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

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).

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, Lévesque 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.

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 [PDF - 13.5 MB] ; November 19, 2018.