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

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Findings and Recommendations

The Community Preventive Services Task Force (CPSTF) recommends multicomponent interventions to increase availability of healthier foods and beverages in schools. This finding is based on evidence that they reduce or maintain the rate of obesity or overweight.

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 three 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.

The full CPSTF Finding and Rationale Statement and supporting documents for Obesity Prevention and Control: Interventions to Support Healthier Foods and Beverages in Schools are available in The Community Guide Collection on CDC Stacks.

Intervention

These interventions aim to provide healthier foods and beverages in schools that will be consumed by students, limit access to less healthy foods and beverages, or both.

Multicomponent interventions must include one component from each of the following:

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 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.

About The Systematic Review

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.

Study Characteristics

  • 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.

Summary of Results

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

Summary of Economic Evidence

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.

Applicability

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

Evidence Gaps

  • Which intervention activities, school breakfast or lunch, fresh fruit and vegetable programs, competitive foods and beverages, classroom 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?

Implementation Considerations and Resources

  • 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.

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