The food environment has a significant influence on dietary choices, and interventions designed to modify the food environment could contribute to the prevention of childhood obesity. Many interventions have been implemented at the school level, but effectiveness in addressing childhood obesity remains unclear. We undertook a systematic review, a meta-analysis, and meta-regression analyses to assess the effectiveness of interventions on the food environment within and around schools to improve dietary intake and prevent childhood obesity. Estimates were pooled in a random-effects meta-analysis with stratification by anthropometric or dietary intake outcome. Risk of bias was formally assessed. One hundred papers were included. Interventions had a significant and meaningful effect on adiposity (body mass index [BMI] z score, standard mean difference: -0.12, 95% confidence interval: 0.15, 0.10) and fruit consumption (portions per day, standard mean difference: +0.19, 95% confidence interval: 0.16, 0.22) but not on vegetable intake. Risk of bias assessment indicated that n = 43 (81%) of non-randomized controlled studies presented a high risk of bias in the study design by not accounting for a control. Attrition bias (n = 34, 79%) and low protection of potential contamination (n = 41, 95%) presented the highest risk of bias for randomized controlled trials. Changes in the school food environment could improve children's dietary behavior and BMI, but policy actions are needed to improve surrounding school food environments to sustain healthy dietary intake and BMI.
CONTEXT: Healthy eating during childhood is important for optimal growth and helps reduce the risk of obesity, which has potentially serious health consequences. Changing the school food environment may offer one way to improve students' dietary intake. This manuscript reports 4 Community Guide systematic reviews examining the effectiveness of interventions in schools promoting healthy eating and weight.
EVIDENCE ACQUISITION: School obesity prevention programs aiming to improve diet were identified from a 2013 Agency for Health Care Research and Quality systematic review and an updated search (August 2012-January 4, 2017). In 2017-2018, Community Guide systematic review methods were used to assess effectiveness as determined by dietary behavior and weight changes.
EVIDENCE SYNTHESIS: Interventions improving school meals or offering fruits and vegetables (n=27 studies) are considered effective. Evidence is insufficient to determine the effectiveness of interventions supporting healthier snack foods and beverages outside of school meal programs given inconsistent findings (n=13 studies). Multicomponent interventions to increase availability of healthier foods and beverages are considered effective. These interventions must include 1 component from school meals or fruit and vegetable programs and interventions supporting healthier snack foods and beverages (n=12 studies). There is insufficient evidence to determine the effectiveness of interventions to increase water access because only 2 studies met inclusion criteria.
CONCLUSIONS: A total of 2 school-based dietary interventions have favorable effects for improving dietary habits and modest effects for improving or maintaining weight. More evidence is needed regarding interventions with insufficient findings. These reviews may inform researchers and school administrators about healthy eating and obesity prevention interventions.
Childhood obesity and associated modifiable risk factors exert significant burden on the health care system. The goal of this systematic review and meta-analysis was to examine the effectiveness of school-based intervention types perceived by Canadian stakeholders in health and education as feasible, acceptable and sustainable in terms of improving physical activity (PA), fruit and vegetable intake, and body weight. We searched multiple databases for studies that evaluated school-based interventions to prevent obesity and associated risk factors (i.e., unhealthy diet, physical inactivity, sedentary behaviour) in children aged 4-18 years from January 1, 2012 to January 28, 2020. From 10,871 identified records, we included 83 and 80 studies in our systematic review and meta-analysis, respectively. Comprehensive School Health (CSH) and interventions which focused on modifications to school nutrition policies showed statistically significant positive effects on fruit intake of 0.13 (95% CI: 0.04, 0.23) and 0.30 (95% CI: 0.1, 0.51) servings per day, respectively. No intervention types showed statistically significant effect on vegetable intake. CSH, modifications to physical education (PE) curriculum, and multicomponent interventions showed statistically significant difference in BMI of -0.26 (95% CI: -0.40, -0.12), -0.16 (95% CI: -0.3, -0.02), and -0.18 (95% CI: -0.29, -0.07), respectively. CSH interventions showed positive effect on step-count per day, but no other types of interventions showed significant effect on any of PA outcome measures. Thus, the results of this systematic review and meta-analysis suggest that decision-makers should carefully consider CSH, multicomponent interventions, modifications to PE curricula and school nutrition policies to prevent childhood obesity.
BACKGROUND: School food environment policies may be a critical tool to promote healthy diets in children, yet their effectiveness remains unclear.
OBJECTIVE: To systematically review and quantify the impact of school food environment policies on dietary habits, adiposity, and metabolic risk in children.
METHODS: We systematically searched online databases for randomized or quasi-experimental interventions assessing effects of school food environment policies on children's dietary habits, adiposity, or metabolic risk factors. Data were extracted independently and in duplicate, and pooled using inverse-variance random-effects meta-analysis. Habitual (within+outside school) dietary intakes were the primary outcome. Heterogeneity was explored using meta-regression and subgroup analysis. Funnel plots, Begg's and Egger's test evaluated potential publication bias.
RESULTS: From 6,636 abstracts, 91 interventions (55 in US/Canada, 36 in Europe/New Zealand) were included, on direct provision of healthful foods/beverages (N = 39 studies), competitive food/beverage standards (N = 29), and school meal standards (N = 39) (some interventions assessed multiple policies). Direct provision policies, which largely targeted fruits and vegetables, increased consumption of fruits by 0.27 servings/d (n = 15 estimates (95%CI: 0.17, 0.36)) and combined fruits and vegetables by 0.28 servings/d (n = 16 (0.17, 0.40)); with a slight impact on vegetables (n = 11; 0.04 (0.01, 0.08)), and no effects on total calories (n = 6; -56 kcal/d (-174, 62)). In interventions targeting water, habitual intake was unchanged (n = 3; 0.33 glasses/d (-0.27, 0.93)). Competitive food/beverage standards reduced sugar-sweetened beverage intake by 0.18 servings/d (n = 3 (-0.31, -0.05)); and unhealthy snacks by 0.17 servings/d (n = 2 (-0.22, -0.13)), without effects on total calories (n = 5; -79 kcal/d (-179, 21)). School meal standards (mainly lunch) increased fruit intake (n = 2; 0.76 servings/d (0.37, 1.16)) and reduced total fat (-1.49%energy; n = 6 (-2.42, -0.57)), saturated fat (n = 4; -0.93%energy (-1.15, -0.70)) and sodium (n = 4; -170 mg/d (-242, -98)); but not total calories (n = 8; -38 kcal/d (-137, 62)). In 17 studies evaluating adiposity, significant decreases were generally not identified; few studies assessed metabolic factors (blood lipids/glucose/pressure), with mixed findings. Significant sources of heterogeneity or publication bias were not identified.
CONCLUSIONS: Specific school food environment policies can improve targeted dietary behaviors; effects on adiposity and metabolic risk require further investigation. These findings inform ongoing policy discussions and debates on best practices to improve childhood dietary habits and health.
Physical inactivity, an unhealthy diet, smoking, and alcohol consumption are key determinants of morbidity and mortality. These health behaviours often begin at a young age and track into adulthood, emphasising a need for interventions in children and young people. Previous research has demonstrated the potential effectiveness of behavioural incentive (BI) interventions in adults. However, little is known about their effectiveness in children and adolescents. Eight bibliographic databases were searched. Eligibility criteria included controlled trials using behavioural incentives (rewards provided contingent on successful performance of the target behaviour) as an intervention component for health behaviour change in children and adolescents. Intervention effects (standardised mean differences or odds ratios) were calculated and pooled by health behaviour, using a random effects model. Twenty-two studies were included (of n = 8392 identified), 19 of which were eligible for meta-analysis: physical activity (n = 8); healthier eating (n = 3); and smoking (n = 8). There was strong evidence that behavioural incentives may encourage healthier eating behaviours, some evidence that behavioural incentives were effective for encouraging physical activity behaviour, and limited evidence to support the use of behavioural incentives for smoking cessation and prevention in adolescents. Findings suggest that behavioural incentives may encourage uptake and initiation of healthy eating and physical activity in young people. However, this is a limited evidence base and a wide range of incentive designs have yet to be explored. Future research should further investigate the acceptability of these intervention approaches for young people. (PsycInfo Database Record (c) 2021 APA, all rights reserved)
BACKGROUND: Effective strategies to improve dietary intake in young children are a priority to reduce the high prevalence of chronic non-communicable diseases in adulthood. This study aimed to assess the impact of family-based and school/preschool nutrition programs on the health of children aged 12 or younger, including the sustainability of these impacts and the relevance to socio-economic inequalities.
METHODS: A systematic review of literature published from 1980 to December 2014 was undertaken. Randomised controlled trials involving families with children aged up to 12 years in high income countries were included. The primary outcomes were dietary intake and health status. Results were presented in a narrative synthesis due to the heterogeneity of the interventions and outcomes.
RESULTS: The systematic search and assessment identified 39 eligible studies. 82% of these studies were set in school/preschools. Only one school study assessed the impact of involving parents systematically. The family-based programs which provided simple positive dietary advice to parents and regular follow-up reduced fat intake significantly. School and family-based studies, if designed and implemented well, increased F&V intake, particularly fruit. Effective school-based programs have incorporated role-models including peers, teachers and heroic figures, rewards and increased access to healthy foods. School nutrition programs in disadvantaged communities were as effective as programs in other communities.
CONCLUSIONS: Family and school nutrition programs can improve dietary intake, however evidence of the long-term sustainability of these impacts is limited. The modest overall impact of even these successful programs suggest complementary nutrition interventions are needed to build a supportive environment for healthy eating generally.
INTRODUCTION: Residents of rural communities in the United States are at higher risk for obesity than their urban and suburban counterparts. Policy and environmental-change strategies supporting healthier dietary intake can prevent obesity and promote health equity. Evidence in support of these strategies is based largely on urban and suburban studies; little is known about use of these strategies in rural communities. The purpose of this review was to synthesize available evidence on the adaptation, implementation, and effectiveness of policy and environmental obesity-prevention strategies in rural settings.
METHODS: The review was guided by a list of Centers for Disease Control and Prevention Recommended Community Strategies and Measurements to Prevent Obesity in the United States, commonly known as the "COCOMO" strategies. We searched PubMed, Cumulative Index of Nursing and Allied Health Literature, Public Affairs Information Service, and Cochrane databases for articles published from 2002 through 2013 that reported findings from research on nutrition-related policy and environmental strategies in rural communities in the United States and Canada. Two researchers independently abstracted data from each article, and resolved discrepancies by consensus.
RESULTS: Of the 663 articles retrieved, 33 met inclusion criteria. The interventions most commonly focused on increasing access to more nutritious foods and beverages or decreasing access to less nutritious options. Rural adaptations included accommodating distance to food sources, tailoring to local food cultures, and building community partnerships.
CONCLUSIONS: Findings from this literature review provide guidance on adapting and implementing policy and environmental strategies in rural communities.
Background: L'obesità è un importante problema di salute pubblica. Trovare il modo per aumentare l'attività fisica e migliorare la nutrizione, in particolare nei bambini, è una priorità chiara. La revisione Cochrane della Salute dell'Organizzazione Mondiale della Sanità scuole di promozione (HPS) quadro trovato questo approccio ha migliorato l'attività fisica degli studenti e fitness, e l'aumento di frutta e verdura. Tuttavia, c'era una notevole eterogeneità nella impatti riportati. Questo documento sintetizza i dati di processo di valutazione da questi studi per individuare i fattori che potrebbero spiegare questa variabilità. Metodi: Abbiamo cercato database 20 di salute, istruzione e delle scienze sociali, e prove registri e siti web pertinenti nel 2011 e il 2013. Sono stati applicati Nessuna lingua o la data di restrizioni. Sono stati inclusi studi randomizzati e controllati a grappolo. I partecipanti sono stati gli studenti della scuola di età compresa tra 4-18 anni. Gli studi sono stati inclusi se: ha preso un approccio HPS (targeting per curriculum, l'ambiente e la famiglia / comunità); focalizzata su attività fisica e / o nutrizionale; e dati di valutazione di processo presentati. Un approccio quadro è stato utilizzato per facilitare l'analisi tematica e la sintesi dei dati di processo. Risultati: Ventisei studi hanno soddisfatto i criteri di inclusione. La maggior parte sono stati condotti in America o in Europa, con i bambini di età compresa tra 12 anni o più giovani. Conclusioni: le alleanze più forti tra la salute e l'istruzione sembrano essenziali per il successo dell'intervento. I ricercatori devono lavorare con le scuole per sviluppare e attuare gli interventi, e di valutare il loro impatto sulla salute e risultati educativi come questo può essere un fattore determinante per la scalabilità. Se l'impegno della famiglia si tenta, modi migliori per raggiungere questo obiettivo è necessario sviluppare e valutati. Sono necessari ulteriori valutazioni degli interventi per promuovere l'attività fisica e l'alimentazione durante l'adolescenza. Infine, le valutazioni di processo devono andare oltre semplici misure di accettabilità / fedeltà a includere informazioni contestuali dettagliate per illuminare esattamente ciò che funziona, per chi, in quali contesti e perché.
