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Table 1 Characteristics of studies

From: Obesity prevention and the Health promoting Schools framework: essential components and barriers to success

Authors and programme name Characteristics HPS intervention elements Summary of results Process evaluation methods
Nutrition interventions
Bere et al. 2006 [22] Country: Curriculum: No difference between intervention and control groups for fruit and vegetable intake. Surveys to teachers, parents and students to assess participation and acceptability (assessed on likert scale).
Fruits and Vegetables Make the Mark Norway Curriculum was delivered in Home Economics lesson over a period of 7 months. Activities included preparing fruit/veg-based meals and snacks, taste testing, and monitoring of fruit and vegetable consumption over 3 days.
Target group: Environment:
11-12 years Schools encouraged to participate in the national fruit and vegetable subscription programme.
Duration: Family/community:
6 months Newsletters, parents meeting.
Evans et al. 2013 [23] Country: Curriculum: No difference between intervention and control groups for intake or portions of fruit and vegetable intake. Questionnaires to teachers, parents and students to assess implementation, participation and acceptability (assessed on likert scale).
Project Tomato UK Teachers were provided with twelve lesson plans.
Target group: Environment:
7-8 years School health committee to co-ordinate activities.
Duration: Family/community:
10 months Advice, newsletters and take-home activity bags.
Foster et al. 2008 [24] Country: Curriculum: Incidence of overweight was significantly lower for intervention than control students (7.5% vs. 14.9%, adjusted odds ratio: 0.67, 95% CI 0.47 to 0.96). Very minimal data provided on staff training and hours of nutrition education. No details on methods provided.
School Nutrition Policy Initiative USA 50 hours of food and nutrition education provided per year. The curriculum was integrated into various classroom subjects.
Target group: Environment:
9-12 years Nutrition Advisory Group set up. Changes made to food sold in schools to ensure they met nutritional standards. Other activities included: limiting use of food as a reward, promoting active recess and providing healthy breakfasts.
Duration: Family/community:
2 years Report card nights, parent education meetings, and weekly nutrition workshops.
Hoffman et al. 2010 [25] Country: Curriculum: By end of year 2, intervention group consumed more fruit (but not vegetables) than the control group (34g vs. 23g, p<0.001). Questionnaires to teachers, lunch aides and students to assess acceptability using 6-point likert scale. Unannounced fidelity checks and observations of lunchtime components. Log book of public service announcements kept.
Athletes in Service, Fruit and Vegetable Promotion Program USA The classroom component included the 5-A-Day Adventures CD-ROM.
Target group: Environment:
5-7 years Loudspeaker announcements and posters to promote fruit/veg. Lunch aides praised children eating fruit and vegetables and offered stickers.
Duration: Family/community
2.5 years Family homework assignments. Parents involved in creating a school cookbook.
Hoppu et al. 2010 [26] Country: Curriculum: No difference between intervention and control group for fruit/veg consumption. Teachers, catering staff and students asked to give their opinions on the intervention (no further details provided on methods or questions asked). Teachers reported use of intervention materials using on-line system.
(no name) Finland Nutrition education was implemented by teachers during regular lessons.
Target group: Environment:
13-14 years Sugary snacks restricted and healthy alternatives encouraged. Drama workshops held.
Duration: Family/community:
8 months Parent information meeting. Healthy eating magazine.
Lytle et al. 2004 [27] Country: Curriculum: No significant differences between intervention and control groups for fruit and vegetable intake. Lesson checklists and observations of classroom sessions. Teacher and student evaluations of curriculum acceptability assed via likert scale. Documentation of family participation via number of behavioural coupons returned and family homework assignments completed. Visits to food service teams. Logs of school nutrition advisory councils.
TEENS USA Ten nutrition education lessons were implemented in both grade 7 and 8. These sessions involved self-monitoring, goal setting, hands-on snack preparation, and skill development.
Target group: Environment:
12-14 years Changes made to school food service to improve nutritional quality of food. School Nutrition Advisory Councils created.
Duration: Family/community:
2 years Newsletters and behavioural coupons.
Nicklas et al. 1998 [28,29] Country: Curriculum: No significant differences between intervention and control groups for fruit and vegetable intake. Observations and evaluation forms for training workshops. Logbooks document family involvement via newsletters/calendar distribution and attendance at parent-teacher meetings. Menu documentation, salad bar assessments and food use surveys. Monthly rates of participation in school lunches recorded.
Gimme 5 USA Five (55 minute) themed workshops provided students with learning opportunities to develop knowledge, positive attitudes and skills necessary to increase fruit and vegetable consumption.
Target group: Environment:
14-15 years School-wide media marketing campaign was implemented including taste testing, posters, public service announcements and student contests. School meals modified to increase fruit and veg provision. Staff training.
Duration: Family/community:
3 years Parents’ brochures, newsletters and a seasonal food calendar. Events held at Parent-Teacher Organization meetings.
Perry et al. 1998 [30,31] Country: Curriculum: Intervention students consumed more servings of fruit (per 100 kcals, difference 0.41, P=0.02) and combined fruit and vegetable servings (per 100 kcals, difference 0.36, P=0.02) and less fat (as % of total kcal, difference −1.81, P=0.02). Training participation rates and feedback from participants. Observations of classroom activities and lunchtimes.
5 A DAY Power Plus USA Sixteen 40–45 minutes classroom sessions were implemented twice a week for 8 weeks. Sessions included skills-building, problem-solving and taste-testing.
Target group: Environment:
9-11 years Changes made to school food provision. Catering staff training. Students were rewarded for eating fruits and vegetables during lunch.
Duration: Family/community:
6 months Home information/activity packs were sent home.
Radcliffe et al. 2005 [32] Country: Curriculum: No significant difference between intervention and control groups for % students skipping breakfast. No details on methods but table provided number of schools implementing each intervention component.
(no name) Australia Variety of changes to the curriculum including: classes focusing on health, nutrition and breakfast; a unit on body image and healthy eating; breakfast information provided to teachers; development of breakfast recipe books and trailing of recipes etc.
Target group: Environment:
12-13 years Working group developed action plans. Variety of activities including: events to promote breakfast; designating a breakfast eating area; change to timetable to enable earlier morning snack times; trialling breakfast tuck shops; improving nutritional quality of breakfast foods sold at the tuckshop.
Duration: Family/community:
11 months Variety of activities including: newsletter; parent education forums; involving parents in classroom activities and special events etc.
Reynolds et al. 2000 [33,34] Country: Curriculum: Intervention children consumed significantly more fruit and vegetables than the control group (3.96 servings vs. 2.28, P<0.0001). Questionnaire to curriculum co-ordinators to assess acceptability (on 5-point likert scale). Classroom observations and checklists. Cafeteria observations. Interviews with food service managers. Assessments of family involvement through checklists, assessments of homework completion and telephone parent surveys.
High 5 USA Nutrition curriculum (14 lessons) d included modelling, self-monitoring, problem-solving, reinforcement, taste testing and other methods.
Target group: Environment:
9-10 years Food service managers training. Cafeteria was rated on a monthly basis and given 2, 3 or 4stars based on their completion of 10 intervention activities.
Duration: Family/community:
1 year Parents’ ‘kick-off’ night. Family homework assignments.
Te Velde et al. 2008 [35,36] Country: Curriculum: At first follow-up intervention children reported greater intake of fruit and vegetables compared to controls. However, by second follow-up (one year later) a significant effect was only seen in one country (Norway, 91.5 additional grams per day, 95% CI 49.8 to 133.2, p=0.04). Teacher questionnaire used to assess fidelity (composite score created ranging from 0–16). Student survey to assess acceptability on 3-point likert scale for different intervention elements. Assessments of family involvement via completion of family homework assignments, use of intervention’s computer programme, and receipt of newsletters.
Pro Children Study Netherlands, Norway, Spain 16 worksheets aimed at increasing knowledge, awareness and skills. Included taste testing activities and computerised tailored feedback.
Target group: Environment:
10-12 years Free fruit/veg provided, Changes to school food provision to increase amount of fruit/veg available.
Duration: Family/community:
2 years Family homework assignments, newsletters and a parent version of the web-based computer-tailored tool.
Physical activity interventions
Eather et al. 2013 [37] Country: Home activity programme comprised of 20 minutes physical activity, three times a week for 8 weeks. Work booklets, information and fitness challenges sent to parents. Significant improvements in intervention group found for: fitness (adjusted mean difference, 1.14 levels, p < 0.001), BMI (mean, − 0.96 kg/m2, p < 0.001) zBMI z-score mean − 0.47 z-scores, p < 0.001), flexibility (sit and reach mean, 1.52 cm, p = 0.0013), muscular fitness (sit-ups) (mean 0.62 stages, p = 0.003) and physical activity (mean, 3253 steps/day, p < 0.001). Questionnaires to teachers and students to assess participation and satisfaction on six-point likert scale.
Fit-4-Fun Australia
Target group:
10-12 years
Duration:
8 weeks
Kriemler et al. 2010 [38] Country: Curriculum: Intervention children showed improvements in skinfold thickness (−0.12, 95% CI −0.21 to −0.03), fitness (0.17, 95% CI 0.01 to 0.32), school MVPA (1.19, 95% CI 0.78 to 1.6) and all-day MVPA (0.44, 95% CI 0.05 to 0.82) and total physical activity in school (0.92, 95% CI 0.35 to 1.5). Questionnaires to teachers and students to assess acceptability on 6-point likert scale.
KISS Switzerland Two additional PE lessons a week were implemented by specialist PE teachers.
Target group: Environment:
6-7, 10–11 years Several short activity breaks (2–5 minutes) were introduced during academic lesson every day.
Duration: Family/community:
11 months Flyers on health topics were sent to parents
Simon et al. 2006 [39] Country: Curriculum: Intervention students had a lower increase in BMI (p<0.01) and age/gender-adjusted BMI (p<0.02). They also had increased participation in supervised physical activity (p<0.001), a decrease in TV/video viewing (p<0.01) and an increase in high-density cholesterol concentrations (p<0.001). Quantitative documentation of number of activities provided and individual attendance at sessions. Number of school hours devoted to curriculum and school debates. Actions initiated by or in collaboration with outside partners were recorded.
ICAPS France Curriculum focused on physical activity and sedentary behaviours. Aimed to transmit knowledge and skills about physical activity.
Target group: Environment:
11-12 years Increased opportunities for physical activity offered at breaks, at lunchtimes and after school.
Duration: Family/community:
4 years Parents and teacher meetings. Policy makers of local communities were requested to provide a supportive environment that promote physical activity. For example, free/low-cost entry to sports facilities.
Wen et al. 2008 [40,41] Country: Curriculum: No difference between intervention and control students reporting walking to school. Semi-structured qualitative interviews with principals and/or teaching co-ordinators to assess fidelity and acceptability.
(no name) Australia Home to school mapping exercise’ used to help students plan their active journey to high school next year. Some schools also used pedometers and an associated classroom program.
Target group: Environment:
9-11 years A consultation group comprised of teachers, parents and officers from local councils set up to encourage active commuting. Banners provided for schools. Walk Safely to School Day activities held.
Duration: Family/community:
2 years Information on active travel provided to parent. Parent events and walks. Newsletters. Local councils reviewed safety and walkability of nearby participating schools and worked to make improvements.
Physical Activity + Nutrition Interventions
Brandstetter et al. 2012 [42] Country: Curriculum: No effect found on BMI, waist circumference and skin-fold thickness after adjustment for time lag between baseline and follow-up. Questionnaire to teachers to assess fidelity (teachers asked to indicate which teaching units has been used in class).
URMEL ICE Germany 29 units (each 30–60 minutes) implemented over one school year. Focused on reducing the amount of sugary drinks consumed and screen time, and increasing physical activity.
Target group: Environment:
7-8 years Two short blocks of physical activity exercises (each 5–7 minutes) were implemented every day. Teachers training.
Duration: Family/community:
9 months Family homework assignments and training and information materials.
Caballero et al. 2003 [43-45] Country: Curriculum: No difference between intervention and control for BMI or other anthropometric measures or physical activity levels. Intervention students reported lower total daily energy intake (1892 vs. 2157 kcal/d, p=0.003) and percentage of energy from fat (31.1% vs. 33.6%, p=0.001) than control students. Quantitative assessments of the four main components of the intervention, including attendance log for training sessions and family events, PE calendars, kitchen visits and parent/student evaluation forms.
Pathways USA Classroom curriculum designed to physical activity and nutrition. In 3rd and 4th grades, two 45-minute lessons delivered for 12 weeks. In 5th grade this decreased to 8 weeks.
Target group: Environment:
89 years School food service guidelines issues to decrease fat content of meals. Minimum of three 30-minute sessions of MVPA per week. Exercise breaks to promote physical activity in the classroom. Teacher training.
Duration: Family/community:
3 years Family action packs. Family events, included cooking demonstrations.
Crespo et al. 2012 [46] Country: Curriculum: No difference between intervention and control groups for BMI. Direct observations and audit tools used to assess fidelity of intervention components (no further details provided).
Aventuras para Niños USA SPARK physical activity curriculum implemented.
Target group: Environment:
5-8 years Improvements were made to school playgrounds and salad bars. Physical activity equipment provided. Posters. Student newsletters.
Duration: Family/community:
5 semesters Improvements made to community parks. Local restaurants asked to create healthy children’s menus. Frequent produce buyers cards distributed.
Foster et al. 2010 [47,48] Country: Curriculum: No difference between intervention and control groups for combined prevalence of overweight/obesity. However, intervention students had greater reductions in zBMI, waist circumference above 90th percentile, fasting insulin levels and prevalence of obesity (p<0.04 for all). Structured observations of PE lessons, curriculum components, school cafeterias and media campaigns. Qualitative interviews with key staff (e.g. physical activity co-ordinators).
HEALTHY USA A classroom based curriculum (FLASH - Fun Learning Activities for Student Health) targeting self-awareness, knowledge, behavioural skills and peer involvement for behavioural change.
Target group: Environment:
11-14 years Changes made to school meals to improve nutritional quality. Changes made to PE lessons to increase the amount of time spent in MVPA.
Duration: Family/community:
3 years Family outreach newsletters and take-home packs.
Grydeland et al. 2013 [49] Country: Curriculum: No overall effect found for impact on BMI, but positive intervention effects were found for BMI (p=0.02) and zBMI girls (p=0.003) but not boys. Unpublished process data mentioned in discussion of paper. Log books and questionnaires with teachers, parents and children.
Health in Adolescents (HEIA) Norway Five class-room sessions on nutrition and physical activity were delivered by teachers to students during the 6th grade.
Target group: Environment:
11-12 years Short (10 minute) physical activity breaks and fruit/veg breaks held once a week during lessons. Sports equipment was provided. Active commuting campaigners. Pedometers given out. PE teacher training.
Duration: Family/community:
20 months Parent fact sheets. Family homework assignments.
Haerens et al. 2006 [50] Country: Curriculum: Overall, no significant effect on BMI was found, although a positive effect was seen for girls (p<0.05). Teacher questionnaire to assess level of implementation assessed on a 5-point scale.
(no name) Belgium Computer-tailored intervention to promote physical activity and healthy eating with personalised feedback.
Target group: Environment:
12-14 years Extra opportunities to be physically activities during breaks, at lunchtime and after school. School health workgroups.
Duration: Family/community:
2 years Parent meetings, information leaflets and CD-rom provides.
Luepker et al. 1996 [51] Country: Curriculum: Intervention students reported more daily vigorous activity than controls (59 vs. 47 minutes, p<0.003) and greater reductions in daily energy intake from fat (2.4% vs. 0.4% reductions, p<0.001). Questionnaires to assess acceptability, attendance and feedback from training sessions, checklists and documentation logs for intervention activities, structured observations of intervention activities.
CATCH USA Classroom curricula implemented in grades 3–5 for between 5 and 12 weeks (depending on grade). Each lesson was 30–40 minutes. The curricula targeted psychosocial factors and skills development.
Target group: Environment:
8-9 years Changes made to school meals to improve nutritional content. Catering staff training. Changes to PE lessons to increase time spent in MVPA. Teacher training.
Duration: Family/community:
3 years Activity packs were sent home to be completed by students and parents together. Family fun nights.
Sahota et al. 2001 [52,53] Country: Curriculum: No difference between intervention and control group for overweight/obesity. Intervention children consumed more vegetables than control group (weighted mean difference: 0.3, 95%CI 0.2 to 0.4). Teacher surveys (no further details provided). Meals monitored by collection of monthly menus, observations and discussions with staff.
APPLES UK Nutrition education incorporated into the curriculum, healthy eating lessons delivered by the project dietician and ‘Fit is Fun’ programme incorporated into physical education lessons.
Target group: Environment:
9-11 years Teacher training, modification of school meals and the development of school action plans designed to promote healthy eating and physical activity.
Duration: Family/community:
10 months Consultation with parents about what the intervention should include. Parents were invited to help run sessions. Information on intervention sent out to parents.
Sallis et al. 2003 [54] Country: Curriculum: Total physical activity levels improved in the intervention group compared to controls (d=0.93, p<0.009). Subgroup analyses revealed the intervention to only be effective for boys. BMI was reduced in boys in the intervention group (d-0.83, P=0.04). No effect seen for total fat or saturated fat. Discussion section of paper describes problems encountered but no detail provided on how these data were collected.
M-SPAN USA Changes to PE lesson context, structure and teacher behaviour to increase physical activity.
Target group: Environment:
11-14 years Physical activity was promoted throughout the school day (e.g. during breaks and lunchtimes). School policies to support physical activity and healthy eating implemented. Changes made to the nutritional quality of food offered in schools. Student health committees set up to implement monthly health-related activities.
Duration: Family/community:
2 years Intervention was promoted to parents via articles in the school newsletter, posters and brochures at open houses and presentations to Parent Teacher Association meetings.
Trevino et al. 2004 [55,56] Country: Curriculum: Fitness scores (p=0.04) and dietary fibre intake (p=0.09) increased significantly in intervention children compared to controls. Focus groups conducted to explore barriers to family involvement. No details provided for methods for assessing fidelity/intensity.
Bienestar USA 50 × 45 minute health education sessions throughout the intervention. Curriculum focuses on nutrition, physical activity, self-esteem, self-control, and diabetes mellitus.
Target group: Environment:
9-10 years School food service staff receive nutritional training. Bienestar health club held once a week after school.
Duration: Family/community:
5 months Variety of parent ‘fun’ activities are held including: cooking demonstrations, salsa classes and games. Parent meetings.
Williamson et al. 2012 Country: Curriculum: No differences between intervention and control students for body fat and BMI z-scores. Questionnaires and observations used to assess integrity of delivery (No further details provided). Tracking system used to monitor usage of internet component
Louisiana (LA) HEALTH [57,58] USA Weekly classroom lessons (20–25 mins) on healthy eating and exercise implemented by teachers, as well as additional internet lessons.
Target group: Environment:
9-12 years Health promotion campaigns carried out in classrooms, hallways and other locations within the school. Modifications to school food provision to increase healthy options. Catering staff training. Vending machines provide healthy options. Regular 5 minute activity breaks in classrooms. Physical activity equipment.
Duration: Family/community:
2.5 years Bi-monthly newsletters sent home to parents. Family homework assignments. Healthy menus sent to parents.
  1. Abbreviations used in table: BMI (Body Mass Index), zBMI (Body Mass Index, standardized by age and gender), MVPA (moderate-to-vigorous physical activity), PE (Physical Education), CI (confidence interval).