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Table 1 Studies examining the teaching strategies/approaches used to promote healthy eating to primary school students

From: Teaching approaches and strategies that promote healthy eating in primary school children: a systematic review and meta-analysis

Author, Year, Country, Funding agency Design, Dominant/Theory Framework* Sample Treatment Length Teaching Strategy/Approach Coupled with Physical Activity Coupled with Specially-resourced teachers Relevant Outcome Categories Statistical Significance (p value /95% CI) Effect Size (Cohen’s d )
M 1 - M 2/SDpooled
Randomised Controlled Trials
Francis et al. (2010) Trinidad & Tobago, Self-funded [40] RCT/NR 579 x Grade 6 students 32 weeks (Curriculum approach) Bloom’s mastery learning model X Children’s Eating Attitude Test-26 (M) <0.05 0.20
Mean age: 10.4 yrs Self Report
SLB consumption (Servings/wk) NS −0.42
Fried food consumption (Servings/day) 0.04 −0.21
HFSS food consumption (<502 kJ/day) NS −0.21
Quasi-experimental Trials
Auld et al. (1998) USA, Kraft Foods [43] QE/SCT, CDT 851 x Grades K-5 students 4 years Cross-curricular & experiential learning X FV Consumption (Plate waste) <.001 Insufficient data reported for calculation
Mean age: NR Self-efficacy (Likert scale)
- Food prep <.01
- Eating FV <.01
4th/5th Grade Knowledge (Test)
- Food Pyramid <.001
- Ingredients <.001
Bell & Lamb (1973) USA, Dairy Council Inc [44] QE/NR 1913 x Grade 5 students 6 weeks Popham Instruction Model (Define behavioural objectives, Diagnose student needs, Present learning opportunities, Evaluate attainment) X X Milk consumption (oz.) NS Insufficient data reported for calculation
Vegetable consumption (oz.) .05
Mean age: NR Nutrition knowledge (Test) .001
Edwards & Hermann (2011) USA, NR [45] QE/NR 11 x Grade 1 students 3 weeks Literary abstraction X X Legume taking (Number) .05 Insufficient data reported for calculation
Mean age: NR Legume tasting (Number) .14
Fahlman et al. (2008) USA, NR [46] QE/NR 576 x students 4 weeks (Curriculum approach) adapted Health Belief Model X 24 hr recall of Daily Dietary Intake
Mean age: 12.2 yrs - Grain consumption (Servings/day) NS −0.08
- Fruit consumption(Servings/day) .047 0.97
- Vegetable consumption (Servings/day) .018 0.49
- Dairy consumption (Servings/day) NS 0.02
- Meat consumption (Servings/day) NS −0.02
Self Efficacy (Likert scale)
- Eat more FV NS 1.11
- Eat less fat NS −0.15
- Drink less SLB NS −0.05
- Eat healthy at FF restaurants NS 1.30
Friel et al. (1999) Ireland, Dept of Health [47] QE/SLT 821 x Grades 3–4 students 10 weeks Cross-curricular X Food Pairing Questionnaire
Mean age: NR - Behaviour <.01 0.72
- Preference <.01 1.00
- Knowledge NS −0.29
Gortmaker et al. (1999) USA, Walton Family Foundation [48] QE/SCT BCT 336 x Grades 4–5 students 2 years Cross-curricular (Math, science, language, social studies, physical education) coupled with a Social Marketing Approach X 24 hr recall of Daily Dietary Intake   Insufficient data reported for calculation
Mean age: 9.1 yrs - Energy from fat (%) .04
- FV consumption (Servings/4184 kJ) .01
- Vitamin C (mg/4184 kJ) .01
Govula et al. (2007) USA, NR [30] QE/NR 33 x Grade 3 students 6 weeks (Curriculum approach) MyPyramid and Medicine Wheel Nutrition for Native Americans X X Block Kids Fruit/Vegetable recall
- F&V consumption (Servings/per day) .010 .10
Mean age: NR Culturally appropriate lessons - Fruit consumption (Servings/per day) .519 −0.26
- Vegetable consumption (Servings/per day) <.001 1.04
Knowledge Questionnaire (% correct) <.001 Insufficient data
Horne et al. (2004) UK, Horticultural Development Council, Fresh Produce Consortium, ASDA, Co-operative Group, Safeway, Sainsbury, Somerfield, Tesco, Bird’s Eye [31] QE/SLT 749 x Grades K-6 students 16 weeks Animation abstraction and contingent reinforcement for F&V consumption X X Consumption based on teacher visual estimates
Mean age: NR - 5-7 yr/old fruit (%) <.002 2.12
- 5-7 yr/old vegetable (%) NR 2.01
- 7-11 yr/old fruit (%) <.002 2.36
- 7-11 yr/old vegetable (%) NR 1.51
Liquori et al. (1998) USA, NR [49] QE/SCT 590 x Grades K-6 students 1 year Experiential learning (Cooking, environment and community garden) X Food intake based on teacher visual estimates (%) Grd K-3 Grd 4–6 Grd K-3 Grd 4-6
<.01 NS −1.90 −2.03
Mean age: NR Self report
- Preference for plant food <.001 <.001 2.51 0.00
- Attitudes NS NS 0.59 0.04
- Knowledge <.05 <.001 1.98 1.94
- Self efficacy in cooking NS <.05 0.79 0.70
- Food intentions <.01 NS 0.63 −0.17
- Paired food choice <.01 NS 1.58 −0.06
Manios et al. (2002), Greece, Kellogg’s, Greek Ministry of Sport, Greek Ministry of Education [50] QE/NR 1006 x Grade 1 students 6 years (Curriculum approach) Literary abstraction Parental reporting (Food Diary)
Age range: 5.5-6.5 yrs - Energy (kJ) <.05 −0.38
- Total fat (g) <.05 −0.38
- Protein (g) <.05 −0.42
- Carbohydrate (g) NS −0.23
McAleese & Rankin (2007), USA, NR [36] QE/NR 99 x Grade 6 students 12 weeks (Curriculum approach) Nutrition in the Garden X X 24 hr recall of Daily Dietary Intake
Mean age: 11.11 yrs Experiential learning (School garden) - Fruit (Servings/day) <.001 1.17
- Vegetables (Servings/day) <.001 0.92
- Vitamin A (μg/day) .004 0.20
- Vitamin C (mg/day) .016 0.49
- Fibre (g/day) .001 0.56
Morgan et al. (2010) Australia, Hunter Medical Research, Coles [51] QE/SCT 127 x Grades 5–6 students 10 weeks (Curriculum approach) Nutrition in the Garden – Modified X X FV knowledge (Gimme 5 Questionnaire) <.02 Insufficient data reported for calculation
Age range: 11-12 yrs Experiential learning (School garden) 24 hr recall of Daily Dietary Intake .22
- Vegetable intake (Servings/day) .23
- Fruit intake (Servings/day)
Simmons-Morton et al. (1991), USA, HHLBI Grant [52] QE/SCT 135 x Grades K-4 students) 40 weeks (Curriculum approach) Behaviour-based Health & Physical Education 24 hr recall of Daily Dietary Intake
Mean age: NR (Canteen) New School Lunch - Analysis of tray lunch (% kcals) <.05 −0.10
- Analysis of bag lunch (% kcals) <.05 0.03
Cluster-Controlled Trials
Agozzino et al. (2007), Italy, NR [53] CT/CogT 570 x students (30 x 4 & 5 grade classes) 40 weeks (Curriculum approach) Didactic-approach to health education X 24 hr recall of Daily Dietary Intake   Insufficient data reported for calculation
- Breakfast consumption (Sufficient) <.001
- Meat consumption (Sufficient) .003
- Fish consumption (Sufficient) .02
- Pulse consumption (Sufficient) .003
- Vegetable consumption (Sufficient) <.001
Amaro et al. (2005), Italy, Amici di Raoul Follereau (AIFO) [54] CT/NR 241 x students Mean age: 12.4 yrs 24 weeks Kalèdo Board Game (15-30mins play time p/w) X X Nutritional knowledge (31 items) <0.05 Insufficient data reported for calculation
BMI (z-score) NS
Anderson et al. (2005), UK, Food Standards Agency [55] CT/TPB 129 x Grades 1–6 students 36 weeks (Curriculum approach) based on experiential learning, video & literary abstraction X X Cognitive & attitudinal (Likert scale)
Mean age: 8.5 yrs Marketing and canteen provisions - Diet heart disease knowledge .001 0.24
- Preference for HFSS foods .034 −0.32
3-day food diary
- FV consumption (g) .617 0.07
- Energy (kJ) .327 0.00
- Sucrose (g) .578 0.01
Baronowski et al. (2000), USA, NR [32] CT/SCT 3347 x Grades 4–6 students 12 weeks (Curriculum approach) Gimme 5 X X 7-day food record
Mean age: NR Experiential learning, goal setting & problem solving, contingent reinforcement for F&V consumption - FV consumption (Servings) <.05 0.03
- Vegetable consumption(Servings) <.01 0.00
Questionnaire (Likert scale)
- Self efficacy (Eating FV) <.10 0.02
- Social norms <.10 0.00
- Asking behaviour <.05 0.06
- Knowledge <.05 0.05
Bere et al. (2006), Norway, Norwegian Research Council [56] CT/SCT 369 x Grade 6 students 28 weeks (Curriculum approach) National Curriculum X 24 hr recall of Daily Dietary Intake   Insufficient data reported for calculation
Mean age: 11.3 yrs Experiential learning (Cooking/Food Prep) - FV consumption (Servings per day) .41
Curriculum enjoyment (Likert scale) .004
Cooke (2011), UK, Medical Research Council National Prevention Research Initiative [57] CT/mixed 442 x Kindergarten students 2 weeks Contingent reinforcement for vegetable tasting X X Liking of vegetables (Likert scale) .001 Insufficient data reported for calculation
Mean age: 6 yrs Intake of vegetables .001
Day et al. (2008), Canada, NR [58] CT/NR 444 x Grades 4–5 students 12 weeks Integrates classroom learning, environmental change strategies, and a family/community component to promote the consumption of FV X X 24 hr recall of Daily Dietary Intake
Mean age: 10.0 yrs - Fruit consumption (Servings) <.05 −0.04
- Vegetable consumption (Servings) NS −0.05
- F V consumption (Servings) <.05 −0.06
- Variety of FV consumption (Servings) <.05 −0.01
Domel et al. (1993) USA, The International Apple Institute [59] CT/SCT 301 x Grades 4–5 students 6 weeks “5 a Day - for Better Health” X X 24 hr recall of Daily Dietary Intake
- F V consumption (Servings) NS 0.47
- Fruit consumption (Servings) .001 0.74
- Juice consumption (Servings) NS −0.14
- Vegetable consumption (Servings) .018 0.28
- Legume consumption (Servings) NS 0.45
Questionnaire (Likert scale)
- Fruit .046 0.35
- Vegetables NS 0.32
FV Knowledge (Multiple choice score) <.001 0.59
Duncan et al. (2011) New Zealand, Health Research Council NZ [60] CT/NR 97 x Grades 5–6 students 6 weeks Curriculum approach with “Healthy Homework” Teaching Resource X Food Diaries   Insufficient data reported for calculation
Mean age: NR Experiential learning (Cooking) - Fruit consumption (Servings/per day) NS
- Vegetable consumption (Servings/per day) .016
- Unhealthy food consumption (Servings per/day) .042
- Unhealthy drink consumption (Servings/per day) NS
Foster et al. (2008), USA, CDC, US Department of Agriculture/Food and Nutrition Service [61] CT/NR 1349 x Grades 4–6 students 2 years The School Nutrition Policy Initiative included the following components: school self-assessment, nutrition education, nutrition policy, social marketing, and parent outreach. Cross-curricular/Integrated learning X BMI (z score) .80 Insufficient data reported for calculation
Mean age: 11.2 yrs Total Energy (kJ/day) .12
Total Fat (g/day) .12
FV Consumption (Servings/per day) .82
Gorely et al. (2009) UK, Great Run, Coca-Cola Company [62] CT/SCT 589 x students 40 weeks (Curriculum approach) Physical education lessons and homework tasks X 24 hr recall of Daily Dietary Intake   Insufficient data reported for calculation
Mean age: 8.8 yrs Fun run event - FV Consumption (Servings/per day) NS
Knowledge of healthy lifestyle (MC Test) NS
Head (1974) USA, Emergency food and Medical Services [63] CT/NR 4,700 x Grades 5, 7 & 10 students 20 weeks Cross Curriculum approach in nutrition, reading, math, history, art, music and science X X Knowledge (% correct) <.05 Insufficient data reported for calculation
Mean age: NR School lunch (% of plate waste) <.05
Acceptance of school served food (%) NS
Hendy et al. (2011) USA, grants from Penn State University [64] CT/SCT 382 x Grades 1–4 students 12 weeks Kid’s Choice Program (KCP), contingent reinforcement supported by parental involvement. X Eating FV first in meals <.001 Insufficient data reported for calculation
SDT Choosing low fat and low sugar drinks <.001
Hoffman et al. (2010) USA, National Institute of Child Health and Human Development [65] CT/SLT 297 x Kindergarten & Grade 1 students 2 years Cross-Curricular program included school-wide, classroom, lunchroom, and family components X X Plate Waste Weight Year 1 Year 2 Year 1 Year 2
- Fruit intake(g) <.001 <.001 0.86 0.55 -
- Vegetable intake (g) <.01 NS 0.34  
James et al. (2005) UK, GlaxoSmithKline, Aventis, Pfizer, Florence Nightingale Foundation [33] CT/NR 644 x 2nd-6th Grade students 40 weeks (Curriculum approach) Reducing SLB consumption X 3-Day Consumption Diary
Mean age: 8.7 yrs Cross curricular approach in Health, Science, Music and Art - SLB Consumption (Servings) 0.02 0.83
Kipping (2010), UK, Department of Health [66] CT/SCT 393 x Grade 5 students 20 weeks (Curriculum approach) Eat Well Keep Moving program X 24 hr recall of Daily Dietary Intake   Insufficient data reported for calculation
BCT Mean age: 9.4 yrs - FV consumption (Servings/per day) NS
- Snack consumption (Servings/per day) NS
- HFF consumption (Servings/per day) NS
- SLB consumption (Servings/per day) NS
Kristjansdottir et al. (2010) Iceland, The University of Iceland, The Icelandic Centre for Research, Brim Seafood [67] CT/NR 171 x Grade 2 students 2 years (Curriculum approach) co developed with teachers and supported by homework, letters to parents and meetings with parents X X Food record by parents
Mean age: NR - FV consumption (g/day) <.001 0.93
- Fruit consumption (g/day) .001 0.62
- Vegetable consumption (g/day) <.001 1.35
Luepker et al. (1996) USA, National Heart, Lung, and Blood Institute [68] CT/NR 5106 x Grade 3 students 3 years (Curriculum Approach) (Child and Adolescent Trial for Cardiovascular Health-CATCH) X School Lunch Menu Analysis
Mean age: NR Enhanced PE and classroom health curricula. 28 additional schools received these components plus family education. - Total energy intake (MJ) <.001 0.02
24 hr recall of Daily Dietary Intake
- Total energy intake (MJ) .01 0.07
- Total energy from fat (%) .001 0.17
Health Behaviour Questionnaire
- Dietary knowledge <.001 0.25
Mangunkusumo et al. (2007) The Netherlands, Organisation for Health Research and Development [69] CT/NR 675 x 7th Grade students 12 weeks Internet-tailored advice followed by dietary counselling X 24 hr recall of Daily Dietary Intake   Insufficient data reported for calculation
Mean age: 10.3 yrs -Vegetable consumption (g/per day) NS
- Behavioural determinants NS
Muth (2008) USA, American Medical Association [70] CT/SCT 73 x 4th Grade students 12 weeks (Curriculum approach) (Improving Meals and Physical Activity in Children and Teens (IMPACT) X X Texas School Physical Activity and Nutrition Questionnaire (SPAN)   Insufficient data reported for calculation
Mean age: 9.9 yrs Train-the-trainer model with HS students trained to teach 4th graders - FV Consumption (Servings/per day) .05
- Nutritional knowledge (%) .01
Panunzio et al. (2007) Italy, NR [71] CT/NR 471 x 4th Grade students 36 weeks (Curriculum approach) Teachers vs Nutritionists X 24 hr recall of Daily Dietary Intake   Insufficient data reported for calculation
Mean age: 9.6 yrs - FV consumption (>1 serving p/day) <0.01
- Legume consumption (>1 serving p/day) <0.01
- Chips consumption (>1 serving p/day) <0.01
- SLB consumption (>1 serving p/day) <0.01
Parcel et al. (1989) USA, National Heart, Lung, and Blood Institute [72] CT/SLT 398 x K-4th Grade students 14 weeks (Curriculum approach) 3 concurrent programs: the New School Lunch, Children’s Active Physical Education (CAPE), and Go For Health classroom instruction. X Behavioural Capability Questionnaire
Mean age: NR - Diet behavioural capability (Score) <.01 0.89
- Diet self-efficacy (Score) NS 0.15
- Diet behavioural expectations (Score) <.01 0.73
Self-Reported Behaviour
- Salt use (Daily use) NS 0.00
- FV consumption (% of total intake) NS 0.13
Parmer (2009) USA, NR [73] CT/ELT 115 x 2nd Grade students 28 weeks (Curriculum approach) X X FV Survey (Likert Scale)
Mean age: 7.3 yrs Nutrition lessons + school garden - MyPyramid food groups NS 0.59
Experiential Learning (Gardening + Food Prep) - Nutrient–food association < .001 1.13
- Nutrient–job association < .001 0.99
- F V identification < .01 2.03
Researcher Observed Lunch Choices
- Vegetable choice (Servings) <.01 1.09
- Vegetable consumption (Servings) <.01 1.41
Perry et al. (1998) USA, National Cancer Institute [74] CT/SLT 441 x 4- 5th Grade students 40 weeks The 5-a-Day Power Plus Program X X Researcher Observed Lunch Choices   Insufficient data reported for calculation
Mean age: NR - behavioural curricula - FV consumption (Servings) <.001
- parental involvement/education - Vitamin A (μg) .02
- school food service changes - Vitamin C (mg) <.001
- industry involvement and support. 24 hr recall of Daily Dietary Intake  
- Fruit consumption (Servings) .02
- Total fat consumption (%/kcal) .02
- Calcium (mg) .04
Health Behaviour Questionnaire  
- Asking for F V (LIkert Scale) .03
- Servings of FV (Nominal Scale) <.001
- Knowledge of servings (Nominal Scale) <.001
Perry, Mulis et al. (1985), USA, NR [75] CT/SLT 371 x 3rd-4th Grade students 10 weeks (Curriculum approach) Hearty Heart and Friends program X X 24 hr recall of Daily Dietary Intake   Insufficient data reported for calculation
PBT Mean age: NR - Sugared cereal consumption (Less) <.05
- Green vegetable consumption <.02
- Fruit consumption <.01
- Fried food consumption (Less) <.005
- Added salt consumption (Less) <.05
Powers et al. (2005), USA. State Cooperative Extension System and State Department of Human Resources [76] CT/SCT 1100 x 2nd- 3rd Grade students 6 weeks Pizza Please Board Game with Nutrition education X Dietary Consumption Behaviour (Self report frequency) <.001 0.23
Mean age: 7.6 yrs - Dairy consumption .001 0.22
- FV consumption .016 0.15
Nutrition Knowledge (Item matching) <.001 0.77
- Food appropriate Food Guide Pyramid <.001 0.31
- Nutrient-food association <.001 0.54
- Nutrient-job association <.001 0.60
Quinn et al. (2003) USA, Kappa Omicron Nu, Food Bank of Central New York [77] CT/NR 126 x 5th Grade students 40 weeks Experiential learning (Cooking) Modified CookShop program. Taught in schools with the support of parents X X 24 hr recall of Daily Dietary Intake & Food Frequency Questionnaire (NCI)
- Dietary Fibre (mg) <.05 0.33
- Folate (mcg) <.05 0.16
- Fruit consumption (Servings) <.05 0.28
- Milk consumption (Servings) <.001 0.47
Resnicow et al. (1998) USA, National Heart, Lung and Blood Institute [78] CT/SCT 966 x 4th - 5th Grade students 6 weeks (Curriculum approach) Gimme-5 curriculum. X - FV preference (Likert scale) <.001 Insufficient data reported for calculation
Mean age: NR Teachers received the teacher wellness program involving 54 workshops over 2 yrs (in favour of control)
Reynolds et al. (2000) USA, National Cancer Institute Grant [79] CT/SCT 1698 x 4th Grade students 2 years High 5 intervention on FV consumption based around 3 interventions: classroom component, Parent component, Food Service component. X 24 hr recall of Daily Dietary Intake   Insufficient data reported for calculation
Mean age:8.7 yrs - Fruit consumption (Servings) <.001
- Vegetables consumption (Servings) <.001
- FV consumption (Servings) <.001
- Calories from fat (%) <.041
- Calories from carbohydrates (%) <.017
- Fibre (g) <.012
- Folate (μg) <.034
- β-Catotine (μg) <.034
- Vitamin C (mg) <.048
Sahota et al. (2001) UK, Northern and Yorkshire Region Research and Development Unit [80] CT/NR 636 x 4th-5th Grade students Mean age: 8.4 yrs 40 weeks Active programme promoting lifestyle in schools (APPLES program) X 24 hr recall of Daily Dietary Intake   Insufficient data reported for calculation
Multidisciplinary, multiagency programme designed to influence diet and physical activity - Vegetable consumption <.05
Cross Curricular whole school community including parents, teachers, and catering staff
Shannon & Chen (1988), USA, Pennsylvania State Department of Education [81] CT/NR 1707 x 3rd Grade students 3 years (Curriculum approach) Nutrition in a Changing World (K-12 program). X X Knowledge (Test scores) <.001 Insufficient data reported for calculation
Mean age:NR Food attitudes (Likert scale) <.001
Eating behaviours (24 hr recall) <.001
Smolak et al. (1998), USA, Ohio Dept of Education[82] CT/NR 253 x 5th Grade students 24 weeks (Curriculum approach) Eating Smart, Eating for Me X 24 hr recall of Daily Dietary Intake   Boys Girls
Mean age: NR - Vegetable consumption (Servings) NS   
(<.05 by sex) −0.31 0.24
Spiegel & Foulk (2006), USA, Institute for America’s Health [83] CT/TRA 1013 x 4th-5th Grade students 24 weeks Wellness, Academics & You (WAY) Program X BMI (kg/m2) 0.01 −0.38
Mean age: NR Cross-curricular – Language arts, mathematics, science & health education FV Consumption (Survey) NS -
Taylor et al. (2007), New Zealand, NR[34] CT/NR 730 x primary students 2 years APPLE Project - Community driven healthy eating & physical activity initiative. Three-day recall intakes
Cross curricular school-based science nutrition lessons, recess activities & GoTri card game - SLB consumption (Servings) 0.04 −0.21
- Juice consumption (Servings) 0.03 −0.24
- Water consumption (Servings) 0.07 0.24
- Fruit consumption (Servings) <0.01 0.32
BMI (z-score) <0.05 −0.49
te Velde et al. (2007), The Netherlands, Norway, Spain, Commission of European Communities (RTD) programme[84] CT/SCT 1472 x 5th-6th Grade students 52 weeks Pro-children intervention (Three countries) X 24 hr recall of Daily Dietary Intake
Mean age: 10.7 yrs - Curriculum approach (w/web based feedback tool) - FV consumption (g/d) All Countries <0.02 0.18
- Free FV provision in schools - FV consumption (g/d) Norway <0.05 0.37
- Family web based feedback tool - FV consumption (g/d) Spain <0.05 0.15
- FV consumption (g/d) The Netherlands <0.05 0.12
  1. TPB = Theory of Planned Behaviour; SCT = Social Cognitive Theory; CDT = Cognitive Development Theory; SLT = Social Learning Theory; BCT = Behavioural Choice Theory; CogT = Cognitive Theory; SDT = Self Determination Theory; GST = Group Socialization Theory; ELP = Experiential Learning Theory; PBT = Problem Behaviour Theory; TRA = Theory of Reasoned Action; RCT = Randomised controlled trial; QE = Quasi-experimental; CT = Cluster-controlled trial; NR = Not reported; NS = Not significant; FV = Fruit and vegetable; SLB = Sugar-laden beverages; HFSS = High fat, sugar & salt; HFF = High Fat Food; FF = Fast food, BMI = Body Mass Index.