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Background School meals hold considerable potential to shape children’s diets and reduce food-related greenhouse gas emissions (GHGE)—in the short and long term. This study applied linear optimization to develop a GHGE-reduced, nutritionally adequate, and affordable school lunch menu. The effects on food waste, consumption and pupils’ satisfaction with the meals were evaluated. Methods A pre-post design was employed to assess the effects of implementing an optimized lunch menu on daily food waste, consumption, and pupils’ school meal satisfaction in three schools (grades 0–9) from one Swedish municipality. A food list containing amounts, prices, nutrient content, and GHGE-values of all foods used for a previously served (baseline) four-week lunch menu was created. Using linear programming, this food list was optimized for minimum deviation and constrained to ensure nutritional adequacy and a reduced climate impact. The optimized food list was developed into a new (intervention) four-week lunch menu by a professional meal planner, following the baseline menu as closely as possible. The baseline and intervention menus were served for four weeks, respectively, with a two week break in between. Prepared, wasted and leftover food were weighed daily by the school kitchen staff during both periods. Interrupted time series analysis assessed mean and slope differences in daily food waste and consumption between the two periods. School lunch satisfaction was assessed with an online questionnaire at baseline and during the intervention. Results Optimization resulted in a food list that was 40% lower in GHGE, met all nutrient recommendations for school meals, and cost 11% less compared to baseline. The intervention menu was served as planned, with only minor changes required (for practical reasons). Plate waste, serving waste, consumption and school lunch satisfaction did not differ significantly from baseline, in any of the schools. Conclusions The findings demonstrate that school meals can successfully be improved regarding health and environmental sustainability using linear optimization, without negative effects on food waste, consumption or cost. This approach offers the necessary flexibility to tailor menus towards different priorities and could therefore be transferred to other types of meal services. Trial registration The trial is registered at clinicaltrials.gov ( NCT04168632 Fostering Healthy and Sustainable Diets Through School Meals (OPTIMAT).

Predictive sports data analytics can be revolutionary for sports performance. Existing literature discusses players' or teams' performance, independently or in tandem. Using Machine Learning (ML), this paper aims to holistically evaluate player-, team-, and conference (season)-level performances in Division-1 Women's basketball. The players were monitored and tested through a full competitive year. The performance was quantified at the player level using the reactive strength index modified (RSImod), at the team level by the game score (GS) metric, and finally at the conference level through Player Efficiency Rating (PER). The data includes parameters from training, subjective stress, sleep, and recovery (WHOOP straps), in-game statistics (Polar monitors), and countermovement jumps. We used data balancing techniques and an Extreme Gradient Boosting (XGB) classifier to predict RSI and GS with greater than 90% accuracy and a 0.9 F1 score. The XGB regressor predicted PER with an MSE of 0.026 and an R 2 of 0.680. Ensemble of Random Forest, XGB, and correlation finds feature importance at all levels. We used Partial Dependence Plots to understand the impact of each feature on the target variable. Quantifying and predicting performance at all levels will allow coaches to monitor athlete readiness and help improve training.

ObjectiveTo evaluate rates, risk factors and outcomes of delayed diagnosis of seven serious paediatric conditions.MethodsThis was a retrospective, cross-sectional study of children under 21 years old visiting 13 community and tertiary emergency departments (EDs) with appendicitis, bacterial meningitis, intussusception, mastoiditis, ovarian torsion, sepsis or testicular torsion. Delayed diagnosis was defined as having a previous ED encounter within 1 week in which the condition was present per case review. Patients with delayed diagnosis were each matched to four control patients without delay by condition, facility and age. Conditional logistic regression models evaluated risk factors of delay. Complications were compared between by delayed diagnosis status.ResultsAmong 14 972 children, delayed diagnosis occurred in 1.1% (range 0.3% for sepsis to 2.6% for ovarian torsion). Hispanic (matched OR 2.71, 95% CI 1.69 to 4.35) and non-Hispanic black (OR 2.40, 95% CI 1.21 to 4.79) race/ethnicity were associated with delayed diagnosis, whereas Asian and other race/ethnicity were not. Public (OR 2.21, 95% CI 1.42 to 3.44) and other (OR 2.43, 95% CI 1.50 to 3.93) insurance were also associated with delay. Non-English language was associated with delay (OR 1.65, 95% CI 1.02 to 2.69). Abnormal vital signs were associated with a lower likelihood of delay (OR 0.15, 95% CI 0.09 to 0.25). In an adjusted model, Hispanic race/ethnicity, other insurance, abnormal vital signs and complex chronic conditions (CCCs) were associated with delay. The odds of a complication were 2.5-fold (95% CI 1.6 to 3.8) higher among patients with a delay.ConclusionDelayed diagnosis was uncommon across 13 regional EDs but was more likely among children with Hispanic ethnicity, CCCs or normal vital signs. Delays were associated with a higher risk of complications.

Background Brief scales to measure parental self-efficacy (PSE) in relation to children’s obesogenic behaviours have not been developed and validated using more rigorous methodology such as invariance testing, limiting their generalisability to sub-groups. This study aimed to assess the construct validity and measurement invariance of brief PSE scales for children’s intake of vegetables, soft drinks, and sweets, and physical activity. Methods Parents ( n  = 242) of five-to-seven-year-old children in disadvantaged and culturally diverse settings in Sweden responded to a questionnaire in Swedish with 12 items assessing PSE in relation to healthy and unhealthy behaviours. Construct validity was assessed with confirmatory factor analysis, invariance testing compared the scales by groups of parental sex, education, and child weight status. Criterion validity was evaluated using objective measures of children’s physical activity and semi-objective measures of diet. Results Two-factor models showed moderate to excellent fit to the data. Invariance was supported across all groups for healthy behaviour scales. Unhealthy behaviour scales were invariant for all groups except parental education where partial metric invariance was supported. Scales were significantly correlated with physical activity and diet. Conclusion This study provides preliminary evidence for the validity of brief PSE scales and invariance across groups suggesting their utility for research and clinical management of weight-related behaviours.

Background There is an urgent need to align human diets with goals for environmental sustainability and population health. The OPTIMAT™-intervention study was developed to implement and evaluate a nutritionally adequate and climate-friendly 4-week lunch menu in Swedish primary schools. This study aimed to explore pupils’ and kitchen staff’s experiences of the intervention and to identify barriers and facilitators to successful implementation of sustainable school meals. Methods An inductive manifest qualitative method was used. Nine focus group discussions (FGDs) were conducted, six with pupils in grades 5 (ages 10–11) and 8 (ages 14–15) ( n  = 29) and three with kitchen staff ( n  = 13). Data were analyzed using qualitative content analysis. Results Five main categories and 11 subcategories at a manifest level emerged. The five main categories were: 1) Experiences with the new menu , unfolding variations in how the new menu was received and kitchen staff’s experiences of working with it ; 2) The meaning of diet sustainability , comprising pupils’ and kitchen staff’s perceptions about diet sustainability as a concept and part of their everyday lives; 3) Factors influencing plant-based food acceptance , covering aspects such as the influence of sensory factors, habits and peer pressure; 4) Opportunities to increase plant-based eating , including factors related to pupils’ and kitchen staff’s ideas for how to increase plant-based food acceptance ; and 5) Need for a supportive environment to achieve dietary change , comprising pupils’ and kitchen staff’s thoughts on the importance of more knowledge, resources and involvement of stakeholders to eat more plant-based meals in schools. Conclusions Successful implementation of sustainable school meals would require more knowledge among pupils and kitchen staff. Staff also need more training in cooking of sustainable meals. Barriers among pupils could be tackled by introducing new plant-based meals more gradually and by more carefully considering the seasoning, naming and aesthetics of dishes. An increased leadership support for change and involvement of stakeholders from multiple levels within society will be key in the transition to sustainable school meals at scale. Trial registration The trial registration for the OPTIMAT™-intervention may be found at clinicaltrials.gov ( NCT04168632 Fostering Healthy and Sustainable Diets Through School Meals (OPTIMAT)).

BackgroundThis specialist children’s hospital used unlicensed midazolam 2.5 mg/ml oral solution for preoperative sedative. This product had various problems such as a bitter taste which often led to poor patient acceptability and a short expiry once opened. In this Trust midazolam oral solution is stored and recorded in CD registers and discrepancies in the running balance are often reported as clinical incidents and destruction of expired stock is also time-consuming. When a licensed midazolam 5 mg/ml oral solution single dose preparation became available, the Trust wanted to investigate whether a switch to this product would be beneficial. The new product is supplied as a single dose preparation and is orange flavoured.MethodPharmacy completed a ‘new drug risk assessment’ for the product ensuring that the excipients were appropriate for paediatric patients. The risk assessment also identified possible problems associated with the implementation of the new product across the trust (eg different strength, single use bottle, time taken for dispensing of single bottles rather than a stock bottle, storage capacity for multiple bottles, changes to documentation in CD registers) [This hospital stores and records midazolam in CD cupboards]. Any potential cost pressure was also identified and highlighted to the finance department. A pilot was undertaken with 10 patients. Nurses and anaesthetists were asked for feedback regarding a switch to this product prior to implementing a complete switch. The electronic prescribing system was updated, and communications circulated to the hospital to alert all staff of the change of product.ResultsAll nurses and anaesthetists involved in the pilot were positive in their evaluation of the new product. Comments such as ‘the child took this well and then accepted other medicines’ were recorded. Since the switch occurred there have not been any clinical incidents reported of issues with running balances or patient safety incidents involving oral midazolam. All areas reported no impact upon department due to storage capacity or increased workload based upon record keeping. Since moving to the new product feedback from clinicians has continued to be positive particularly relating to improved patient compliance due to both flavouring and smaller administrative volumes. The pharmacy has also not had any requests for return for destruction of midazolam as all destructions of remaining liquid is carried out at a ward level. The additional cost was £18,300 but the Trust were happy to offset this against the reduced risk of cancelled operations due to inadequate pre-medication. The nursing staff have noted no increased workload in practice. The has been a neutral impact upon pharmacy workload as although there is increased dispensing times as more bottles are dispensed per order the pharmacy has not been required to destroy expired stocks.ConclusionThe move to the licensed oral midazolam liquid for pre-medication has resulted in better patient compliance, there have been no clinical incidents reported and workload has not been adversely affected.

Background The rise in overweight and obesity among children is a global problem and effective prevention interventions are urgently required. Parents play an important role in children’s lifestyle behaviours and body weight development and therefore there is a great need to investigate how to involve parents effectively in health promotion and prevention programmes. The aim of the study was to describe parents’ experiences of barriers and facilitators of participating in the Healthy School Start Plus (HSSP) intervention study. Methods HSSP is a parental support programme, conducted in Sweden, with the aim to promote a healthy diet, physical activity and preventing obesity in 5-7-year-old children starting school. In total 20 parents from 7 schools participated in semi-structured telephone-based interviews. The data was analysed using qualitative content analysis, with a deductive approach based on the Consolidated Framework for Implementation Research (CFIR). Results Parental experiences of barriers and facilitators informing the implementation of the HSSP intervention were identified within all five domains of the CFIR. Two additional constructs, not included in the CFIR were identified: Social factors and Cooperation. The findings of parental experiences of barriers and facilitators related to the importance of (1) adaptation of the intervention to fit the abilities of the parents with different social and cultural backgrounds; (2) the need for continuous delivery of information related to healthy behaviours; (3) the commitment and efforts of the deliverers of the intervention; (4) the need for repetition of information related to healthy behaviours given by the deliverers of the intervention; (5) encouragement and facilitation of the involvement of the family and key people around them through the intervention activities and by the deliverers of the intervention; (6) awareness of unexpected impacts and social and cultural conditions complicating the execution of the intervention and; (7) cooperation and a well-functioning interaction between parents and school staff. Conclusions Barriers and facilitators indicated by the parents highlighted that interventions like the HSSP need to be adapted to fit the parents’ abilities, with reminders, follow-ups and delivery of relevant information. Variations in social and cultural conditions need to be taken into consideration. The commitment of the school and the interaction between the school staff and the family as well as key people around them appears to be important. Trial registration The Healthy School Start Plus trial was retrospectively registered in the International Standard Randomised Controlled Trial Number Registry on January 4, 2018 and available online at ClinicalTrials.gov: No. NCT03390725.

Background In Sweden, childhood overweight and obesity rates have risen significantly over the last decades, necessitating scalable interventions. The evidence-based Healthy School Start (HSS) program integrates school and family components to promote healthy habits and prevent overweight and obesity among children. The IMPROVE trial aimed to compare the effect of two tailored implementation strategy bundles (Basic and Enhanced) on fidelity to the HSS program. Methods A hybrid type III cluster-randomized trial with two parallel arms was conducted in 45 schools (cluster) in three municipalities in Stockholm Sweden from August 2021 to June 2024. The program was implemented in two consecutive cohorts over two academic school years. Fidelity was measured with an adherence score (0–4) and parent’s responsiveness (1–5) to the four intervention components (health brochure, motivational interviewing health talk, classroom module and type 2 diabetes risk test). Data were analyzed using mixed-effects linear and logistic regression models. Key findings A total of 946 parents and 655 children participated. Overall fidelity, assessed as an adherence score, was around 75%, with most components implemented as expected. The adherence score in the Basic bundle showed no significant difference compared to the Enhanced implementation strategy bundle (β = 0.01, p  = 0.95, 95% CI: –0.24, 0.25). Two of four Enhanced implementation strategies, educational outreach visits and networking between school and primary health care, did not happen mainly due to lack of interest and time among personnel. Parents born within the Nordic countries had twice the odds ( p  < 0.001, 95% CI: 1.14–3.43) of completing the motivational interviewing health talk compared to those born outside the Nordics. Discussion Enhancing the Basic implementation bundle with additional strategies did not consistently improve adherence or responsiveness. However, improvements observed over time underscore the importance of targeted support during the initial implementation year. Additional motivational actions might be needed in schools with a high proportion of children whose parents are born outside the Nordic region. These findings highlight the complex interplay between context and implementation success, emphasizing the need to adapt strategies over time to optimize their effectiveness rather than merely adding more. Moreover, the essentially null findings also point to broader methodological challenges in implementation science, particularly how to prioritize among determinants, strategy selection and tailoring. Trial registration ClinicalTrials.gov, Unique Protocol ID: NCT04984421. Registered July 30, 2021, https://register.clinicaltrials.gov/ .

Background Systematic reviews conclude that interventions to prevent overweight and obesity in children obtain stronger effects when parents are involved. Parenting practices and parent-child interactions shape children’s health-related behaviours. The Healthy School Start Plus intervention aims to promote healthy dietary habits and physical activity and prevent obesity in children through parental support in disadvantaged areas with increased health needs, delivered by teachers and school nurses. This protocol describes the design, outcome and process evaluation of the study. Methods Effectiveness of the intervention is compared to standard care within school health services. The 6-month programme, based on Social Cognitive Theory, consists of four components: 1) Health information to parents regarding the child; 2) Motivational Interviewing with the parents by the school nurse concerning the child; 3) classroom activities for the children by teachers; and 4) a web-based self-test of type-2 diabetes risk by parents. Effects will be studied in a cluster randomised trial including 17 schools and 352 six-year old children. The primary outcome is dietary intake of indicator foods, and secondary outcomes are physical activity, sedentary behaviour and BMI. Outcomes will be measured at baseline, at 6 months directly after the intervention, and at follow-up 18 months post baseline. Statistical analysis will be by mixed-effect regression analysis according to intention to treat and per protocol. Mediation analysis will be performed with parental self-efficacy and parenting practices. Quantitative and qualitative methods will be used to study implementation in terms of dose, fidelity, feasibility and acceptability. The hypothesis is that the programme will be more effective than standard care and feasible to perform in the school context. Discussion The programme is in line with the cumulated evidence regarding the prevention of childhood obesity: That schools should be a focal point of prevention efforts, interventions should involve multiple components, and include the home environment. If effective, it will fill a knowledge gap concerning evidence-based health promotion practice within school health services to prevent obesity, and in the long term reduce social inequalities in health. Trial registration The trial was retrospectively registered on January 4, 2018 and available online at ClinicalTrials.gov : No. NCT03390725 .