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As children hold a position of being a vulnerable population, it is significant to ensure that we are educating them in a way that will benefit their health literacy. With the available resources that are present, the population of children as well as the caretakers will benefit from reviewing the files. Children's health and nutrition including their eating habits and physical activity is very significant to their bodies and they must be well educated on the topics.

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The Guide to Community Preventive Services (The Community Guide)

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Tabs

Snapshot

Summary of CPSTF Finding

The Community Preventive Services Task Force (CPSTF) finds insufficient evidence to determine the effectiveness of combining interventions that increase the availability of healthier snack foods and beverages sold or offered with physical activity interventions in schools. Evidence was inconsistent for dietary, physical activity, and weight-related 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 reviews of school-based interventions to prevent obesity.

Intervention

These interventions aim to improve student health by combining interventions to support healthier foods and beverages sold or offered with physical activity interventions.

Interventions supporting healthier snack foods and beverages sold or offered 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. Interventions must include one or more of the following components:

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 as "competitive foods and beverages" because they are sold in competition with school meal programs. They may be available through in-school fundraisers, à la carte options, 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

Rules or policies that encourage nonfood items as alternative rewards for academic achievement

Physical activity interventions engage students in physical activity each day. Interventions must include one or more of the following components:

Physical education classes that engage students in physical activity

School policies or practices that provide opportunities for physical activity during the school day (i.e., physical activities for students such as recess and classroom breaks)

Large-scale environmental changes that provide or improve space, facilities, or equipment to make physical activity easy and appealing (e.g., renovating a school playground)

Interventions may also include one or more of the following:

Healthy food and beverage marketing strategies

Educational programs that address nutrition or build knowledge and skills needed to maintain physically active lifestyles

Addition of small-scale equipment to promote physical activity (e.g., jump ropes, balls, cones, team vests, pedometers)

Staff involvement

Family and community engagement

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

Promotional Materials

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What the CPSTF Found

About The Systematic Review

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.

Context

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.

Summary of Results

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.

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?)

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?

Study Characteristics

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).

Supporting Materials

Analytic Framework

Effectiveness Review

Analytic Framework [PDF - 97 kB]
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.

Summary Evidence Table

Effectiveness Review

Summary Evidence Table [PDF - 861 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).
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.

Search Strategies

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")

Review References

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.

Considerations for Implementation

Considerations for Implementation

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:

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

# data[].attributes.attachment_link.description
Snapshot The Community Preventive Services Task Force (CPSTF) finds insufficient evidence to determine the effectiveness of combining interventions that increase the availability of healthier snack foods and beverages sold or offered with physical activity interventions in schools. Evidence was inconsistent for dietary, physical activity, and weight-related outcomes.

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Children's physical activity and physical self-perceptions.: EBSCOhost