Obesity: Multicomponent Interventions to Increase Availability of Healthier Foods and Beverages in Schools

The CPSTF finding is based on evidence from a systematic review published in 2013 (Wang, 15 studies, search period search period through August 2012) combined with more recent evidence (36 studies, search period August 2012 January 2017). Of the 51 studies, 11 evaluated multicomponent interventions to increase availability of healthier foods and beverages in schools.

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.

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

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

The systematic review included 11 studies.

Weight-related Outcomes:

• The prevalence of overweight/obesity stopped increasing (5 studies)
• BMIz score no change (1 study)

Diet Outcomes:

• Energy intake mixed findings (3 studies)
• Sugar-sweetened beverage intake favorable findings (2 of 3 studies)
• Fruit and vegetable intake increases (3 of 4 studies)
• Milk/dairy alternative intake significant increases

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

The economic review included three studies (2 from the United States, 1 from United Kingdom). All monetary values are reported in 2016 U.S. dollars.

• Intervention cost per student per year for multicomponent interventions
  • Increase fruit and vegetable consumption: $4.34 (1 study)
  • Improve nutrition content of school meals: $15.26 (1 study)
• A survey of high school foodservice directors in Pennsylvania reported a mean revenue of $691 per school per day from la carte sales (1 study)
• No studies estimated cost-effectiveness or cost-benefit of the interventions.

If the intervention is adapted to the target population and delivery context, findings should be applicable to the following:

• Elementary, middle, and high school school-aged children
• Girls and boys
• Students from different racial and ethnic backgrounds
• 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, competitive foods and beverages, class room celebrations, parties, or special events, nonfood items as rewards or combinations of these 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 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 control trial (3 studies) repeat cross sectional (5 studies), before-after (2 studies), and post-only with comparison (1 study).
• Studies were conducted in the United States (6 studies), Canada (3 studies), and the United Kingdom (2 studies).
• Studies were conducted in schools alone (9 studies) or in schools plus one or more additional settings (2 studies).
• Studies were conducted in elementary schools (6 studies), middle schools (1 study), or a combination of elementary, middle, or high schools (4 studies).
• Studies were set in urban (3 studies), suburban (1 study), rural (1 study), or a combination of urban, suburban or rural (4 studies) settings.

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 – 503 kB]

Economic Review

Summary Evidence Table – Economic Review [PDF – 205 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

Anderson AS, Porteous LE, Foster E, Higgins C, Stead M, Hetherington M, et al. The impact of a school-based nutrition education intervention on dietary intake and cognitive and attitudinal variables relating to fruits and vegetables. Public Health Nutr 2005;8(6):650-6.

Coleman KJ, Shordon M, Caparosa SL, Pomichowski ME, Dzewaltowski DA. The healthy options for nutrition environments in schools (Healthy ONES) group randomized trial: using implementation models to change nutrition policy and environments in low income schools. International Journal of Behavioral Nutrition and Physical Activity 2012;9(80).

Cullen KW, Watson K, Zakeri I. Improvements in Middle School Student Dietary Intake After Implementation of the Texas Public School Nutrition Policy. American Journal of Public Health 2008;98(1):111-7.

Frerichs L. Architecture and design for healthy eating in schools. Dissertation Abstracts International: Section B: The Sciences and Engineering 2015;75(12-B[E]).

Fung C, McIsaac JLD, Kuhle S, Kirk SFL, Veugelers PJ. The impact of a population-level school food and nutrition policy on dietary intake and body weights of Canadian children. Preventive Medicine 2013;57(6):934-940.

M sse LC, de Niet-Fitzgerald JE, Watts AW, Naylor PJ, Saewyc EM. Associations between the school food environment, student consumption and body mass index of Canadian adolescents. Int J Behav Nutr Phys Act 2014;11(1):29.

Mendoza JA, Watson K, Cullen KW. Change in dietary energy density after implementation of the Texas Public School Nutrition Policy. J Am Diet Assoc 2010;110(3):434-40.

Mullally ML, Taylor JP, Kuhle S, Bryanton J, Hernandez KJ, MacLellan DL, et al. A province-wide school nutrition policy and food consumption in elementary school children in prince Edward Island. Canadian Journal of Public Health 2010;101(1):40-3.

Rappaport EB, Daskalakis C, Sendecki JA. Using routinely collected growth data to assess a school-based obesity prevention strategy. International Journal of Obesity 2013;37:79-85.

Sanchez-Vaznaugh EV, Sanchez BN, Baek J, Crawford PB. ‘Competitive’ food and beverage policies: are they influencing childhood overweight trends? Health Affairs 2010;29(3):436-46.

Spence S, Delve J, Stamp E, Matthews JN, White M, Adamson AJ. The impact of food and nutrient-based standards on primary school children’s lunch and total dietary intake: a natural experimental evaluation of government policy in England. PLoS One 2013;8(10):e78298.

Economic Review

Anderson A, Porteous L, Foster E, et al. The impact of a school-based nutrition education intervention on dietary intake and cognitive and attitudinal variables relating to fruits and vegetables. Public Health Nutrition 2005;8(06):650-6.

Mobley CC, Stadler DD, Staten MA, et al. Effect of nutrition changes on foods selected by students in a middle school-based diabetes prevention intervention program: the HEALTHY Experience. Journal of School Health 2012;82(2):82-90.

Probart C, McDonnell E, Hartman T, Weirich JE, Bailey-Davis L. Factors associated with the offering and sale of competitive foods and school lunch participation. Journal of the American Dietetic Association 2006;106(2):242-7.

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.

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

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.

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
• Increase the proportion of schools that don’t sell less healthy foods and drinks — ECBP-D02