Obesity: Meal or Fruit and Vegetable Snack Interventions to Increase Healthier Foods and Beverages Provided by Schools

In 2013, the Agency for Healthcare Research and Quality (AHRQ) conducted a meta-analysis on the effectiveness of childhood obesity prevention programs implemented in 6 intervention settings. The CPSTF finding is based on a subset of studies from the review that focused on dietary-only approaches in schools (Wang et al., 2013; 15 studies, search period through August 2012) combined with more recent evidence (36 additional studies, search period August 2012 to January 2017).

This review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice and policy related to obesity prevention and control. The 2016 findings about school interventions to prevent obesity update and replace the 2003 CPSTF findings on School-Based Programs Promoting Nutrition and Physical Activity [PDF – 124 KB] and School-Based Programs to Prevent Obesity [PDF – 679 kB].

Healthy eating during childhood is important (CDC , 1998; Dietary Guidelines Advisory Committee, 2010). Schools can play an important role in preventing obesity by providing nutritious and appealing foods and beverages (CDC, 2016a; CDC, 2011).

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement [PDF – 1 MB].

The systematic review included 25 studies with 26 study arms.

Weight-Related Outcomes

• Overweight/obesity prevalence median decrease of 9.6 percentage points (5 studies)
• BMI z-score median increase of 0.01 (not significant; 3 studies)

Diet-Related Outcomes

• Fruit or vegetable intake 20.0% increase (9 study arms)

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement.

A systematic review of economic evidence indicates that meal interventions and fruit and vegetable snack interventions are cost-effective. All monetary values are reported in 2016 U.S. dollars.

The economic review included 7 studies (4 from the United States, 1 from Norway, 1 from the Netherlands, and 1 from Taiwan).

• Median intervention cost per student per year for fruit and vegetable snack interventions: $50 (3 studies)
• Incremental intervention cost per student per year to provide school meals that meet nutrition guidelines: $198 and $624 (2 studies)
• Lifetime savings per student in healthcare costs due to two fruit and vegetable snack interventions: $28 and $17 (1 study)
• Annual savings per student in healthcare cost due to improved nutritional content of school meals: $17 (1 study)
• Cost per quality adjusted life year (QALY) gained was $10,800 (1 study). This estimate is less than $50,000 a benchmark for cost-effectiveness.
• Costs per disability adjusted life year (DALY) averted were $8,014 and $14,934 (2 studies). Both estimates are considered cost-effective based on a per capita annual income of $49,390 in the Netherlands.

Based on results for interventions in different settings and populations, findings should be applicable to the following:

• Elementary and middle school-aged children
• Girls and boys
• Students from different racial and ethnic backgrounds
• Students from different income levels
• Urban, suburban, and rural environments

The CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

• Which intervention activities, school breakfast or lunch, fresh fruit and vegetable programs, or combinations of activities are most effective? Which activities are critical to success?
• What are the cumulative effects of adding intervention components? Is a single component equally effective?
• In order to increase comparability what are the best measures for dietary intake outcomes?
• Do children act as agents of change by discussing changes in the school environment with parents? Do parents incorporate healthier dietary habits at home?
• How often do schools implement interventions with fidelity? What amount of training is needed for faculty?
• Does effectiveness vary by students’ age group?
• Are national, state, or local policies most effective?
• For studies reporting on milk products and alternatives to dairy, what is the fat content of these foods and beverages?
• Do interventions lead to other health benefits such as improvements in cholesterol or blood pressure?
• What does the intervention cost to implement and what are the major drivers of cost?
• What are long term benefits of averted healthcare cost and improved productivity in adulthood associated with interventions shown to improve nutrition and prevent obesity in childhood?

• Study designs included group randomized controlled trials (7 studies), group non-randomized (2 studies), repeat cross-sectional with comparison (1 study), time series (1 study), single group before-after (4 studies), repeat cross-sectional (3 studies), or post-test only with comparison (7 studies).
• Studies were conducted in the United States (12 studies), Canada (3 studies), Norway (3 studies), the United Kingdom (1 study), the Netherlands (1 study), Spain (1 study), Australia (1 study), Denmark (1 study), Greece (1 study), and one study collected data from 3 countries (Norway, the Netherlands, and Spain).
• Studies were conducted in schools alone (23 studies) or in schools plus one or more additional settings (2 studies).
• Studies were conducted in elementary schools (11studies), middle schools (6 studies), high school (2 studies), or a combination of elementary, middle, or high schools (6 studies).
• Studies were set in urban (3 studies), rural (2 studies), or a combination of urban, suburban or rural (9 studies) settings.
• About half of each study population was female (22 studies; 3 studies did not provide information).
• Twelve studies reported race/ethnicity with study populations identifying as white (median: 58.9%; 9 studies), black (median: 15.4%; 8 studies), Hispanic (median: 18.5%; 8 studies), First Nation (100.0%; 2 studies), and other (100%; 1 study).

Wethington HR, Finnie RKC, Buchanan LR, et al. Healthier food and beverage interventions in schools: four Community Guide systematic reviews. American Journal of Preventive Medicine 2020;59(1):e15-26.

Community Preventive Services Task Force. Healthier food and beverage interventions in schools: recommendation of the Community Preventive Services Task Force. American Journal of Preventive Medicine 2020;59(1):e11-4.

Effectiveness Review

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Analytic Framework [PDF – 293 kB]

Effectiveness Review

Summary Evidence Table – Effectiveness Review [PDF – 639 kB]

Economic Review

Summary Evidence Table – Economic Review [PDF – 236 kB]

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Effectiveness Review

Affenito SG, Thompson D, Dorazio A, Albertson AM, Loew A, Holschuh NM. Ready-to-eat cereal consumption and the school breakfast program: relationship to nutrient intake and weight. J Sch Health 2013;83(1):28-35.

Amin SA, Yon BA, Taylor JC, Johnson RK. Impact of the National School Lunch Program on fruit and vegetable selection in Northeastern elementary schoolchildren, 2012-2013. Public Health Rep 2015;130(5):453-7.

Bere E, Veierod MB, Bjelland M, Klepp KI. Outcome and process evaluation of a Norwegian school-randomized fruit and vegetable intervention: Fruits and Vegetables Make the Marks (FVMM). Health Educ Res 2006a;21(2):258-67.

Bere E, Veierod MB, Bjelland M, Klepp KI. Free school fruit sustained effect 1 year later. Health Educ Res 2006b;21(2):268-75.

Bere E, Veierod MB, Klepp KI. The Norwegian School Fruit Programme: evaluating paid vs. no-cost subscriptions. Preventive Medicine 2005;41(2):463-70.

Campos Pastor MM, Serrano Pardo MD, Fernandez Soto ML, Luna Del Castillo JD, Escobar-Jimenez F. Impact of a ‘school-based’ nutrition intervention on anthropometric parameters and the metabolic syndrome in Spanish adolescents. Ann Nutr Metab 2012;61(4):281-8.

Chang H-H. Food preparation for the school lunch program and body weight of elementary school children in Taiwan. International Food and Agribusiness Management Review 2014;17(1):21-36.

Cohen JF, Smit LA, Parker E, Austin SB, Frazier AL, Economos CD, et al. Long-term impact of a chef on school lunch consumption: findings from a 2-year pilot study in Boston middle schools. J Acad Nutr Diet 2012;112(6):927-33.

Cullen KW, Chen TA, Dave JM. Changes in foods selected and consumed after implementation of the new National School Lunch Program meal patterns in southeast Texas. Prev Med Rep 2015;2:440-443.

Damsgaard CT, Dalskov S-M, Laursen RP, Ritz C, Hjorth MF, Lauritzen L, et al. Provision of healthy school meals does not affect the metabolic syndrome score in 8 11-year-old children, but reduces cardiometabolic risk markers despite increasing waist circumference. British Journal of Nutrition 2014;112(11):1826-1836 11p.

Davis EM, Cullen KW, Watson KB, Konarik M, Radcliffe J. A Fresh Fruit and Vegetable Program improves high school students’ consumption of fresh produce. J Am Diet Assoc 2009;109(7):1227-31.

Gates M, Hanning RM, Gates A, McCarthy DD, Tsuji LJS. Assessing the Impact of Pilot School Snack Programs on Milk and Alternatives Intake in 2 Remote First Nation Communities in Northern Ontario, Canada. Journal of School Health 2013;83(2):69-76.

Hanbazaza MA, Triador L, Ball GDC, Farmer A, Maximova K, First Nation A, et al. The Impact of School Gardening on Cree Children’s Knowledge and Attitudes toward Vegetables and Fruit. Canadian Journal of Dietetic Practice & Research 2015;76(3):133-139 7p. (linked with Triador)

Jamelske EM, Bica LA. Impact of the USDA Fresh Fruit and Vegetable Program on Children’s Consumption. Journal of Child Nutrition & Management 2012;36(1).

Kastorini CM, Lykou A, Yannakoulia M, Petralias A, Riza E, Linos A. The influence of a school-based intervention programme regarding adherence to a healthy diet in children and adolescents from disadvantaged areas in Greece: the DIATROFI study. J Epidemiol Community Health 2016.

Lin YC, Fly AD. USDA Fresh Fruit and Vegetable Program Is More Effective in Town and Rural Schools Than Those in More Populated Communities. J Sch Health 2016;86(11):769-777.

Moore L, Tapper K. The impact of school fruit tuck shops and school food policies on children’s fruit consumption: a cluster randomised trial of schools in deprived areas. J Epidemiol Community Health 2008;62(10):926-31.

Olsho LE, Klerman JA, Ritchie L, Wakimoto P, Webb KL, Bartlett S. Increasing Child Fruit and Vegetable Intake: Findings from the US Department of Agriculture Fresh Fruit and Vegetable Program. J Acad Nutr Diet 2015;115(8):1283-90.

Perry CL, Bishop DB, Taylor GL, Davis M, Story M, Gray C, et al. A randomized school trial of environmental strategies to encourage fruit and vegetable consumption among children. Health Educ Behav 2004;31(1):65-76.

Qian Y. The effect of school and neighborhood environmental factors on childhood obesity. Dissertation Abstracts International Section A: Humanities and Social Sciences 2015;75(8-A(E)):No-Specified.

Radcliffe B, Ogden C, Welsh J, Carroll S, Coyne T, Craig P. The Queensland School Breakfast Project: a health promoting schools approach. Nutrition & Dietetics 2005;62(1):33-40.

Taber DR, Chriqui JF, Chaloupka FJ. State laws governing school meals and disparities in fruit/vegetable intake. Am J Prev Med 2013a;44(4):365-72.

Taber DR, Chriqui JF, Powell L, Chaloupka FJ. Association between state laws governing school meal nutrition content and student weight status: implications for new USDA school meal standards. JAMA Pediatr 2013b;167(6):513-9.

Tak NI, Te Velde SJ, Brug J. Ethnic differences in 1-year follow-up effect of the Dutch Schoolgruiten Project – promoting fruit and vegetable consumption among primary-school children. Public Health Nutr 2007;10(12):1497-507.

Te Velde SJ, Brug J, Wind M, Hildonen C, Bjelland M, Perez-Rodrigo C, et al. Effects of a comprehensive fruit- and vegetable-promoting school-based intervention in three European countries: the Pro Children Study. Br J Nutr 2008;99(4):893-903.

Triador L, Farmer A, Maximova K, Willows N, Kootenay J. A School Gardening and Healthy Snack Program Increased Aboriginal First Nations Children’s Preferences Toward Vegetables and Fruit. Journal of Nutrition Education & Behavior 2015;47(2):176-180 5p.

Economic Review

Bere E, Veier d MB, Klepp K-I. The Norwegian School Fruit Programme: evaluating paid vs. no-cost subscriptions. Preventive Medicine 2005;41(2):463-70.

Bere E, Veier d M, Bjelland M, Klepp K. Free school fruit sustained effect 1 year later. Health Education Research 2006;21(2):268-75.

Bere E, Veier d MB, Skare , Klepp K-I. Free school fruit sustained effect three years later. International Journal of Behavioral Nutrition and Physical Activity 2007;4(1):1.

Bere E, Klepp K-I, verby NC. Free school fruit: can an extra piece of fruit every school day contribute to the prevention of future weight gain? A cluster randomized trial. Food & Nutrition Research 2014;58.

Chang H-H. Food preparation for the school lunch program and body weight of elementary school children in Taiwan. International Food and Agribusiness Management Review 2014;17(1):21-35.

Gortmaker SL, Wang YC, Long MW, Giles CM, Ward ZJ, et al. Three interventions that reduce childhood obesity are projected to save more than they cost to implement. Health Affairs 2015;34(11):1932-9.

Montgomery D, Scaife B, Evans A. The effect of a food service intervention (catch Eat Smart) on school meal cost. Journal of the American Dietetic Association 1996;96(9):A09.

Qian Y. Effect of School and Neighborhood Environmental Factors on Childhood Obesity [dissertation]. Fayetteville: University of Arkansas; 2014.

Qian Y, Nayga RM, Thomsen MR, Rouse HL. The effect of the Fresh Fruit and Vegetable Program on childhood obesity. Appl Econ Perspect Pol 2016;38:260-75.

Te Velde SJ, Veerman JL, Tak NI, Bosmans JE, Klepp K-I, Brug J. Modeling the long term health outcomes and cost-effectiveness of two interventions promoting fruit and vegetable intake among school children. Economics & Human Biology 2011;9(1):14-22.

Wagner B, Senauer B, Runge CF. An empirical analysis of and policy recommendations to improve the nutritional quality of school meals. Applied Economic Perspectives and Policy 2007;29(4):672-88.

The search strategy described below was used for the following reviews of interventions to support healthier foods and beverages in schools:

• Meal or fruit and vegetable snack interventions to increase healthier foods and beverages provided by schools
• Interventions supporting healthier snack foods and beverages sold or offered as a reward in schools
• Multicomponent interventions to increase availability of healthier foods and beverages in schools
• Interventions to increase water access in schools

The CPSTF findings are based on evidence from a systematic review published in 2013 (Wang et al, 2013) combined with more recent evidence. Wang et al. searched five bibliographic databases: MEDLINE , EMBASE , PsychInfo , CINAHL , and the Cochrane Library for relevant studies from their inception through April 22, 2013. The Community Guide systematic review team conducted an updated search for evidence through January 4, 2017. In the updated search for evidence, PubMed was used instead of MEDLINE , and a search was conducted using Clinicaltrials.com.

Search terms and search strategies were adjusted to each database, based on controlled and uncontrolled vocabularies and search software. Once the literature search was completed, Community Guide staff reviewed the citations using inclusion and exclusion criteria to narrow down the publications to be included.

Search Strategy – Effectiveness Review

Database: Embase (OVID)

Date Searched: 1/04/2017

Search Strategy:

1. (school or schools or afterschool or kindergarten or educational-setting*).ti,ot,sh,ab,tw.
2. school/ or high school/ or kindergarten/ or middle school/ or primary school/
3. exp obesity/
4. exp body composition/
5. waist hip ratio/ or waist to height ratio/
6. (bmi or healthy weight or body weight or adiposity or body mass index or skinfold thickness or body fat or waist circumference or waist hip ratio or waist to height ratio or body composition or overweight or obese or obesity or over weight).ti,ot,sh,ab,tw.
7. body weight/
8. (normal weight or normal weights or hip circumference).ti,ot,sh,ab,tw.
9. body fat/
10. body mass index/
11. skinfold thickness/
12. waist circumference/
13. 1 or 2
14. 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12
15. 13 and 14
16. 2014*.em. or 2015*.em. or 2016*.em. [Individual update weeks were no longer available to be searched for 2014.]
17. 15 and 16
18. limit 17 to english language

Search Strategy – Economic Review

The published literature was searched for economic information about the two interventions that were found to be effective.

• Meal or fruit and vegetable snack interventions to increase healthier foods and beverages provided by schools
• Multicomponent interventions to increase availability of healthier foods and beverages in schools

The search for economic evidence included studies identified in the search for effectiveness evidence described earlier (search period through March 8, 2016) and a search within specialized databases at CRD-York and in EconLit (search period through January 5, 2016). Search terms and strategies were adjusted for each database, based on controlled and uncontrolled vocabularies and software. In addition, reference lists in included studies were screened and subject matter experts were consulted for additional studies that may have been missed.

Database: CRD-York (NHS-EED)

Date Searched: 01/05/2016

Search Strategy:

1. (obesity or overweight or “over weight” or adiposity or obese or “body fat” OR “waist hip” or “waist to hip” or “skinfold thickness” or “skinfold measurement” or “skin fold thickness” or “skin fold measurement” or “hip circumference” or “waist circumference”)
2. (“normal weight” or “bmi” or “body mass index” OR “waist to height” or “body composition” or “body fat”)
3. #1 OR #2
4. (school or schools or “educational setting” or kindergarten or schoolchild* or preschool*)
5. #3 AND #4

Limit to NHS EED studies

EconLit (EBSCOHOST)

Date Searched: 01/05/2016

Search Strategy:

Modes – Boolean/Phrase

S10 (S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7 OR S8) AND (S9)

S9 TX “educational setting” OR TX school OR TX schools OR TX kindergarten* OR TX “educational settings” OR TX “academic setting” OR TX “academic settings”

S8 TX “adiposity”

S7 TX “skinfold thickness”

S6 TX overweight or TX “over weight”

S5 TX “healthy weight” or TX “waist hip” OR TX “waist to height” OR TX “waist circumference”

S4 TX “body mass” OR TX bmi OR TX “body composition” or TX “normal weight”

S3 TX obesity or TX obese

S2 TX “skinfold thickness” OR TX “hip measurement” OR TX “waist measurement”

S1 TX “body fat” OR TX “hip circumference” OR TX “waist to hip”

Centers for Disease Control and Prevention. Recommendations to prevent and control iron deficiency in the United States. MMWR 1998;47: 1-29.

Centers for Disease Control and Prevention. School health guidelines to promote healthy eating and physical activity. MMWR 2011;60(5):1-76.

Centers for Disease Control and Prevention. School Nutrition Environment. Atlanta (GA): 2016 [cited 2017 Jan 4]. Available from: https://www.cdc.gov/healthyschools/nutrition/schoolnutrition.htm.

Dietary Guidelines Advisory Committee. Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans, 2010 (Report to the Secretary of Agriculture and the Secretary of Health and Human Services). Washington (DC): 2010 [cited 2017 Jan 4]. Available from: http://www.nutriwatch.org/05Guidelines/dga_advisory_2010.pdf.

Wang Y, Wu Y, Wilson RF, Bleich S, Cheskin L, et al. Childhood Obesity Prevention Programs: Comparative Effectiveness Review and Meta-Analysis. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2013. Report No.: 13-EHC081-EF.

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion.

• Different possible combinations of components, the levels at which changes are made (i.e., federal, state or provincial, district, or school), and the school capacity for implementing the intervention(s) may impact intervention effectiveness.
• Some intervention components (e.g., implementing National School Lunch Program guidelines) may be required if a school is participating in the National School Lunch program.
• Intervention success may vary based on school characteristics and intervention components. Schools with greater resources will likely be better able to implement interventions with high fidelity compared with schools that have higher needs.
• Some school communities may be resistant to change due to time or monetary constraints.
• Interventions that include an educational component must compete with other educational demands in the school.

Evidence-Based Cancer Control Programs (EBCCP)

Find programs from the EBCCP website that align with this systematic review. (What is EBCCP?)

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• Reduce the proportion of children and adolescents with obesity — NWS‑04
• Increase fruit consumption by people aged 2 years and over — NWS 06
• Increase vegetable consumption by people aged 2 years and older — NWS 07