[MUSIC] Hi, my name is Camilla Damsgaard. I'm an Associate Professor in Child Nutrition at the Department of Nutrition, Exercise, and Sports at the University of Copenhagen. I was project manager of the OPUS School Meal Study from 2010 to 14. And in the following I will present you with some of the most interesting results of the study. The main purpose of the OPUS School Meal Study was to examine the effects of Nordic school meals on children's diets, their body size, cardiometabolic health and academic performance. Today, I will focus on the effects on cardiometabolic health. In children, cardiometabolic health can be measured by, for example, blood pressure, blood cholesterol and insulin. In adults, high values of these risk markers are linked to cardiovascular disease. Children normally don't get cardiovascular disease. But we know that children who have, for example, high blood pressure are also likely to have high blood pressure as adults. And, therefore, we think that small reductions in the cardiometabolic risk markers in childhood may be important for long-term health. The OPUS School Meal Study had a randomized controlled crossover design. We included 46 school classes, at 3rd and 4th grade, from Southeastern Denmark. 834 children participated. This corresponds to 82% of those invited. The children received free school meals based on the New Nordic Diet for 3 months. For another three months, they had their ordinary packed lunch brought from home. The order of the two types of diets were randomly assigned for each grade. Three times during the study, at baseline before study start, at the cross-over point after 3 months and at endpoint after 6 months, we conducted a number of measurements in our double decker truck. This study design allowed us to compare the effects of the school meals with the ordinary lunch packs, using each child as its own control. At each time point, we measured anthropometry, body composition by DEXA, blood pressure and sugar fasting blood sample. Before the clinical examinations, the children recorded their diet at home for 7 consecutive days using a web based software. They also wore an accelerometer, that measures physical activity. The participants were between 8 and 11 years old, and most of them were normal weight, 14% were overweight or obese. About 10% were immigrants or descendants of immigrants. Overall, the children were fairly representative of Danish children. Okay, so what did we find in the study? First of all, compared to lunch packs the Nordic school meals improved children's diets. The children consumed a lot more fish, more vegetables, more potatoes when they received the school meals. They also consumed more berries, more nuts and more seeds. Overall, this led to a higher intake of dietary fiber and protein, and less fat. To our surprise, the school meals also resulted in a lower intake of whole grain. But this was probably because the majority of Danish children have whole grain, sourdough rye bread in their lunch packs. Whereas, the hot school meals often contained potatoes instead. So did the school meals affect the children's cardiometabolic health? Yes, it did. When the children received the Nordic school meals, they had lower blood pressure, they had lower insulin, and lower triacylglycerol fat in the blood, compared to the period where they had their own lunch packs. And this was despite the fact that the children had a slightly higher waist circumference after receiving the school meals, an effect that would normally increase the cardiometabolic risk markers. However, it wasn't much, about five millimeters in circumference. We don't know why this occurred, but maybe the children ate slightly more when they received the nice, hot school meals compared to lunch packs. But at the same time, there were beneficial effects because the meals were so healthy. It's uncertain what these results mean for children's long-term health. However, we know that cardiovascular diseases develop slowly over the life course. And, therefore, we believe that small, beneficial changes in children's cardiometabolic profile are important for their long-term health if sustained over time. We have done some additional analyses to try to find out which components of the school meals had the beneficial effects. And it seems that the increased intake of fish was the main driver of these good effects. Fish, especially the oily types, such as salmon, mackerel and herring, contain omega-3 fatty acids, which are known to reduce cardiovascular risk in adults. But we lack evidence on the effects of fish in children. So in my new study, FiSK Junior, we are now investigating whether oily fish, per se, can improve children's cardiometabolic health. The data we collected in the OPUS School Meal Study is unique material. And since more than 800 children participated, we have gained a lot of new knowledge about children's nutrition and health, just by looking cross-sectionally at the data we collected at baseline, that is, before the intervention started. Here are some examples of what we found. The first result relates to social inequality and health. It's widely known that diet and health varies according to socioeconomic status. Most often, we see that higher education is associated with better diets, lower obesity and better health. Likewise, children of parents with short education have higher obesity rates than children of parents with long education, at a group level. However, whether this social inequality also effects children's cardiometabolic profiles is uncertain. And, therefore, we investigated this using baseline data from the OPUS School Meal Study. We found that children from households with 10 years of schooling or less were more overweight and obese. Furthermore, they had higher concentrations of insulin and triacylgycerol fat in their blood than children from households with a long high education. When we examined these differences closer, we saw that the inequality in the cardiometabolic risk markers was not only explained by higher fat mass among the less advanced children. But also by their lower intake of dietary fiber and lower levels of omega-3 fatty acids in the blood, which is a biomarker of lower fish intake. In addition to overweight, these dietary factors may, therefore, be important targets in public health initiatives to reduce social inequality in health from childhood. Another very hot topic is vitamin D, which is important for optimal bone health. Vitamin D status is typically measured by 25-hydroxyvitamin D in the blood. And low vitamin D status is particularly a concern in northern latitudes during winter, where the sun does not give vitamin D production in the skin. Oily fish contains vitamin D, but few other foods are naturally rich in vitamin D. In Denmark, we generally don't fortify foods with vitamins, so the overall intake of this vitamin D is low. So first, we investigated children's vitamin D status during September to November when they have their first blood sample taken in the OPUS truck. Here, we found that 28% of the children had insufficient vitamin D levels in the blood, which is less than 50 nanomolars per liter. However, only 2% were deficient, having less than 25 nanomolars per liter. But when we looked specifically at children with an immigrant or descendant background, almost 20% of the girls were deficient. And these blood samples were taken after the summer period where most children have good vitamin D status from being outside in the sun. So these children are expected to have even lower levels during winter. It is well known that the more pigment in the skin, the lower production of vitamin D from the sun. And our results support previous reports that dark-skinned girls, or girls with immigrant or descendant background living in northern latitudes, are a particularly vulnerable group that need special attention, and a daily vitamin D supplement to assure optimal vitamin D status. During the last year, vitamin D has also been investigated for its potential role in extra-skeletal functions, such as protection from cardiovascular disease. And some studies in adults have shown that low vitamin D status is associated with overweight, with high blood pressure and with hyperlipidemia. And this has not been thoroughly investigated in children. So we decided to investigate where the children's vitamin D status was associated with the cardiometabolic risk markers, again, using baseline data from the School Meal Study. We found that the higher the vitamin D status was among the children, the lower the blood pressure, their insulin levels and their cholesterol. And apart from blood pressure, these associations were still there after we adjusted for a number of potential confounders, including omega-3 status, fat mass and physical activity. Physical activity could be a behavioral confounder, as it effects the cardiometabolic risk markers, and at the same time may effect vitamin D status if the physical activity is performed outdoors when the sun is shining. From our cross-section study, we cannot determine whether vitamin D affects children's cardiometabolic health in a causal manner. However, this is something we will definitely investigate further in the future. These were some of the most important findings of the OPUS School Meal Study. Overall, I think the study shows that healthy eating is important for children's cardiometabolic health, here and now. Long-term studies are needed to clarify which role diets rich in fish, vegetables and fiber plays for children's health later in life. Thanks for your attention. [MUSIC]
