Obesity Prevention and Control: Meal or Fruit and Vegetable Snack Interventions Combined with Physical Activity Interventions in Schools

Summary of CPSTF Finding

The Community Preventive Services Task Force (CPSTF) recommends school-based interventions that combine meal or fruit and vegetable snack interventions with physical activity interventions to improve health among elementary school students (through grade 6).

Evidence shows these combined interventions increase students’ physical activity, modestly increase their fruit and vegetable consumption, and decrease the prevalence of overweight and obesity. There were not enough studies to determine whether these interventions work for middle and high school students.

The CPSTF recommends the following related intervention approaches:

Healthy Eating Interventions Alone

Physical Activity Interventions

The CPSTF finds insufficient evidence for two other intervention approaches that focus on healthy eating in schools alone and three other intervention approaches that focus on healthy eating combined with physical activity in schools. Read a summary of the findings from reviews of school-based interventions to prevent obesity.

Intervention

These interventions aim to improve student health by combining meal or fruit and vegetable snack interventions and physical activity interventions.
  • Meal or fruit and vegetable snack interventions are designed to provide healthier foods and beverages* that will be consumed by students, limit access to less healthy foods and beverages, or both. Interventions must include one of more of the following components:
    • School meal policies that ensure school breakfasts or lunches meet specific nutrition requirements (e.g., School Breakfast Program, National School Lunch Program)
    • Fruit and vegetable programs that provide fruits and vegetables to students during lunch or snack
  • Physical activity interventions engage students in physical activity each day. Interventions must include one of more of the following components:
    • Physical education classes that engage students in physical activity
    • School policies or practices that provide opportunities for physical activity during the school day (i.e., physical activities for students such as recess and classroom breaks)
    • Large-scale environmental changes that provide or improve space, facilities, or equipment to make physical activity easy and appealing (e.g., renovating a school playground)

Interventions may also include one or more of the following:

  • Healthy food and beverage marketing strategies
  • Educational programs that address nutrition or build knowledge and skills needed to maintain physically active lifestyles
  • Addition of small-scale equipment to promote physical activity (e.g., jump ropes, balls, cones, team vests, pedometers)
  • Staff involvement
  • Family and community engagement

*Healthier foods and beverages include fruits, vegetables, whole grains, low-fat or fat-free dairy, lean meats, beans, eggs, nuts, and items that are low in saturated fats, salt, and added sugars, and have no trans fats. Less-healthy foods and beverages include those with more added sugars, fats, and sodium.

CPSTF Finding and Rationale Statement

Read the full CPSTF Finding and Rationale Statement for details including implementation issues, possible added benefits, potential harms, and evidence gaps.

About The Systematic Review

The CPSTF finding is based on evidence from a systematic review of 21 studies with 22 study arms (search period January 1990 July 2017).

The systematic 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.

Context

Most U.S. children ages 5 to 18 years attend school for an average of six to seven hours a day during the school year. Schools can provide students nutritious and appealing foods and beverages and opportunities for physical activity to help students get the recommended 60 minutes of physical activity each day (CDC 2011; DHHS, 2018).

While there are many approaches available to schools, this CPSTF finding focuses on the combination of interventions that provide students healthier meals or fruit and vegetable snack interventions and physical activity interventions. Read a summary of all CPSTF findings for school-based interventions to prevent or control obesity.

Summary of Results

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

The systematic review included 21 studies with 22 study arms.

Overweight and Obesity Prevalence

The prevalence of overweight and obesity decreased by a median of 2.0 percentage points (7 studies).

Physical Activity

Physical activity increased by a median of 22 minutes per day (6 studies).

Students’ cardiorespiratory fitness measures improved (8 studies).

Fruit and Vegetable Consumption

Students consumed 12% more fruits and vegetables per day (4 studies).

The number of times per day students consumed fruits and vegetables increased by 3.0% (5 studies).

Summary of Economic Evidence

The CPSTF did not issue an economic finding for this intervention because only one study was identified in a search for evidence (search period 1990 through July 2017).

Applicability

The CPSTF finding should be applicable to elementary schools (kindergarten through grade 6; single-sex or co-educational).

Evidence Gaps

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?)
  • What are the best measures for dietary intake, physical activity, and weight-related outcomes? Increased consensus on definitions would improve comparability and the ability to synthesize evidence.
  • Do these interventions lead to other benefits (e.g., academic achievement) or potential harms (e.g., body dissatisfaction)?
  • Are schools implementing interventions correctly?
  • What amount of training is needed for faculty?
  • Are interventions effective among middle and high school students?

Study Characteristics

  • Included studies were conducted in the U.S. (13 studies), Canada (1 study), Denmark (1 study), Greece (1 study), Iceland (1 study), New Zealand (2 studies), and Norway (1 study); one study took place in two countries (Germany and the Netherlands).
  • Study populations represented a range of racial/ethnic groups. Students were white (6 studies), black (8 studies), or Hispanic (8 studies). Four of the 14 studies were conducted with a predominant race/ethnicity: Native American (1 study), black (1 study), and predominantly Hispanic (2 studies).

Analytic Framework

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 – 97 kB]

Summary Evidence Table

Effectiveness Review

Summary Evidence Table [PDF – 861 kB]

Included Studies

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).

Angelopoulos PD, Milionis HJ, Grammatikaki E, Moschonis G, Manios Y. Changes in BMI and blood pressure after a school based intervention: the CHILDREN study. European Journal of Public Health 2009;19(3):319-25.

Arbeit ML, Johnson CC, Mott DS, Harsha DW, Nicklas TA, Webber LS, Berenson GS. The Heart Smart cardiovascular school health promotion: behavior correlates of risk factor change. Preventive Medicine 1992;21(1):18-32.

Bergh IH, Bjelland M, Grydeland M, Lien N, Andersen LF, et al. Mid-way and post-intervention effects on potential determinants of physical activity and sedentary behavior, results of the HEIA study – a multi-component school-based randomized trial. International Journal of Behavioral Nutrition and Physical Activity 2012;9: 63.

Bjelland M, Bergh IH, Grydeland M, Klepp KI, Andersen LF, et al. Changes in adolescents’ intake of sugar-sweetened beverages and sedentary behaviour: results at 8 month mid-way assessment of the HEIA study–a comprehensive, multi-component school-based randomized trial. International Journal of Behavioral Nutrition and Physical Activity 2011;8:63 DOI: 10.1186/1479-5868-8-63.

Bugge A, El-Naaman B, Dencker M, Froberg K, Holme IM, et al. Effects of a three-year intervention: the Copenhagen School Child Intervention Study. Med Sci Sports Exerc 2012;44(7):1310-7.

Caballero B, Clay T, Davis SM, Ethelbah B, Holy Rock B, et al. Pathways: a school-based, randomized controlled trial for the prevention of obesity in American Indian schoolchildren.” American Journal of Clinical Nutrition 2003;78(5):1030-8.

Caballero B, Himes JH, Lohman T, Davis SM, Stevens J, et al. Body composition and overweight prevalence in 1704 schoolchildren from 7 American Indian communities.” American Journal of Clinical Nutrition 2003;78(2):308-12.

Coleman KJ, Tiller CL, Sanchez J, Heath EM, Sy O, et al. Prevention of the epidemic increase in child risk of overweight in low-income schools: the El Paso coordinated approach to child health. Arch Pediatr Adolesc Med 2005;159(3):217-24.

Crespo NC, Elder JP, Ayala GX, Slymen DJ, Campbell NR, et al. Results of a multi-level intervention to prevent and control childhood obesity among Latino children: the Aventuras Para Ninos Study. Annals of Behavioral Medicine 2012;43(1):84-100.

Elder JP, Arredondo EM, Campbell N, Baquero B, Duerksen S, et al. Individual, family, and community environmental correlates of obesity in Latino elementary school children [corrected][published erratum appears in J SCH HEALTH 2010 Mar;80(3):159]. Journal of School Health 2010;80(1):20-30.

Going S, Thompson J, Cano S, Stewart D, Stone E, et al. The effects of the Pathways Obesity Prevention Program on physical activity in American Indian children. Preventive Medicine 2003;37(6 Pt 2):S62-9.

Grydeland M, Bergh IH, Bjelland M, Lien N, Andersen LF, et al. Intervention effects on physical activity: The HEIA study – a cluster randomized controlled trial. International Journal of Behavioral Nutrition and Physical Activity 2013;10:17.

Grydeland M, Bjelland M, Anderssen SA, Klepp KI, Bergh IH, et al. Effects of a 20-month cluster randomised controlled school-based intervention trial on BMI of school-aged boys and girls: the HEIA study. British Journal of Sports Medicine 2014;48(9):768-73.

Heath EM, Coleman KJ. Evaluation of the institutionalization of the coordinated approach to child health (CATCH) in a U.S./Mexico border community. Health Education & Behavior 2002;29(4):444-60.

Heath EM, Coleman KJ. Adoption and institutionalization of the Child and Adolescent Trial for Cardiovascular Health (CATCH) in El Paso, Texas. Health Promotion Practice 2003;4(2):157-64.

Himes JH, Ring K, Gittelsohn J, Cunningham-Sabo L, Weber J, et al. Impact of the Pathways intervention on dietary intakes of American Indian schoolchildren. Preventive Medicine 2003;37(6 Pt 2):S55-61.

Hoelscher DM, Feldman HA, Johnson CC, Lytle LA, Osganian SK, et al. School-based health education programs can be maintained over time: results from the CATCH Institutionalization study. Preventive Medicine 2004;38(5):594-606.

Hoelscher DM, Springer AE, Ranjit N, Perry CL, Evans AE, et al. Reductions in child obesity among disadvantaged school children with community involvement: the Travis County CATCH Trial. Obesity 2010;18 Suppl 1:S36-44.

Hollar D, Lombardo M, Lopez-Mitnik G, Hollar TL, Almon M, et al. Effective multi-level, multi-sector, school-based obesity prevention programming improves weight, blood pressure, and academic performance, especially among low-income, minority children. Journal of Health Care for the Poor and Underserved 2010;21(2 Suppl):93-108.

Hollar D, Messiah SE, Lopez-Mitnik G, Hollar TL, Almon M, Agatston AS. Effect of a two-year obesity prevention intervention on percentile changes in body mass index and academic performance in low-income elementary school children. American Journal of Public Health 2010;100(4):646-53.

Hollar D, Messiah SE, Lopez-Mitnik G, Hollar TL, Almon M, Agatston AS. Healthier options for public schoolchildren program improves weight and blood pressure in 6- to 13-year-olds. J Am Diet Assoc 2010;110(2):261-7.

Hrafnkelsson H, Magnusson KT, Thorsdottir I, Johannsson E, Sigurdsson EL. Result of school-based intervention on cardiovascular risk factors. Scandinavian Journal of Primary Health Care 2014;32(4):149-55.

Jensen BW, von Kappelgaard LM, Nielsen BM, Husby I, Bugge A, et al. Intervention effects on dietary intake among children by maternal education level: results of the Copenhagen School Child Intervention Study (CoSCIS). British Journal of Nutrition 2015;113(6): 963-74.

Jimenez MM, Receveur O, Trifonopoulos M, Kuhnlein H, Paradis G, Macaulay AC. Comparison of the dietary intakes of two different groups of children (grades 4 to 6) before and after the Kahnawake Schools Diabetes Prevention Project. Journal of the American Dietetic Association 2003;103(9):1191-4.

Kristjansdottir AG, Johannsson E, Thorsdottir I, Kristjansdottir AG, Johannsson E, et al. Effects of a school-based intervention on adherence of 7-9-year-olds to food-based dietary guidelines and intake of nutrients. Public Health Nutrition 2010;13(8):1151-61.

Lien N, Bjelland M, Bergh IH, Grydeland M, Anderssen SA, et al. Design of a 20-month comprehensive, multicomponent school-based randomised trial to promote healthy weight development among 11-13 year olds: the HEalth In Adolescents study. Scandinavian Journal of Public Health 2010;38(S5):38-51.

Luepker RV, Perry CL, McKinlay SM, Nader PR, Parcel GS, et al. Outcomes of a field trial to improve children’s dietary patterns and physical activity. The Child and Adolescent Trial for Cardiovascular Health. CATCH collaborative group. JAMA 1996;275(10):768-76.

Macaulay AC, Paradis G, Potvin L, Cross EJ, Saad-Haddad C, et al. The Kahnawake Schools Diabetes Prevention Project: intervention, evaluation, and baseline results of a diabetes primary prevention program with a native community in Canada. Preventive Medicine 1997;26(6):779-90.

Madsen K, Linchey J, Gerstein D, Ross M, Myers E, et al. Energy Balance 4 Kids with Play: Results from a Two-Year Cluster-Randomized Trial. Childhood Obesity 2015;11(4): 375-383.

Magnusson KT, Sigurgeirsson I, Sveinsson T, Johannsson E. Assessment of a two-year school-based physical activity intervention among 7-9-year-old children. International Journal of Behavioral Nutrition and Physical Activity 2011;8:138.

Myers EF, Gerstein DE, Foster J, Ross M, Brown K, et al. Energy balance for kids with play: design and implementation of a multi-component school-based obesity prevention program. Childhood Obesity 2014;10(3):251-9.

Nader PR, Stone EJ, Lytle LA, Perry CL, Osganian SK, et al. Three-year maintenance of improved diet and physical activity: the CATCH cohort. Child and Adolescent Trial for Cardiovascular Health. Archives of Pediatrics & Adolescent Medicine 1999;153(7):695-704.

Naul R, Schmelt D, Dreiskaemper D, Hoffmann D, l’Hoir M. ‘Healthy children in sound communities’ (HCSC/gkgk)–a Dutch-German community-based network project to counteract obesity and physical inactivity. Fam Pract 2012;29 Suppl 1: i110-6.

Newton RL, Jr., Han H, Anton SD, Martin CK, Stewart TM, et al. An environmental intervention to prevent excess weight gain in African-American students: a pilot study. American Journal of Health Promotion 24(5):340-3.

Paradis G, L vesque L, Macaulay AC, Cargo M, McComber A, et al. Impact of a diabetes prevention program on body size, physical activity, and diet among Kanien’keha’:ka (Mohawk) children 6 to 11 years old: 8-year results from the Kahnawake Schools Diabetes Prevention Project. Pediatrics 2005;115(2): 333-9.

Resnicow K, Cohn L, Reinhardt J, Cross D, Futterman R, et al. A three-year evaluation of the know your body program in inner-city schoolchildren. Health Education Quarterly 1992;19(4):463-80.

Resnicow K, Cross D, Wynder E. The Know Your Body program: a review of evaluation studies. Bulletin of the New York Academy of Medicine 1993;70(3):188-207.

Resnicow K, Cross D, Wynder E. The role of comprehensive school-based interventions. Annals of the New York Academy of Sciences 1991;623(1):285-98.

Simons-Morton BG, Parcel GS, Baranowski T, Forthofer R, O’Hara NM. Promoting physical activity and a healthful diet among children: results of a school-based intervention study. American Journal of Public Health 1991;81(8):986-91.

Swinburn BA, Millar L, Utter J, Kremer P, Moodie M, et al. The Pacific Obesity Prevention in Communities project: project overview and methods. Obesity Reviews 2011;12 Suppl 2: 3-11.

Taylor RW, McAuley KA, Barbezat W, Farmer VL, Williams SM, et al. Two-year follow-up of an obesity prevention initiative in children: the APPLE project. American Journal of Clinical Nutrition 2008;88(5): 1371-7.

Taylor RW, McAuley KA, Barbezat W, Strong A, Williams SM, et al. APPLE Project: 2-y findings of a community-based obesity prevention program in primary school age children. American Journal of Clinical Nutrition 2007;86(3):735-42.

Taylor RW, McAuley KA, Williams SM, Barbezat W, Nielsen G, et al. Reducing weight gain in children through enhancing physical activity and nutrition: the APPLE project. International Journal of Pediatric Obesity 2006;1(3): 146-52.

Utter J, Scragg R, Robinson E, Warbrick J, Faeamani G, et al. Evaluation of the Living 4 Life project: A youth-led, school-based obesity prevention study. Obesity Reviews 2011;12(SUPPL. 2): 51-60.

Utter J, Warbrick J, Scragg R, Denny S, Schaaf D. Design, development, and achievements of a youth-led nutrition and physical activity intervention in a Pacific community in New Zealand. Journal of the American Dietetic Association 2010;110(11):1634-7.

Webber LS, Osganian SK, Feldman HA, Wu M, McKenzie TL, et al. Cardiovascular risk factors among children after a 2 1/2-year intervention-The CATCH Study. Preventive Medicine 1996;25(4):432-41.

Webber LS, Osganian V, Luepker RV, Feldman HA, Stone EJ, et al. Cardiovascular risk factors among third grade children in four regions of the United States. The CATCH Study. Child and Adolescent Trial for Cardiovascular Health. Am J Epidemiol 1995;141(5):428-39.

Williamson DA, Copeland AL, Anton SD, Champagne C, Han H, et al. Wise Mind project: a school-based environmental approach for preventing weight gain in children. Obesity 2007;15(4):906-17.

Williamson DA, Han H, Johnson WD, Martin CK, Newton RL, Jr. Modification of the school cafeteria environment can impact childhood nutrition. Results from the Wise Mind and LA Health studies. Appetite 2013;61(1): 77-84.

Search Strategies

Effectiveness Review

The following six bibliographic databases were searched between 1990 and July 2017, using the search terms listed below.

  • PubMed
  • Embase (Ovid)
  • CINAHL
  • PsycINFO (Ovid)
  • Cochrane
  • Medline (OVID)

The databases covered publications in medical and social sciences, behavioral sciences, and nursing and allied health. The types of documents retrieved by the search included journal articles, books, book chapters, reports, and conference papers.

Following are search strategies specific for Medline. Search terms and search strategies were adjusted to each database, based on controlled and uncontrolled vocabularies and search software.

Medline (OVID)

1. (school or schools or kindergarten*).ab,hw,ti.

2. (school cafeteria* or school provided or school located or school lunch* or school breakfast* or school week* or during school or school clinic* or school health or school setting* or “school nutrition” or “lunchroom” or lunchrooms or canteen* school intervention* or school environment* or school day or school hours or school provided or school located or school lunch* or school breakfast* or school week* or during school or school clinic* or school health or ‘in school’ or school based or on site or ‘at school’).mp.

3. (nutrition or diet or diets or dieting or vending machine* or candy or sweets or fruits or vegetables or vegetarian or vegan or sweetened drinks or sweetened beverages or soda or carbonated or low fat or gluten free or water or dietary or food or foods or pop or dessert* or cake or cookies or brownies or baked goods or carbohydrates or sugary or sugars or sugar or soft drink* or “Exercise” or “stair climbing” or “recess” or “volleyball” or “golf” or “golfing” or “yoga” or “pilates” or “baseball” or “gymnastics” or “gym” or “pe” or “physical education” or “playtime” or “movement” or “active living” or “play time” or “calisthenics” or jazzercise or “badminton” or “walk” or “walked” or “walking” or “jogging” or “jog” or “jogged” or “physical activity” or “physical activities” or “exercise” or “exercising” or “running” or “dance” or “dancing” or “aerobics” or “tennis” or “lacrosse” or “football” or “soccer” or weight lifting or weigh training or hand ball or handball or net ball or basketball or basket ball or netball or racket ball or racquet ball or horseback or roller skates or roller skating or skateboard* or skate board* or bicycle* or bicycling or cycling or sport or sports or school sports or walk or walking).mp.

4. (“Program Evaluation” or “benchmark” or “benchmarking” or “outcome” or “outcomes” or “program evaluation” or “evaluate” or “evaluated” or “evaluating” or “evaluation” or “improve” or “improvement” or “improvements” or “improving” or “improved” or “lessen” or “lessening” or “increase” or “increased” or “increasing” or “decrease” or “decreased” or “decreasing” or measur* or “weight” or “body mass” or “bmi” or “circumference” or consum* or “intake” or promot* or “add” or “added” or “additional” or “success” or “successes” or “successful” or “fitness”).mp

5. 1 AND 2 AND 3 AND 4

6. (“Afghanistan” or “Benin” or “Burkina Faso” or “Burundi” or “Central African Republic” or “Chad” or “Comoros” or “Congo” or “Eritrea” or “Ethiopia” or “Guinea” or “Haiti” or “North Korea” or “Liberia” or “Madagascar” or “Malawi” or “Mali” or “Mozambique” or “Nepal” or “Rwanda” or “Senegal” or “Sierra Leone” or “Somalia” or “South Sudan” or “Tanzania” or “Togo” or “Uganda” or “Zimbabwe” or “Gambia” or “Niger” or “Mexico” or “Guinea” or “Ecuador” or “Ecuador” or “Montenegro” or “Montenegro” or “Dominica” or “Dominica” or “Marshall Islands” or “Micronesia” or “Micronesia” or “Tuvalu” or “Dominican Republic” or “Mauritius” or “Mauritius” or “Venezuela” or “Venezuela” or “Equatorial Guinea” or “Colombia” or “Colombia” or “Macedonia Republic” or “Macedonia”) and “Republic”) or “Macedonia Republic” or “Macedonia” or “Thailand” or “Thailand” or “Costa Rica” or “Malaysia” or “Malaysia” or “Turkey” or “Turkey” or “Cuba” or “Cuba” or “Indian Ocean Islands” or “Indian”) and “Ocean” and “Islands”) or “Indian Ocean Islands” or “Maldives” or “Turkmenistan” or “Turkmenistan” or “Saint Lucia” or “Bulgaria” or “Bulgaria” or “Lebanon” or “Lebanon” or “St. Vincent” or “Saint Vincent” or “Saint Vincent And The Grenadines” or “Saint”) and “Vincent” and “Grenadines”) or “Saint Vincent And The Grenadines” or “Grenadines” or “China” or “China” or “Libya” or “Libya” or “Suriname” or “Suriname” or “Bosnia And Herzegovina” or “Bosnia”) and “Herzegovina”) or “Bosnia And Herzegovina” or “Bosnia” or “Bosnia And Herzegovina” or “Bosnia”) and “Herzegovina”) or “Bosnia And Herzegovina” or “Herzegovina” or “Jamaica” or “Jamaica” or “Serbia” or “Serbia” or “Botswana” or “Botswana” or “Jordan” or “Jordan” or “South Africa” or “Brazil” or “Brazil” or “Kazakhstan” or “Kazakhstan” or “St. Lucia” or “Paraguay” or “Paraguay” or “Azerbaijan” or “Azerbaijan” or “Guyana” or “Guyana”) and “Peru”) or “Peru” or “Republic Of Belarus” or “Republic”) and “Belarus”) or “Republic Of Belarus” or “Belarus” or “Iran” or “Iran” or “Romania” or “Romania” or “Belize” or “Belize” or “Iraq” or “Iraq” or “Russian Federation” or “Russia” or “India” or “India” or “Philippines” or “Philippines” or “Zambia” or “Zambia” or “Albania” or “Albania” or “Fiji” or “Fiji” or “Namibia” or “Namibia” or “Algeria” or “Algeria” or “Gabon” or “Gabon” or “Palau” or “Palau” or “Samoa” or “Samoa” or “Angola” or “Angola” or “Grenada” or “Grenada” or “Guatemala” or “Guatemala” or “Pakistan” or “Pakistan” or “West Bank” or Gaza or “Palestine” or “Honduras” or “Honduras” or “Papua New Guinea” or “New Guinea” or “Yemen” or “Yemen” or “Uzbekistan” or “Uzbekistan” or “El Salvador” or “Nicaragua” or “Nicaragua” or “Vanuatu” or “Vanuatu” or “Ghana” or “Ghana” or “Nigeria” or “Nigeria” or “Vietnam” or “Vietnam” or “Cote d’Ivoire” or “Ivory Coast” or “Mongolia” or “Mongolia” or “Tunisia” or “Tunisia” or “Djibouti” or “Djibouti” or “Morocco” or “Morocco” or “Ukraine” or “Ukraine” or “Egypt” or “Egypt” or “Myanmar” or “Myanmar” or “Mauritania” or “Mauritania” or “Tajikistan” or “Tajikistan” or “Cameroon” or “Cameroon” or “Micronesia” or “Micronesia” or “Timor-Leste” or “Timor” or “Congo” or “Congo” or “Moldova” or “Moldova” or “Tonga” or “Tonga” or Lao or “Laos” or “Laos” or “Swaziland” or “Swaziland” or “Cabo Verde” or “Costa Verde” or “Lesotho” or “Lesotho” or “Syria” or “Syria” or “Syrian Arab Republic” or “Cambodia” or “Cambodia” or “Armenia” or “Armenia” or “Micronesia” or “Micronesia” or “Kiribati” or “Solomon Islands” or “Bangladesh” or “Bangladesh” or “Kosovo” or “Kosovo” or “Sri Lanka” or “Sri”) and “Lanka”) or “Sri Lanka” or “Bhutan” or “Bhutan” or Kyrgyz or “Sudan” or “Sudan” or “Bolivia” or “Bolivia” or “Africa” or “Georgia Republic” or “Panama” or “low income country” or “low income countries” or “low income economy” or “low income economies” or “middle income country” or “developing countries” or “developing nations” or “developing country” or “developing nation” or “middle income countries” or “middle income nation” or “middle income nations” or “middle income economies” or “low income nations” or “third world” or developmental* delay* or adhd or attention deficit or injury or injuries or tumor or tumors or cancer* or leukemia* or disability or disabilities or arthritis or developmental disorder* or arthritis or “scoliosis” or “Kawasaki” or asthma* or cerebral palsy or prematur* or infant* or newborn* or “sickle cell” or arthritis or schizophren* or surgery or osteoarthritis or elderly or food allerg* or (mexico not new mexico).mp.

7. 5 NOT 6

8. Limit 7 (english language and yr=”1990 -Current”)

Review References

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

U.S. Department of Health and Human Services. Physical Activity Guidelines for Americans. 2nd edition. Washington (DC): 2018. Retrieved from URL https://health.gov/paguidelines/second-edition/pdf/Physical_Activity_Guidelines_2nd_edition.pdf; November 19, 2018.

Considerations for Implementation

The following considerations for implementation are drawn from studies included in the evidence review, the broader literature, and expert opinion.
  • Program duration most of the evaluated interventions ran for two or more school years
  • Intervention guidelines most schools used existing guidelines such as the National School Lunch Program for the dietary interventions; physical activity interventions varied
  • Education programs typically included an educational component to emphasize the importance of nutrition and physical activity for chronic disease prevention
  • Staffing studies in this review relied primarily on existing school staff (e.g., teachers, food service staff) to implement programs and policies, though some also included outside professionals (e.g., registered dietitians)
  • Existing models program planners may want to use models to assist with program implementation. The Whole School, Whole Community, Whole Child model, promoted by CDC, provides information about the school nutrition environment, nutrition services, physical education, and physical activity.