Obesity Prevention and Control: Supporting Healthier Snack Foods and Beverages Sold or Offered Combined with Physical Activity Interventions in Schools

The CPSTF finding is based on evidence from a systematic review of four 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. This gives schools a chance to offer students nutritious 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 snack foods and beverages and interventions that increase the amount of physical activity students get during the school day. 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 four studies.

Weight-related Outcomes

Of the three studies that reported weight-related outcomes, two reported favorable findings (one for Body Mass Index z-score [BMIz] and one for combined overweight/obesity prevalence), and one reported unfavorable results for BMIz.

Physical Activity

Of the three studies that reported physical activity outcomes, two reported favorable findings and one reported no change in physical activity.

Dietary-related Outcomes

Two studies reported on consumption of fruits and vegetables, sugar-sweetened beverages, and low nutrient foods (i.e., high-energy dense foods). Findings were inconsistent for the three dietary outcomes.

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 combined interventions effective?
• Do these interventions lead to other benefits (e.g., academic achievement) or potential harms (e.g., body dissatisfaction or overexertion from physical activity)?
• How effective are these interventions across different populations, including students with disabilities?

• Included studies were conducted in the United States (1 study), Sweden (1 study), Germany (1 study), and Italy (1 study).
• Included studies were conducted in elementary schools (1 study), middle schools (1 study), or schools that spanned across elementary, middle, and high school (2 studies).

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).

Cadzow RB, Chambers MK, Sandell AMD. School-based obesity intervention associated with three year decrease in student weight status in a low-income school district. Journal of Community Health 2015;40(4):709-13.

Elinder LS, Heinemans N, Hagberg J, Quetel A-K, Hagstromer M. A participatory and capacity-building approach to healthy eating and physical activity- SCIP-school: a 2-year controlled trial. International Journal of Behavioral Nutrition and Physical Activity 2012;9:145.

Ermetici F, Zelaschi RF, Briganti S, Dozio E, Gaeta M, Ambrogi F, et al. Association between a school-based intervention and adiposity outcomes in adolescents: The Italian “EAT” project. Obesity 2016;24(3):687-95.

Siegrist M, Lammel C, Haller B, Christle J, Halle M. Effects of a physical education program on physical activity, fitness, and health in children: the JuvenTUM project. Scandinavian Journal of Medicine & Science in Sports 2013;23(3):323-30.

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.

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.

• Guidance documents are available to assist with program implementation:
  • The U.S. Department of Agriculture has Smart Snacks standards required nutrition standards for foods and beverages sold outside of the school meal program.
  • CDC’s Comprehensive School Physical Activity Program Framework outlines how to address physical education and physical activity within schools.