Acceptability and Feasibility of Best Practice School Lunches by Elementary School-Aged Children in a Serve Setting: A Randomized Crossover Trial
Abstract
:1. Introduction
2. Materials and Methods
2.1. Participants
2.2. Sample Size and Power Calculations
2.3. Study Design
2.4. Data Collection
2.4.1. Acceptability
2.4.2. Feasibility
2.5. Statistical Analysis
3. Results
3.1. Participant Characteristics
3.2. Differences in Acceptability between BPSL and TSL
3.2.1. Taste Test Evaluation
3.2.2. Plate Waste Assessment
3.2.3. Changes in Hunger
3.2.4. Differences by Group
3.3. Influence of Presence of Competitive Foods on Acceptability
3.3.1. Meal Selection
3.3.2. Taste Test Evaluation
3.3.3. Plate Waste Assessment
3.3.4. Change in Hunger
3.4. Qualitative Results Regarding Acceptability
3.5. Differences in Feasibility between BPSL and TSL
3.5.1. Meal Cost
3.5.2. Preparation Time
3.5.3. Skill
3.5.4. Equipment
4. Discussion
4.1. Strengths
4.2. Limitations
4.3. Directions for Future Research
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Acknowledgments
Conflicts of Interest
Appendix A
- Knowledge of principles and methods of preparing food in large quantities according to appropriate food safety and sanitation procedures.
- Practice proper operation of equipment to assure safety and avoid damage to equipment and clean and sanitize equipment properly.
- Follow and scale standardized recipes; weigh and measure food ingredients accurately. Requires basic math skills and knowledge of common weights and measures.
- Operate the following kitchen equipment: oven, warmer, and cooler.
- Utilize the following kitchenware: knives, spatula, whisk, tongs, and measuring cups and spoons.
- Knowledge of principles and methods of preparing food in large quantities according to appropriate food safety and sanitation procedures.
- Practice proper operation of equipment to assure safety and avoid damage to equipment and clean and sanitize equipment properly.
- Follow food safety procedures for the handling of fresh ready-to-eat (RTE) produce.
- Follow and scale standardized recipes; weigh and measure food ingredients accurately. Requires basic math skills and knowledge of common weights and measures.
- Utilize the following kitchenware: knives, spatulas, whisk, and measuring cups and spoons.
- Knowledge of principles and methods of preparing food in large quantities according to appropriate food safety and sanitation procedures.
- Practice proper operation of equipment to assure safety and avoid damage to equipment and clean and sanitize equipment properly.
- Follow and scale standardized recipes; weigh and measure food ingredients accurately. Requires basic math skills and knowledge of common weights and measures.
- Operate the following kitchen equipment: electric mixers, and ovens.
- Utilize the following kitchenware: knives, spatula, whisk, and measuring cups and spoons.
- Knowledge of principles and methods of preparing food in large quantities according to appropriate food safety and sanitation procedures.
- Practice proper operation of equipment to assure safety and avoid damage to equipment and clean and sanitize equipment properly.
- Follow and scale standardized recipes; weigh and measure food ingredients accurately. Requires basic math skills and knowledge of common weights and measures.
- Knowledge of baking techniques.
- Operate the following kitchen equipment: electric mixer, dough hook, and oven.
- Utilize the following kitchenware: knives, pizza cutter, spatula, whisk, tong, rolling pin, and measuring cups and spoons.
- Knowledge of principles and methods of preparing food in large quantities according to appropriate food safety and sanitation procedures.
- Practice proper operation of equipment to assure safety and avoid damage to equipment and clean and sanitize equipment properly.
- Follow and scale standardized recipes; weigh and measure food ingredients accurately. Requires basic math skills and knowledge of common weights and measures.
- Operate the following kitchen equipment: stove top, tilt-skillets, and tilt-kettles.
- Utilize the following kitchenware: knives and measuring cups and spoons.
- Knowledge of principles and methods of preparing food in large quantities according to appropriate food safety and sanitation procedures.
- Practice proper operation of equipment to assure safety and avoid damage to equipment and clean and sanitize equipment properly.
- Operate the following kitchen equipment: oven, warmer, and cooler.
- Utilize the following kitchenware: tongs.
- Knowledge of principles and methods of preparing food in large quantities according to appropriate food safety and sanitation procedures.
- Practice proper operation of equipment to assure safety and avoid damage to equipment and clean and sanitize equipment properly.
- Operate the following kitchen equipment: oven, warmer, and cooler.
- Utilize the following kitchenware: knives, pizza cutter, and spatula.
- Knowledge of principles and methods of preparing food in large quantities according to appropriate food safety and sanitation procedures.
- Practice proper operation of equipment to assure safety and avoid damage to equipment and clean and sanitize equipment properly.
- Follow and scale standardized recipes; weigh and measure food ingredients accurately. Requires basic math skills and knowledge of common weights and measures.
- Operate the following kitchen equipment: oven, warmer, and cooler.
- Utilize the following kitchenware: knives, tongs, and measuring cups and spoons.
- Knowledge of principles and methods of preparing food in large quantities according to appropriate food safety and sanitation procedures.
- Practice proper operation of equipment to assure safety and avoid damage to equipment and clean and sanitize equipment properly.
- Follow food safety procedures for the handling of fresh ready-to-eat (RTE) vegetables and fruits.
- Follow and scale standardized recipes; weigh and measure food ingredients accurately. Requires basic math skills and knowledge of common weights and measures.
- Operate the following kitchen equipment: oven, food processor, and cooler
- Utilize the following kitchenware: knives, spatulas, whisks, and measuring cups and spoons
- Knowledge of principles and methods of preparing food in large quantities according to appropriate food safety and sanitation procedures.
- Practice proper operation of equipment to assure safety and avoid damage to equipment and clean and sanitize equipment properly.
- Operate the following kitchen equipment: oven, stovetop, warmer, and cooler.
- Utilize the following kitchenware: tongs.
- Knowledge of principles and methods of preparing food in large quantities according to appropriate food safety and sanitation procedures.
- Practice proper operation of equipment to assure safety and avoid damage to equipment and clean and sanitize equipment properly.
- Operate the following kitchen equipment: oven, warmer, and cooler.
- Utilize the following kitchenware: tongs.
Appendix B
- Kitchen equipment: oven, warmer, cooler
- Kitchenware: knives, spatula, whisk, tongs, measuring cups and spoons
- Kitchenware: knives, spatulas, whisk, measuring cups and spoons
- Kitchen equipment: electric mixers, ovens
- Kitchenware: knives, spatula, whisk, measuring cups and spoons
- Kitchen equipment: electric mixer, dough hook, oven
- Kitchenware: knives, pizza cutter, spatula, whisk, tong, rolling pin, measuring cups and spoons
- Kitchen equipment: stove top, tilt-skillets, tilt-kettles
- Kitchenware: measuring cups and spoons
- Kitchen equipment: oven, warmer, cooler
- Kitchenware: tongs
- Kitchen equipment: oven, warmer, cooler
- Kitchenware: knives, pizza cutter, spatula
- Kitchen equipment: oven, warmer, cooler
- Kitchenware: knives, tongs, measuring cups and spoons
- Kitchen equipment: oven, food processor, cooler
- Kitchenware: knives, spatulas, whisks, measuring cups and spoons
- Kitchen equipment: oven, stove top, warmer, cooler
- Kitchenware: tongs
- Kitchen equipment: oven, warmer, cooler
- Kitchenware: tongs
References
- Patel, K.J.; Strait, K.M.; Hildebrand, D.A.; Amaya, L.L.; Joyce, J.M. Variability in dietary quality of elementary school lunch menus with changes in National School Lunch Program nutrition standards. Curr. Dev. Nutr. 2020, 4 (Suppl. 2), 1730. [Google Scholar] [CrossRef]
- Final Rule Nutrition Standards in the National School Lunch and School Breakfast Programs. Available online: http://www.fns.usda.gov/sites/default/files/dietaryspecs.pdf (accessed on 8 February 2016).
- New Meal Pattern Requirements and Nutrition Standards: USDA’s National School Lunch and School Breakfast Programs. Available online: http://www.fns.usda.gov/sites/default/files/LAC_03-06-12_0.pdf (accessed on 8 February 2016).
- How the HEI is Scored. Available online: https://www.fns.usda.gov/how-hei-scored (accessed on 19 August 2020).
- Dietary Guidelines for Americans 2015–2020: Eighth Edition. Available online: http://health.gov/dietaryguidelines/2015/guidelines/full/ (accessed on 22 February 2016).
- CACFP Meal Pattern Revision: Best Practices. Available online: http://www.fns.usda.gov/sites/default/files/cacfp/CACFP_bestpractices.pdf (accessed on 23 October 2016).
- Marshall, S.; Burrows, T.; Collins, C.E. Systematic review of diet quality indices and their associations with health-related outcomes in children and adolescents. J. Hum. Nutr. Diet. 2014, 27, 577–598. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Perry, C.P.; Keane, E.; Layte, R. The use of a dietary quality score as a predictor of childhood overweight and obesity. BMC Public Health 2015, 15, 581–590. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Dahm, C.C.; Chomistek, A.K.; Jakobsen, M.U. Adolescent diet quality and cardiovascular disease risk factors and incident cardiovascular disease in middle-aged women. J. Am. Heart Assoc. 2016, 5, e003583. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Golley, R.; Baines, E.; Bassett, P.; Wood, L.; Pearce, J.; Nelson, M. School lunch and learning behaviour in primary schools: An intervention study. Eur. J. Clin. Nutr. 2010, 64, 1280–1288. [Google Scholar] [CrossRef] [Green Version]
- Haapala, E.A.; Eloranta, A.M.; Venalainen, T. Diet quality and academic achievement: A prospective study among primary school children. Eur. J. Clin. Nutr. 2017, 56, 2299–2308. [Google Scholar] [CrossRef] [PubMed]
- Belot, M.; James, J. Healthy school meals and educational outcomes. J. Health Econ. 2011, 30, 489–504. [Google Scholar] [CrossRef] [Green Version]
- Bellisle, F. Effects of diet on behaviour and cognition in children. Br. J. Nutr. 2004, 92, S227–S232. [Google Scholar] [CrossRef] [Green Version]
- Interim Final Rule: Child Nutrition Program Flexibilities for Milk, Whole Grains, and Sodium Requirements. Available online: https://www.fns.usda.gov/school-meals/fr-113017 (accessed on 28 May 2018).
- Fox, M.K.; Condon, E. School Nutrition Dietary Assessment Study-IV: Summary of Findings; US Department of Agriculture, Food and Nutrition Service, Office of Research and Analysis: Alexandria, VA, USA, 2012.
- Nollen, N.L.; Befort, C.A.; Snow, P.; Daley, C.M.; Ellerbeck, E.F.; Ahluwalia, J.S. The School Food Environment and Obesity: Qualitative insights from high school principals and food service personnel. Int. J. Behav. Nutr. Phys. Act. 2007, 4, 1–12. [Google Scholar] [CrossRef] [Green Version]
- Brouse, C.H.; Wolf, R.L.; Basch, C.E. School food service directors’ perceptions of barriers to and strategies for improving the school food environment in the United States. Int. J. Health Promot. Educ. 2009, 47, 88–93. [Google Scholar] [CrossRef]
- Fulkerson, J.A.; French, S.A.; Story, M.; Snyder, P.; Paddock, M. Foodservice staff perceptions of their influence on student food choices. J. Am. Diet. Assoc. 2002, 102, 97–99. [Google Scholar] [CrossRef]
- Smith, S.L.; Cunningham-Sabo, L. Food choice, plate waste and nutrient intake of elementary- and middle-school students participating in the US National School Lunch Program. Public Health Nutr. 2013, 17, 1255–1263. [Google Scholar] [CrossRef] [Green Version]
- Marlette, M.A.; Templeton, S.B.; Panemangalore, M. Food type, food preparation, and competitive food purchases impact school lunch plate waste by sixth-grade students. J. Am. Diet. Assoc. 2005, 105, 1779–1782. [Google Scholar] [CrossRef]
- Cohen, J.F.W.; Richardson, S.; Parker, E.; Catalano, P.J.; Rimm, E.B. Impact of the new USDA school meal standards on food selection, consumption, and waste. Am. J. Prev. Med. 2014, 46, 388–394. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Byker, C.J.; Farris, A.R.; Marcenelle, M.; Davis, G.C.; Serrano, E.L. Food waste in a school nutrition program after implementation of new lunch program guidelines. J. Nutr. Educ. Behav. 2014, 46, 406–411. [Google Scholar] [CrossRef] [Green Version]
- Adams, M.A.; Pelletier, R.L.; Zive, M.M.; Sallis, J.F. Salad bars and fruit and vegetable consumption in elementary schools: A plate waste study. J. Am. Diet. Assoc. 2005, 105, 1789–1792. [Google Scholar] [CrossRef] [PubMed]
- Gase, L.N.; McCarthy, W.J.; Robles, B.; Kuo, T. Student receptivity to new school meal offerings: Assessing fruit and vegetable waste among middle school students in the LA Unified School District. Prev. Med. 2014, 67, 528–533. [Google Scholar] [CrossRef] [Green Version]
- Cohen, J.F.W.; Gorski, M.T.; Hoffman, J.A. Healthier standards for school meals and snacks: Impact on school food revenues and lunch participation rates. Am. J. Prev. Med. 2016, 51, 485–492. [Google Scholar] [CrossRef] [Green Version]
- Cluss, P.A.; Fee, L.; Culyba, R.; Bhat, K.B.; Owen, K. Effect of food service nutrition improvements on elementary school cafeteria lunch purchase patterns. J. Sch. Health 2014, 84, 355–362. [Google Scholar] [CrossRef]
- Trevino, R.P.; Pham, T.; Mobley, C.; Harstein, J.; El ghormli, L.; Songer, T. HEALTHY study school food service revenue and expense report. J. Sch. Health 2012, 82, 417–423. [Google Scholar] [CrossRef] [Green Version]
- Guagliano, J.M.; Rosenkranz, R.R. Physical activity promotion and obesity prevention in Girl Scouts: Scouting Nutrition and Activity Program +. Pediatrics Int. 2012, 54, 810–815. [Google Scholar] [CrossRef] [PubMed]
- BMI Percentile Calculator for Child and Teen. Available online: https://nccd.cdc.gov/dnpabmi/calculator.aspx (accessed on 23 June 2018).
- Automated Self-Administered 24-hour (ASA24) Dietary Assessment Tool. Available online: https://asa24.nci.nih.gov/?CallingFrom=ResearcherSite&ReturnUrl=https://asa24.nci.nih.gov/researchersite/ASA242013.aspx (accessed on 25 June 2018).
- Taste Testing in Schools: Resource Guide. Available online: http://www.ohioactionforhealthykids.org/wp-content/uploads/2012/01/OAFHK-2012-Taste-Testing-Toolkit-WEB.pdf (accessed on 24 March 2017).
- Try-Day Taste-Testing Ballot. Available online: https://www.fns.usda.gov/sites/default/files/tn/TNevents_appendixrepro1.pdf (accessed on 24 March 2017).
- Cohen, J.F.W.; Richardson, S.; Austin, S.B.; Economos, C.D.; Rimm, E.B. School Lunch Waste among Middle School Students: Implications for Nutrients Consumed and Food Waste Costs. Am. J. Prev. Med. 2013, 44, 114–121. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Nichols, P.J.; Porter, C.; Hammond, L.; Arjmandi, B.H. Food intake may be determined by plate waste in a retirement living center. J. Am. Diet. Assoc. 2002, 102, 1142–1144. [Google Scholar] [CrossRef]
- Jacko, C.C.; Dellava, J.; Ensle, K.; Hoffman, D.J. Use of the plate-waste method to measure food intake in children. J. Ext. 2007, 45, 6RIB7. [Google Scholar]
- Hunger Scale. Available online: https://thrive.kaiserpermanente.org/care-near-you/northern-california/santaclara/hunger-scale/ (accessed on 20 August 2020).
NSLP Meal Component | Meal Condition 1 | Meal Condition 2 | Meal Condition 3 | |||
---|---|---|---|---|---|---|
BPSL 1 | BPSL 2 | TSL 1 | TSL 2 | BPSL | TSL | |
Meat/Meat Alternate | Oven fried chicken * | Homemade cheese pizza * | Frozen chicken nuggets | Frozen cheese pizza | BBQ pulled pork * | Beef hot dog |
Grain | Whole grain cornbread * | Whole grain crust * | White roll | (crust) | Whole grain slider buns | White hot dog bun |
Vegetable | Broccoli salad * | Mixed greens salad with carrots, tomato, cucumber | Broccoli with cheese sauce | Carrots with ranch dip | Asian coleslaw * | Frozen French fries |
Fruit | Grapes | Clementine | Pineapple fruit cup in 100% fruit juice | Mandarin orange fruit cup in 100% fruit juice | Apple slices | Peach fruit cup in 100% fruit juice |
Milk | 1% low fat milk, plain | 1% low fat milk, plain | 1% low fat milk, plain | 1% low fat milk, plain | 1% low fat milk, plain | 1% low fat milk, plain |
Characteristic | All Participants | Group 1 (n = 11) | Group 2 (n = 11) | Group 3 (n = 14) | |
---|---|---|---|---|---|
Proportion (%) | |||||
Grade Level | Kindergarten | 16.7% | 18.1% | 28.6% | 16.2% |
1st | 16.7% | 18.1% | 21.4% | 16.2% | |
2nd | 16.7% | 9.1% | 21.4% | 16.2% | |
3rd | 33.3% | 36.4% | 7.1% | 24.3% | |
4th | 8.3% | 9.1% | 7.1% | 16.2% | |
5th | 8.3% | 9.1% | 14.3% | 10.8% | |
Sex | Female | 50% | 54.5% | 50% | 59.5% |
Male | 50% | 45.5% | 50% | 40.5% | |
Ethnicity | Caucasian | 83.3% | 81.8% | 85.7% | 78.4% |
Hispanic | 0 | 0 | 14.3% | 2.7% | |
African American | 0 | 0 | 0 | 5.4% | |
Native American | 0 | 0 | 0 | 0 | |
Asian/Pacific Islander | 8.3% | 9.1% | 0 | 5.4% | |
Other | 8.3% | 9.1% | 0 | 8.1% | |
BMI Percentile Category | <85th, Healthy | 69.4% | 81.8% | 45.5% | 78.6% |
85–95th, Overweight | 13.9% | 18.2% | 18.2% | 7.1% | |
>95th, Obese | 16.7% | 0 | 36.4% | 14.3% | |
Mean ± Standard Deviation | |||||
Age (years) | 7.7 ± 1.7 | 7.5 ± 1.7 | 8.3 ± 1.1 | 7.3 ± 2.1 | |
Height (cm) | 130.2 ± 10.5 | 127.1 ± 10.4 | 136.7 ± 5.8 | 127.6 ± 11.7 | |
Weight (kg) | 30.2 ± 8.3 | 26.1 ± 6.2 | 36.7 ± 7.6 * | 28.2 ± 7.6 | |
BMI Percentile | 61.4 ± 30.2 | 43.4 ± 32.6 | 77.5 ± 22.0 | 63.0 ± 27.7 | |
Waist Circumference (cm) | 56.1 ± 11.7 | 49.3 ± 16.5 | 61.6 ± 8.5 | 57.0 ± 6.2 |
Baseline Characteristic | Odds Ratio + (95% Confidence Interval) |
---|---|
Sex | |
Male * | 1.00 |
Female | 0.58 (0.10–3.38) |
Grade Level | |
K & 1st * | 1.00 |
2nd & 3rd | 0.50 (0.07–3.65) |
4th & 5th | 0.33 (0.03–3.84) |
BMI Percentile | |
Healthy (<85th) * | 1.00 |
Overweight (85–95th) | 0.34 (0.02–7.11) |
Obese (>95th) | 0.80 (0.08–8.47) |
Fruit Consumption | |
Low (<1 serving/day) * | 1.00 |
High (>1 servings/day) | 0.21 (0.02–2.04) |
Vegetable Consumption | |
Low (<0.5 serving/day) * | 1.00 |
Moderate (0.5–1 serving/day) | 0.12 (0.01–2.60) |
High (>1 serving/day) | 1.25 (0.20–7.96) |
Added Sugar Consumption | |
Low (0–8 g/day) * | 1.00 |
Moderate (8–16 g/day) | 0.14 (0.01–3.28) |
High (>16 g/day) | 2.26 (0.32–15.76) |
Meal | Food Items | Food Item Preparation Time (min) | Food Item Cost per Serving | Number of Servings Prepared | Total Meal Preparation Time (min) | Total Meal Cost per Serving |
---|---|---|---|---|---|---|
BPSL1 (MC1) | Chicken nuggets | 177 (Start prep 11, marinade 105, finish prep 26, bake 35) | $0.50 | 18 | 379 | $3.83 |
Broccoli salad | 120 (Prep 72, marinade 48) | $0.98 | ||||
Cornbread | 56 (Prep 18, preheat 14, bake 24) | $0.29 | ||||
Grapes | 26 | $0.44 | ||||
Milk | 0 | $1.62 | ||||
BPSL2 (MC1) | Pizza Crust | 135 (Prep 43, set 92) | $0.10 | 18 | 239 | $3.37 |
Pizza Sauce | 30 (Prep 15, cook 15) | $0.63 (sauce + cheese) | ||||
Pizza | 61 (Prep 15, preheat 20, bake 26) | $0.73 (crust + sauce + cheese) | ||||
Salad | 13 | $0.84 | ||||
Clementine | 0 | $0.18 | ||||
Milk | 0 | $1.62 | ||||
BPSL (MC3) | Pulled pork | 117 (Preheat 12, prep 10, bake 75, pull 20) | $1.21 (+BBQ sauce) | 12 | 183 | $4.20 |
Slider buns | 0 | $0.18 | ||||
Apples | 9 | $0.40 | ||||
Coleslaw | 57 (Prep 55, set 2) | $0.79 | ||||
Milk | 0 | $1.62 | ||||
Overall BPSL | 267 | $3.80 | ||||
TSL1 (MC2) | Roll (frozen) | 28 (Preheat 13, bake 15) | $0.51 (+butter) | 13 | 86 | $4.36 |
Broccoli (frozen) with cheese sauce (prepared) | 12 (Prep 2, steam 9, mix with cheese sauce 1) | $0.57 | ||||
Chicken nuggets (frozen) | 46 (Preheat 14, bake 32) | $1.04 (+ketchup) | ||||
Fruit cup (canned) | 0 | $0.62 | ||||
Milk | 0 | $1.62 | ||||
TSL2 (MC2) | Pizza (frozen) | 37 (Preheat 17, bake 20) | $0.87 | 13 | 37 | $3.39 |
Carrots with dip | 0 | $0.28 (+ranch dip) | ||||
Fruit cup (canned) | 0 | $0.62 | ||||
Milk | 0 | $1.62 | ||||
TSL (MC3) | Hot dog | 31 (Boil water 21, cook 10) | $0.69 | 12 | 56 | $3.28 |
Hot dog bun | 0 | $0.45 | ||||
French fries (frozen) | 37 (Preheat 12, bake 25) | $0.21 (+ketchup) | ||||
Fruit cup (canned) | 0 | $0.31 | ||||
Milk | 0 | $1.62 | ||||
Overall TSL | 60 | $3.68 |
© 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).
Share and Cite
Joyce, J.M.; Harris, K.; Mailey, E.L.; Rosenkranz, R.R.; Rosenkranz, S.K. Acceptability and Feasibility of Best Practice School Lunches by Elementary School-Aged Children in a Serve Setting: A Randomized Crossover Trial. Int. J. Environ. Res. Public Health 2020, 17, 6299. https://doi.org/10.3390/ijerph17176299
Joyce JM, Harris K, Mailey EL, Rosenkranz RR, Rosenkranz SK. Acceptability and Feasibility of Best Practice School Lunches by Elementary School-Aged Children in a Serve Setting: A Randomized Crossover Trial. International Journal of Environmental Research and Public Health. 2020; 17(17):6299. https://doi.org/10.3390/ijerph17176299
Chicago/Turabian StyleJoyce, Jillian M., Kyleen Harris, Emily L. Mailey, Richard R. Rosenkranz, and Sara K. Rosenkranz. 2020. "Acceptability and Feasibility of Best Practice School Lunches by Elementary School-Aged Children in a Serve Setting: A Randomized Crossover Trial" International Journal of Environmental Research and Public Health 17, no. 17: 6299. https://doi.org/10.3390/ijerph17176299