS & VARIABLES: Data collection occurred between March and September 2021 using an online survey. RESULTS: Having strong within-immediate family relationships and family members who underwent more screening procedures was associated with increased breast cancer screening, and having more family members with cancer was associated with colorectal cancer screening. Having a large family, having family members who underwent screening for more cancers, and having strong social cohesion among families were associated with an increased rate of genetic testing. IMPLICATIONS FOR NURSING: Nurses working with families affected by cancer should focus on strategies to strengthen relationships among family members to improve knowledge of cancer screening and available genetic services.

Community coalition efforts to prevent childhood obesity: two-year results of the Shape Up Under 5 study.

BACKGROUND: Cross-sector collaborations and coalitions are promising approaches for childhood obesity prevention, yet there is little empirical evidence about how they affect change. We hypothesized that changes in knowledge of, and engagement with, childhood obesity prevention among coalition members can diffuse through social networks to influence policies, systems, and environments. METHODS: We studied a community coalition (N = 16, Shape Up Under 5 "SUU5 Committee") focused on early childhood obesity prevention in Somerville, MA from 2015-17. Knowledge, engagement, and social network data were collected from Committee members and their network contacts (n = 193) at five timepoints over two years. Policy, systems, and environment data were collected from the SUU5 Committee. Data were collected via the validated COMPACT Stakeholder-driven Community Diffusion survey and analyzed using regression models and social network analysis. RESULTS: Over 2 years, knowledge of (p = 0.0002), and engagement with (p = 0.03), childhood obesity prevention increased significantly among the SUU5 Committee. Knowledge increased among the Committee's social network (p = 0.001). Significant changes in policies, systems, and environments that support childhood obesity prevention were seen from baseline to 24 months (p = 0.003). CONCLUSION: SUU5 had positive effects on "upstream" drivers of early childhood obesity by increasing knowledge and engagement. These changes partially diffused through networks and may have changed "midstream" community policies, systems, and environments.

Tracing coalition changes in knowledge in and engagement with childhood obesity prevention to improve intervention implementation.

BACKGROUND: While most coalition research focuses on studying the effects of peer relationship structure, this study examines the coevolution of coalition structure and behavior across three communities in the U.S. with the goal of identifying coalition dynamics that impact a childhood obesity prevention intervention.  METHODS: Over two years (2018-2020), three communities within the U.S. participated in a childhood obesity prevention intervention at different times. This intervention was guided by the Stakeholder-Driven Community Diffusion theory, which describes an empirically testable mechanism for promoting community change. Measures are part of the Stakeholder-driven Community Diffusion (SDCD) survey with demonstrated reliability, which include knowledge of and engagement with childhood obesity prevention and social networks. Data from three coalition-committees and their respective networks were used to build three different stochastic actor-oriented models. These models were used to examine the coevolution of coalition structure with coalition behavior (defined a priori as knowledge of and engagement with obesity prevention) among coalition-committee members and their nominated alters (Network A) and coalition-committee members only (Network B).  RESULTS: Overall, coalitions decrease in size and their structure becomes less dense over time. Both Network A and B show a consistent preference to form and sustain ties with those who have more ties. In Network B, there was a trend for those who have higher knowledge scores to increase their number of ties over time. The same trend appeared in Network A but varied based on their peers' knowledge in and engagement with childhood obesity prevention. Across models, engagement with childhood obesity prevention research was not a significant driver of changes in either coalition network structure or knowledge. CONCLUSIONS: The trends in coalition Network A and B's coevolution models may point to context-specific features (e.g., ties among stakeholders) that can be leveraged for better intervention implementation. To that end, examining tie density, average path length, network diameter, and the dynamics of each behavior outcome (i.e., knowledge in and engagement with childhood obesity prevention) may help tailor whole-of-community interventions. Future research should attend to additional behavioral variables (e.g., group efficacy) that can capture other aspects of coalition development and that influence implementation, and to testing the efficacy of network interventions after trends have been identified.

Social connections and the healthfulness of food choices in an employee population.

Unhealthy food choice is an important driver of obesity, but research examining the relationship of food choices and social influence has been limited. We sought to assess associations in the healthfulness of workplace food choices among a large population of diverse employees whose food-related social connections were identified using passively collected data in a validated model. Data were drawn from 3 million encounters where pairs of employees made purchases together in 2015-2016. The healthfulness of food items was defined by 'traffic light' labels. Cross-sectional simultaneously autoregressive models revealed that proportions of both healthy and unhealthy items purchased were positively associated between connected employees. Longitudinal generalized estimating equation models also found positive associations between an employee's current food purchase and the most recent previous food purchase a coworker made together with the employee. These data indicate that workplace interventions to promote healthy eating and reduce obesity should test peer-based strategies.

Evolution of a Coalition Network during a Whole-of-Community Intervention to Prevent Early Childhood Obesity.

Background: Community coalitions often lead and coordinate "whole-of-community" childhood obesity prevention interventions. A growing body of work suggests that coalition network ties, which facilitate transmission of information and advocacy, may be a key part of how such leadership operates. This study provides an understanding of the structure of coalition networks and how this structure changes over time. Methods: We administered semiannual network surveys during a pilot whole-of-community intervention in Somerville, MA (2015-2017). Participants included 16 multisector coalition members and their nominated discussion partners ("first-degree alters") related to childhood obesity prevention. Coalition and first-degree alter respondents named up to 20 discussion partners and reported ties' interaction frequency and perceived influence. Networks were assessed with visualization, descriptive analysis, and exponential random graph models. Results: Total network included 558 stakeholders representing community-based organizations, parents, health care, childcare, universities, among others. Size and membership varied over time. We observed the largest network (n = 256) during intervention planning, and the largest proportion of stakeholders communicating frequently (daily/weekly) about childhood obesity prevention during the peak intervention period. Networks were sparsely interconnected (1%-3% of possible ties observed) and most and least centralized at baseline and follow-up, respectively. Over time, ties were increasingly perceived as influential and siloed within community groups. Conclusions: The network's extensive evolving membership may indicate access to a wide range of resources, ideas, and an ability to broadly disseminate intervention messages. The attenuating network hierarchy over time may have supported more equal participation and control over intervention efforts. Future research should assess generalizability of network patterns, network influences on implementation processes, and possible network interventions.

Is having an educationally diverse social network good for health?

While network research often focuses on social integration as a predictor of health, a less-explored idea is that connections to dissimilar others may benefit well-being. As such, this study investigates whether network diversity is associated with changes in four health outcomes over a 3-year period of time in the U.S.A. Specifically, we focus on how an underexplored measure of network diversity-educational attainment assortativity-is associated with common self-reported outcomes: propensity to exercise, body-mass index, mental health, and physical health. We extend prior research by conducting multilevel analyses using this measure of diversity while adjusting for a range of socio-demographic and network confounders. Data are drawn from a longitudinal probability sample of U.S. adults (n = 10, 679) in which respondents reported information about themselves and eight possible alters during three yearly surveys (2013-2015). We find, first, that higher educational attainment is associated with more educationally insular networks, while less-educated adults have more educationally diverse networks. Results further suggest that having educationally similar networks is associated with higher body-mass index among the less educated. Further exploration of the relationship between ego network diversity, tie strength, and health is warranted.

Timing of puberty in boys and girls: Implications for population health.

Puberty is marked by substantial increases and emerging sex differences in psychological disorders and risky behaviors. However, few studies have examined these effects beyond adolescence, and the previous literature has been dominated by samples of White girls. The current study examines the broadest known set of health sequelae related to traditional pubertal markers and peer-relative pubertal timing in a representative sample of 14,545 U.S. youth from the National Longitudinal Study of Adolescent to Adult Health. Maturational timing was assessed by age at menarche for girls and physical development for boys (e.g., facial hair, voice change), and then categorized as early (1 SD below mean), on-time, or late (1 SD above mean) within-sex. Early and late peer-relative timing was assessed by a self-report of looking "much older" or "much younger" than one's peers. We examined psychological (depressive symptoms, antisocial behavior), behavioral (number of sex partners, drug use, physical activity, screen time, sleep hours), and physical health (self-reported health, BMI) outcomes during adolescence and young adulthood in a series of sex-stratified regression analyses using survey weights and a comprehensive set of sociodemographic covariates. Results indicated that, overall, earlier pubertal timing (i.e., maturational timing and peer-relative timing) put both girls and boys at risk during adolescence, while later timing was protective. However, longitudinal models revealed mixed results. For instance, early maturational timing was associated with higher young adult BMI (girls: ß = 0.139, p < .01; boys: ß = 0.107, p < .01), but later timing for boys was associated with both risky (e.g., more screen time; ß = 0.125, p < .05) and health promoting (e.g., more sleep; ß = .296, p < .01) behaviors. Analysis of this holistic set of outcomes with sex differences in mind allows for more careful evidence-based recommendations for adolescent health promotion.

Challenges and Lessons Learned From Digital Storytelling With Parenting Women in Recovery.

With the national increase in opioid use disorder among pregnant and parenting women, innovative mechanisms are being utilized to engage with mothers to build social support and promote recovery. This is particularly important in rural settings where other support systems may be limited. Digital storytelling is an interactive tool that often facilitates social connectedness among participants and may foster empowerment and community building among mothers in recovery. We conducted one digital storytelling workshop with rural mothers in recovery in 2018 to examine the feasibility of employing this method to engage with mothers in recovery in a community setting and promote social support among participants. In this article, we describe what we learned from working with the mothers to guide others considering using digital storytelling with women with opioid use disorder in future research or public health intervention projects.

Impacts of Adolescent and Young Adult Civic Engagement on Health and Socioeconomic Status in Adulthood.

The present study examines links between civic engagement (voting, volunteering, and activism) during late adolescence and early adulthood, and socioeconomic status and mental and physical health in adulthood. Using nationally representative data from the National Longitudinal Study of Adolescent to Adult Health, a propensity score matching approach is used to rigorously estimate how civic engagement is associated with outcomes among 9,471 adolescents and young adults (baseline Mage  = 15.9). All forms of civic engagement are positively associated with subsequent income and education level. Volunteering and voting are favorably associated with subsequent mental health and health behaviors, and activism is associated with more health-risk behaviors and not associated with mental health. Civic engagement is not associated with physical health.

Context Matters: Adolescent Neighborhood and School Influences on Young Adult Body Mass Index.

PURPOSE: Both schools and neighborhoods play important roles in determining adolescent weight status, but little is known about their relative importance, particularly in predicting long-term weight outcomes. We assessed the impacts of both school and neighborhood socioeconomic composition, social connectedness, and built environment during adolescence on weight status in young adulthood. METHODS: The study sample consisted of 14,625 respondents from Waves I and IV of the National Longitudinal Study of Adolescent to Adult Health. Data were analyzed using cross-classified multilevel modeling to examine the joint effect of adolescents' school and neighborhood predictors on body mass index (BMI) 13 years later. RESULTS: Living in a neighborhood with lower average parent education during adolescence, and attending a school with lower average parent education, were each associated with higher BMI in young adulthood. Living in a neighborhood with more physical activity resources predicted lower young adult BMI, independent of adolescent weight, parent obesity status, and demographic characteristics. School physical activity resources and perceptions of social connectedness (in the school or neighborhood) were not significantly associated with young adult BMI. CONCLUSIONS: These findings highlight the importance of school and neighborhood socioeconomic composition during adolescence on young adult weight status. Results also suggest that improving neighborhood infrastructure may promote healthy weight.

Design of ChooseWell 365: Randomized controlled trial of an automated, personalized worksite intervention to promote healthy food choices and prevent weight gain.

BACKGROUND/AIMS: Behavioral nudges in the food environment increase healthy choices, but it is unknown if they improve diet and health. The ChooseWell 365 study will determine if an automated, personalized worksite intervention to nudge healthier choices improves overall diet and cardiometabolic health. DESIGN: Randomized controlled trial of 602 hospital employees who regularly use on-site cafeterias and pay with an employee ID. INTERVENTION: The intervention combines an environmental strategy (traffic-light labeling) with objective feedback and personalized nudges (health/lifestyle tips, social norms, incentives) to promote healthy food choices. The ChooseWell 365 software platform automatically generates personalized emails and letters that integrate employees' weight goals with health, lifestyle, and cafeteria purchasing data. Over one year, the intervention group receives two weekly emails. One provides a log of daily purchases; the second provides personalized health/lifestyle tips. The intervention group receives monthly mailed letters with social norm comparisons and financial incentives for healthier purchases. The one-year intervention will be completed in February 2019; all follow-up will be completed March 2020. OUTCOMES: Weight, cardiometabolic risk factors, and dietary intake at one and two-year follow-up. Other outcomes include worksite food purchases by study participants and other non-participant employees who are socially connected (inferred from purchasing data) to participants. CONCLUSIONS: ChooseWell 365 tests a novel strategy to deliver a scalable worksite prevention program that is integrated into the workday. The intervention is personalized but automated and therefore does not require costlier individual counseling. In the future, this program could be applied broadly in other worksite settings.

Development and testing of a novel survey to assess Stakeholder-driven Community Diffusion of childhood obesity prevention efforts.

BACKGROUND: Involving groups of community stakeholders (e.g., steering committees) to lead community-wide health interventions appears to support multiple outcomes ranging from policy and systems change to individual biology. While numerous tools are available to measure stakeholder characteristics, many lack detail on reliability and validity, are not context specific, and may not be sensitive enough to capture change over time. This study describes the development and reliability of a novel survey to measure Stakeholder-driven Community Diffusion via assessment of stakeholders' social networks, knowledge, and engagement about childhood obesity prevention. METHODS: This study was completed in three phases. Phase 1 included conceptualization and online survey development through literature reviews and expert input. Phase 2 included a retrospective study with stakeholders from two completed whole-of-community interventions. Between May-October 2015, 21 stakeholders from the Shape Up Somerville and Romp & Chomp interventions recalled their social networks, knowledge, and engagement pre-post intervention. We also assessed one-week test-retest reliability of knowledge and engagement survey modules among Shape Up Somerville respondents. Phase 3 included survey modifications and a second prospective reliability assessment. Test-retest reliability was assessed in May 2016 among 13 stakeholders involved in ongoing interventions in Victoria, Australia. RESULTS: In Phase 1, we developed a survey with 7, 20 and 50 items for the social networks, knowledge, and engagement survey modules, respectively. In the Phase 2 retrospective study, Shape Up Somerville and Romp & Chomp networks included 99 and 54 individuals. Pre-post Shape Up Somerville and Romp & Chomp mean knowledge scores increased by 3.5 points (95% CI: 0.35-6.72) and (- 0.42-7.42). Engagement scores did not change significantly (Shape Up Somerville: 1.1 points (- 0.55-2.73); Romp & Chomp: 0.7 points (- 0.43-1.73)). Intraclass correlation coefficients (ICCs) for knowledge and engagement were 0.88 (0.67-0.97) and 0.97 (0.89-0.99). In Phase 3, the modified knowledge and engagement survey modules included 18 and 25 items, respectively. Knowledge and engagement ICCs were 0.84 (0.62-0.95) and 0.58 (0.23-0.86). CONCLUSIONS: The survey measures upstream stakeholder properties-social networks, knowledge, and engagement-with good test-retest reliability. Future research related to Stakeholder-driven Community Diffusion should focus on prospective change and survey validation for intervention effectiveness.

Social network analysis of stakeholder networks from two community-based obesity prevention interventions.

INTRODUCTION: Studies of community-based obesity prevention interventions have hypothesized that stakeholder networks are a critical element of effective implementation. This paper presents a quantitative analysis of the interpersonal network structures within a sub-sample of stakeholders from two past successful childhood obesity prevention interventions. METHODS: Participants were recruited from the stakeholder groups (steering committees) of two completed community-based intervention studies, Romp & Chomp (R&C), Australia (2004-2008) and Shape Up Somerville (SUS), USA (2003-2005). Both studies demonstrated significant reductions of overweight and obesity among children. Members of the steering committees were asked to complete a retrospective social network questionnaire using a roster of other committee members and free recall. Each participant was asked to recall the people with whom they discussed issues related to childhood obesity throughout the intervention period, along with providing the closeness and level of influence of each relationship. RESULTS: Networks were reported by 13 participants from the SUS steering committee and 8 participants from the R&C steering committee. On average, participants nominated 16 contacts with whom they discussed issues related to childhood obesity through the intervention, with approximately half of the relationships described as 'close' and 30% as 'influential'. The 'discussion' and 'close' networks had high clustering and reciprocity, with ties directed to other steering committee members, and to individuals external to the committee. In contrast, influential ties were more prominently directed internal to the steering committee, with higher network centralization, lower reciprocity and lower clustering. DISCUSSION AND CONCLUSION: Social network analysis provides a method to evaluate the ties within steering committees of community-based obesity prevention interventions. In this study, the network characteristics between a sub-set of stakeholders appeared to be supportive of diffused communication. Future work should prospectively examine stakeholder network structures in a heterogeneous sample of community-based interventions to identify elements most strongly associated with intervention effectiveness.

Eating with others and meal location are differentially associated with nutrient intake by sex: The Diabetes Study of Northern California (DISTANCE).

Though eating with others is often a social behavior, relationships between social contexts of eating and nutrient intake have been underexplored. This study evaluates how social aspects of eating - frequencies of eating meals with others, meals prepared at home, and meals outside the home - are associated with nutrient intake. Because diet improvement can reduce complications of diabetes mellitus, we surveyed a multi-ethnic cohort of persons with type 2 diabetes (n = 770) about social aspects of diet (based on 24-hour recalls). Sex-stratified multiple regression analyses adjusted for confounders assessed the relationship between frequency of eating with others and nutrient intake (total energy, energy from fat, energy from carbohydrates, Healthy Eating Index/HEI, Dietary Approaches to Stop Hypertension/DASH score). Although there was slight variation in men's versus women's propensity to share meals, after adjustment for confounders, there was no consistently significant association between meals with others and the 5 nutrient intake measures for either men or women. The directions of association between categories of eating with others and diet quality (HEI and DASH scores) - albeit not significant - were different for men (positive) and women (mostly negative), which warrants further investigation. The next analyses estimated nutrient intake associated with meals prepared at home, and meals consumed outside the home. Analyses indicated that greater meal frequency at home was associated with significantly better scores on diet quality indices for men (but not women), while meal frequency outside the home was associated with poorer diet quality and energy intake for women (but not men). Better measurement of social dimensions of eating may inform ways to improve nutrition, especially for persons with diabetes for whom diet improvement can result in better disease outcomes.

The intergenerational transmission of obesity: The role of time preferences and self-control.

Previous research has found that impatient time preferences and self-control problems (present bias) are related to increased obesity risk. However, scant evidence exists pertaining to whether parents' impatience and self-control problems impact the obesity status of their children, too. Accordingly, we explore this study question among a large national sample of US adults and their children. Study results confirm previous findings indicating that intertemporal preferences are related to adults' obesity status. Moreover, these results extend the literature by finding that children of impatient or present-biased parents have a significantly higher likelihood of being obese, too. Specifically, parents' low levels of patience and present bias were each independently related to a five-percentage point increase in the likelihood of obesity of their children. These findings were more pronounced when all children were combined in analyses and for the first child; however, they varied for the second and third child. Thus, findings suggest that parents' time preferences and self-control problems likely affect not only their own weight status but that of their children.

Associations between social network characteristics, cognitive function, and quality of life among residents in a dementia special care unit: A pilot study.

Social integration has a significant influence on physical and mental health. Older adults experience an increased risk of social isolation as their social networks contract. The purpose of this study is to examine associations between dementia special care unit residents' overall well-being and cognition with structural aspects of their coresident relationships. Design and Methods Measures of social network structure were calculated from self-reported social contact data within three cohorts of residents in one dementia special care unit. Pearson correlations were used to describe associations between overall quality of life and cognition, with network characteristics indicative of social integration. Results Approximately half the ties sent or received were reciprocated and positive associations were found between social integration and quality of life. However, inconsistent associations were found between social integration and cognitive function. Friendship ties were more frequent between people of adjacent cognitive status categories. In addition, comparing across personal networks, residents tended to be tied to residents of higher quality of life status (43.3%, n = 13 personal networks) as opposed to lower (30%, n = 9 networks) or same (26.7%, n = 8 networks). There is a strong positive correlation between quality of life and respondent's betweenness centrality, suggesting that individuals with high quality of life tend to be important intermediaries between others in the community. Implications Among the "oldest old," quality of life and cognitive function are unevenly distributed, yet these health indicators tend to cluster in social networks. This reinforces that while quality of life may be highly individual, it is in part linked to relationships with others.

Are school meals a viable and sustainable tool to improve the healthiness and sustainability of children´s diet and food consumption? A cross-national comparative perspective.

There is little agreement among governments, institutions, scientists and food activists as to how to best tackle the challenging issues of health and sustainability in the food sector. This essay discusses the potential of school meals as a platform to promote healthy and sustainable food behavior. School meal programs are of particular interest for improving public diet because they reach children at a population scale across socio-economic classes and for over a decade of their lives, and because food habits of children are more malleable than those of adults. Current research on the history and health implications of school meal programs is reviewed in a cross-national comparative framework, and arguments explored that speak for the need of a new developmental phase of school meals as an integrative learning platform for healthy and sustainable food behavior. Nutritional, social, practical, educational, economical, political, and cultural perspectives and challenges linked to the implementation of healthy and sustainable school meals are discussed. Finally, the need for long-term interventions and evaluations is highlighted and new research directions are proposed.