Obesity Prevention and Control: Multicomponent Interventions (Meal or Fruit and Vegetable Snack Interventions + Healthier Snack Foods and Beverages) Combined with a Physical Activity Intervention in Schools

The CPSTF finding is based on evidence from a systematic review of 14 studies (search period 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.

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 (National Center for Education Statistics, 2010). Schools can provide students nutritious and appealing foods and beverages and opportunities for physical activity to help students accumulate the recommends children and adolescents engage in 60 minutes of physical activity per day (CDC 2011; DHHS, 2018).

While there are many approaches available to schools, this CPSTF finding focuses on the combining meal or fruit and vegetable snack Interventions, interventions supporting healthier snack foods and beverages, and a physical activity intervention. Read a summary of all CPSTF findings for school-based interventions to prevent or control obesity.

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

The systematic review included 14 studies.

Weight-related Outcomes

The combined prevalence of overweight and obesity decreased by a median of 0.4 percentage points (6 studies).

Students’ body mass index z-scores (BMIz) increased by a median of 0.005 units (8 study arms).

Dietary Outcomes

Fruit and Vegetable Consumption

The number of servings of fruits and vegetables students consumed per day increased by 0.10 servings (6 study arms).

Other outcomes related to fruit and vegetable consumption showed either no change or small decreases (3 studies).

Sugar-sweetened Beverage Consumption

The number of glasses of sugar-sweetened beverages students consumed per day decreased by 0.08 glasses (5 study arms).

Other measures of sugar-sweetened beverage consumption showed inconsistent results (3 studies).

Physical Activity

Students increased time spent in physical activity (10 studies).

Other measures of physical activity (e.g., cardiorespiratory fitness or proportion of students active) showed inconsistent results (5 studies).

An economic review of this intervention was not conducted because the CPSTF did not have enough information to determine if the intervention works.

Applicability of this intervention across different settings and populations was not assessed because the CPSTF did not have enough information to determine if the intervention works.

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?)

• Are these interventions effective?
• Are programs implemented at some system levels (i.e., Federal, state, district, school, classroom) more effective than others?
• How effective are these interventions across different populations, including students with disabilities?
• Do interventions lead to body dissatisfaction?

• Included studies were conducted in the United States (6 studies), Canada (2 studies), Australia (2 studies), Belgium (1 study), The Netherlands (1 study), New Zealand (1 study), and Sweden (1 study).
• Study populations represented a range of racial and ethnic groups.

Buchanan LR, Wethington HR, Finnie RKC, et al. A Community Guide systematic review: school dietary and physical activity interventions [PDF – 786 KB]. American Journal of Preventive Medicine 2023;64(3):441−51.

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]

Effectiveness Review

Summary Evidence Table [PDF – 861 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).

Benjamins MR, Whitman S. A culturally appropriate school wellness initiative: results of a 2-year pilot intervention in two Jewish schools. Journal of School Health 2010;80(8):378-86.

Cheadle A, Rauzon S, Spring R, Schwartz PM, Gee S, Gonzalez E, et al. Kaiser Permanente’s Community Health Initiative in Northern California: evaluation findings and lessons learned. American Journal of Health Promotion 2012;27(2):e59-68.

Dalton WT, Schetzina, K., Conway-Williams, E. A coordinated school health approach to obesity prevention among Applachian youth: middle school outcomes from the Winning With Wellness Project. International Journal of Health Sciences Education 2014;2(1).

Foster GD, Linder B, Baranowski T, Cooper DM, Goldberg L, Harrell JS, et al. A school-based intervention for diabetes risk reduction. New England Journal of Medicine 2010;363(5):443-53.

Fung C, Kuhle S, Lu C, Purcell M, Schwartz M, Storey K, et al. From “best practice” to “next practice”: the effectiveness of school-based health promotion in improving healthy eating and physical activity and preventing childhood obesity. International Journal of Behavioral Nutrition and Physical Activity 2012;9:27.

Gore CJ, Owen N, Pederson D, Clarke A. Educational and environmental interventions for cardiovascular health promotion in socially disadvantaged primary schools. Australian and New Zealand Journal of Public Health 1996;20(2):188-94.

Haerens L, Deforche B, Maes L, Cardon G, Stevens V, De Bourdeaudhuij I. Evaluation of a 2-year physical activity and healthy eating intervention in middle school children. Health Education Research 2006;21(6):911-21.

Haerens L, Deforche B, Maes L, Stevens V, Cardon G, De Bourdeaudhuij I. Body mass effects of a physical activity and healthy food intervention in middle schools. Obesity 2006;14(5):847-54.

Haerens L, De Bourdeaudhuij I, Maes L, Cardon G, Deforche B. School-based randomized controlled trial of a physical activity intervention among adolescents. Journal of Adolescent Health 2007;40(3):258-65.

Jamerson T, Sylvester R, Jiang Q, Corriveau N, DuRussel-Weston J, et al. Differences in cardiovascular disease risk factors and health behaviors between black and non-black students participating in a school-based health promotion program. American Journal of Health Promotion 2017;31(4):318-24.

Kakekagumick KE, Naqshbandi Hayward M, Harris SB, Saksvig B, Gittelsohn J, et al. Sandy lake health and diabetes project: a community-based intervention targeting type 2 diabetes and its risk factors in a first nations community. Frontiers in Endocrinology 2013;4:170.

Marcus C, Nyberg G, Nordenfelt A, Karpmyr M, Kowalski J, Ekelund U. A 4-year, cluster-randomized, controlled childhood obesity prevention study: STOPP. International Journal of Obesity 2009;33(4):408-17.

Millar L, Kremer P, de Silva-Sanigorski A, McCabe MP, Mavoa H, et al. Reduction in overweight and obesity from a 3-year community-based intervention in Australia: the ‘It’s Your Move!’ project. Obesity Reviews 2011;12 Suppl 2:20-8.

Millar L, Robertson N, Allender S, Nichols M, Bennett C, Swinburn B. Increasing community capacity and decreasing prevalence of overweight and obesity in a community based intervention among Australian adolescents. Preventive Medicine 2013;56(6):379-84.

Nanney MS, MacLehose R, Kubik MY, Davey CS, Coombes B, Nelson TF. Recommended school policies are associated with student sugary drink and fruit and vegetable intake. Preventive Medicine 2014;62:179-81.

Rush E, Reed P, McLennan S, Coppinger T, Simmons D, Graham D. A school-based obesity control programme: Project Energize. Two-year outcomes. British Journal of Nutrition 2012;107(4):581-7.

Saksvig BI, Gittelsohn J, Harris SB, Hanley AJ, Valente TW, Zinman B. A pilot school-based healthy eating and physical activity intervention improves diet, food knowledge, and self-efficacy for native Canadian children. Journal of Nutrition 2005;135(10):2392-8.

Schetzina KE, Dalton WT, 3rd, Lowe EF, Azzazy N, VonWerssowetz KM, et al. A coordinated school health approach to obesity prevention among Appalachian youth: the Winning with Wellness Pilot Project. Family & Community Health 2009;32(3):271-85.

Singh AS, Chin A Paw MJM, Brug J, van Mechelen W. Dutch obesity intervention in teenagers: effectiveness of a school-based program on body composition and behavior. Archives of Pediatrics & Adolescent Medicine 2009;163(4):309-17.

Vander Ploeg KA, McGavock J, Maximova K, Veugelers PJ. School-based health promotion and physical activity during and after school hours. Pediatrics 2014;133(2):e371-8.

Willi SM, Hirst K, Jago R, Buse J, Kaufman F, El Ghormli L, et al. Cardiovascular risk factors in multi-ethnic middle school students: the HEALTHY primary prevention trial. Pediatric Obesity 2012;7(3):230-9.

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”)

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

National Center for Education Statistics. 2010. Schools and Staffing Survey. Average number of hours in the school day and average number of days in the school year for public schools, by state: 2007-08. Retrieved from https://nces.ed.gov/surveys/sass/tables/sass0708_035_s1s.asp.

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.

Despite the finding of insufficient evidence, the following are considerations for implementation drawn from the broader literature and expert opinion.

• 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.