Obesity: Supporting Healthier Snack Foods and Beverages Sold or Offered as Rewards in Schools

Summary of CPSTF Finding

The Community Preventive Services Task Force (CPSTF) finds insufficient evidence to determine the effectiveness of interventions supporting healthier snack foods and beverages sold or rewarded in schools. Evidence is considered insufficient based on inconsistent findings for sugar-sweetened beverage consumption outcomes and too few studies for weight and other dietary outcomes.

The CPSTF recommends the following related interventions in school settings:

Healthy Eating Interventions Combined with Physical Activity Interventions

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 two other intervention approaches that focus on healthy eating combined with physical activity in schools. Read a summary of the findings from all eight reviews of school-based interventions to prevent obesity.

Intervention

Interventions supporting healthier snack foods and beverages sold or offered as a reward in school aim to provide healthier foods and beverages that will be consumed by students, limit access to less healthy foods and beverages, or both.
  • Policies that require foods and beverages sold during the school day, outside of school meal programs, meet established nutritional standards or guidelines
    • These are often referred to a “competitive foods and beverages” as they are sold in competition with school meal programs. They may include in-school fundraisers, a la carte foods, vending machines, school stores, and snack bars.
  • Celebration rules or policies that encourage healthy foods and beverages be served during classroom celebrations, parties, and special events
  • Reward rules or policies that encourage rewards of nonfood items for academic achievement

Interventions may also include one or more of the following:

  • Healthy food and beverage marketing strategies:
    • Placing healthier foods and beverages where they are easy for students to select
    • Pricing healthier foods and beverages at a lower cost
    • Setting up attractive displays of fruits and vegetables
    • Offering taste tests of new menu items
    • Posting signs or using verbal prompts to promote healthier foods and beverages and new menu items
  • Healthy eating learning opportunities, such as nutrition education and other strategies that give children knowledge and skills to choose and consume healthier foods and beverages

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

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 and School-Based Programs to Prevent Obesity [PDF – 679 kB].

Context

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).

Summary of Results

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

The systematic review included 13 studies with 15 study arms.

Weight-Related Outcomes

  • Prevalence of overweight/obesity one study reported no change (1 study arm) and a significant increase in overweight/obesity prevalence (1 study arm).
  • BMI z-score decreased (1 study with 2 study arms; results were significant in 1 arm)

Diet-Related Outcomes

  • Sugar-sweetened beverage intake mixed outcomes (9 studies)
  • Low-nutrient food intake favorable findings (2 studies)

Summary of Economic Evidence

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

Applicability

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.

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?)
  • Which intervention activities, 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?
  • Approximately half of the studies reported on weight outcomes; future studies should report weight-related outcomes to increase understanding of intervention effectiveness.
  • 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?

Study Characteristics

  • Study designs included before/after design with concurrent comparison group (2 studies), prospective cohort (1 study), repeat cross-sectional with comparison (1 study), repeat cross-sectional (3 studies), or post-test only with comparison (6 studies).
  • All studies were conducted in the United States.
  • All studies evaluated interventions conducted in schools alone.
  • Studies were implemented in elementary schools (1 study), middle schools (4 studies), high schools (5 studies), or a combination of elementary, middle, or high schools (3 studies).
  • Studies were set in urban (1 study) or a combination of urban, suburban, or rural (11 studies) settings.
  • About half of each study population was female (10 studies; 3 studies did not provide information).

Publications

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.

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 – 293 kB]

Summary Evidence Table

Effectiveness Review

Summary Evidence Table – Effectiveness Review [PDF – 500 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).

Alaimo K, Oleksyk SC, Drzal NB, Golzynski DL, Lucarelli JF, Wen Y, et al. Effects of changes in lunch-time competitive foods, nutrition practices, and nutrition policies on low-income middle-school children’s diets. Childhood Obesity 2013;9(6):509-23.

Blum JE, Davee AM, Beaudoin CM, Jenkins PL, Kaley LA, Wigand DA. Reduced availability of sugar-sweetened beverages and diet soda has a limited impact on beverage consumption patterns in Maine high school youth. J Nutr Educ Behav 2008;40(6):341-7.

Cradock AL, McHugh A, Mont-Ferguson H, Grant L, Barrett JL, Wang YC, et al. Effect of school district policy change on consumption of sugar-sweetened beverages among high school students, Boston, Massachusetts, 2004-2006. Preventing Chronic Disease 2011;8(4):A74.

Hennessy E, Oh A, Agurs-Collins T, Chriqui JF, Masse LC, Moser RP, et al. State-level school competitive food and beverage laws are associated with children’s weight status. J Sch Health 2014;84(9):609-16.

Jones SJ, Gonzalez W, Frongillo EA. Policies that restrict sweetened beverage availability may reduce consumption in elementary-school children. Public Health Nutr 2009;13(4):589-95.

Palakshappa D, Fiks AG, Faerber JA, Feudtner C. Association between state school nutrition laws and subsequent child obesity. Prev Med 2016;90:107-13.

Schwartz MB, Novak SA, Fiore SS. The impact of removing snacks of low nutritional value from middle schools. Health Educ Behav 2009;36(6):999-1011.

Taber DR, Chriqui JF, Perna FM, Powell LM, Chaloupka FJ. Weight status among adolescents in States that govern competitive food nutrition content. Pediatrics 2012a;130(3):437-44.

Taber DR, Chriqui JF, Powell LM, Chaloupka FJ. Banning all sugar-sweetened beverages in middle schools: reduction of in-school access and purchasing but not overall consumption. Arch Pediatr Adolesc Med 2012b;166(3):256-62.

Taber DR, Chriqui JF, Chaloupka FJ. Differences in nutrient intake associated with state laws regarding fat, sugar, and caloric content of competitive foods. Arch Pediatr Adolesc Med 2012c;166(5):452-8.

Taber DR, Chriqui JF, Vuillaume R, Kelder SH, Chaloupka FJ. The association between state bans on soda only and adolescent substitution with other sugar-sweetened beverages: a cross-sectional study. Int J Behav Nutr Phys Act 2015;12 Suppl 1:S7.

Terry-McElrath YM, Chriqui JF, O’Malley PM, Chaloupka FJ, Johnston LD. Regular soda policies, school availability, and high school student consumption. Am J Prev Med 2015; 48(4): 436-44.

Wordell D, Daratha K, Mandal B, Bindler R, Butkus SN. Changes in a middle school food environment affect food behavior and food choices. Journal of the Academy of Nutrition and Dietetics 2012;112(1):137-141.

Search Strategies

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

Review References

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. MMWRM 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.

Considerations for Implementation

The CPSTF did not have enough evidence to determine whether the intervention is or is not effective. This does not mean that the intervention does not work, but rather that additional research is needed to determine whether or not the intervention is effective.

Crosswalks

Evidence-Based Cancer Control Programs (EBCCP)

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