Impact of multi-component school food environment interventions on adiposity and food consumption in children and adolescents: systematic review and meta-analysis

Vilela, Luisa Arantes; Duarte, Camila Kümmel; Rocha, Luana Lara; Carvalho, Brenda da Cunha; Carmo, Ariene Silva do; Gratão, Lúcia Helena Almeida; Silva, Thales Philipe Rodrigues da; Pessoa, Milene Cristine; Mendes, Larissa Loures

doi:10.1590/0102-311XEN152824

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REVIEW • Cad. Saúde Pública 41 (11) • 2025 • https://doi.org/10.1590/0102-311XEN152824 linkcopy

Impact of multi-component school food environment interventions on adiposity and food consumption in children and adolescents: systematic review and meta-analysis

Impacto de intervenções multicomponentes no ambiente alimentar escolar na adiposidade e no consumo alimentar de crianças e adolescentes: revisão sistemática e metanálise

Impacto de las intervenciones multicomponentes en el entorno alimentario escolar sobre la adiposidad y el consumo de alimentos en niños y adolescentes: revisión sistemática y metaanálisis

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstracts

Childhood overweight and obesity are growing public health concerns, leading to metabolic consequences such as increased body mass index, larger waist circumference, and excess body fat. Multi-component school interventions that address both the obesogenic environment and individual behaviors have been recommended, but their effectiveness remains uncertain. This review and meta-analysis, conducted following PRISMA guidelines, examined the impact of multi-component interventions - including modifications to the school food environment - on adiposity and food consumption among children and adolescents. A search on MEDLINE, SciELO, CENTRAL, Clinical Trials, Scopus, Embase, and Web of Science identified 51 eligible studies. The meta-analysis showed a small but significant reduction in waist circumference (MD: -0.70cm; 95%CI: -1.22, -0.19; I² = 40%). Interventions were also linked to lower intake of unhealthy foods, total energy, total fat, saturated fat, and increased vegetable consumption. However, no consistent effects were observed for body mass index or body fat percentage. Study quality varied, and intervention designs and implementation strategies were heterogeneous; thus, results should be interpreted cautiously. These findings suggest that while school food environment interventions can improve some dietary behaviors and adiposity indicators, their effectiveness in preventing obesity remains inconclusive. Strengthening policies and ensuring long-term, structured interventions are crucial for meaningful and sustained health improvements in school settings.

Keywords:
School Feeding; School Health Services; Nutrition Policy; Nutrition Programs; Noncommunicable Diseases

Country/Year (study)	Study design/ Intervention duration	Sample: schools (n)/students (n total/CG/IG) */age range	Intervention components		Main results **
Country/Year (study)	Study design/ Intervention duration	Sample: schools (n)/students (n total/CG/IG) */age range	Environmental	Individual
Argentina/2013 (Herscovici et al. ³¹)	cRCT 6 months	6 405 (171/234) 9-11 years	- Offering healthier foods	- Workshops about healthy eating habits and physical activity with students - Health-focused workshops with parents at school	Compared to CG: - boys and girls: ↓ consumption of hamburgers and hot dogs - girls: ↑ consumption of skim milk and orange juice
Australia/2014 (Chellappah et al. ³²)	cRCT 8 weeks	4 271 (137/134) 9-10 years	- Offering fruits every day during break - Encouraging students to eat fruits in class before break	- Did not include this component	Compared to baseline: - ↓ WC Compared to CG: - ↑ vegetable and fruit intake
Australia/2021 (Ooi et al. ³³)	cRCT 6 months	6 862 (389/473) 12-15 years	- Decreasing accessibility and appeal of SSB - Changing the regular curriculum - Installing water fountains - Peer-led school challenge designed and led by a student committee	- Lessons about SSB consumption with students - Sending health messages (push notifications) to students and parents - Sending newsletter snippets to parents	No significant differences
Belgium/2006 (Haerens et al. ³⁴)	cRCT 2 years	15 2,991 (759/2,232 ***) 11-15 years	Group 1 + Group 2: - Offering fruit at very low prices or free of charge at least once a week - Offering water at a lower price than soft drinks or for free - Offering fruit as a dessert during lunch break - Hanging health-related folders and posters - Providing free water cans - Increasing the amount of time students spend in moderate-to-vigorous physical activity - Promoting physical activity during the school day and after school - Receiving box with sports materials (ropes, Frisbees, etc.)	Group 1 + Group 2: - Encouraging teachers to organize extra support activities (healthy food) - Getting personalized feedback regarding physical activity and healthy eating for students Only Group 1: - Sending communications and activities and involving parents in interactive meetings	At 2 years follow-up, compared Group 1 to CG: - girls: lower increase in BMI and BMI (z-score) At 2 years follow-up, compared Group 1 to Group 2: - girls: lower increase in BMI (z-score)
Chile/2004 (Kain et al. ³⁵)	cRCT 6 months	5 3,086 (945/2,141) 6-10 years	- Changing the regular curriculum - Training school canteen staff (including owners) - Providing extra physical activity time for students - Providing sports equipment	- Lessons about healthy eating and physical activity - Healthy snacks contest (stickers and prize) - Training sessions with teachers - Involving parents in meetings	Compared to baseline: - boys: ↓ BMI (z-score), WC
China/2014 and 2015 (Xu et al. ³⁶^,³⁷)	cRCT 8 months	8 1,182 (544/638) 10 years	- Changing the regular curriculum - Hanging health-related messages and posters (school canteen, classroom, gymnasium, and playground) - Promoting fun events	- Lessons about healthy eating habits and physical activity with students - Training sessions with teachers - Involving parents in health classes at school	Compared to CG: - ↓ consumption frequency of red meat, fried snacks and soft drinks - ↑ consumption frequency of vegetables - IG was more likely to achieve a 0.5kg BMI reduction
China/2015 (Cao et al. ³⁸)	cRCT 2 years + 9 months	14 1,854 (889/965) 6-7 years	- Offering more fruits and vegetables in the school canteen - Reducing the fat content of food - Disseminating obesity-related health information (blackboard newspaper, morning meeting, and class meeting) - Increasing the amount of time students spend in physical activity - Providing a strip of skipping rope to students (physical activity at home)	- Lessons about health education (theme class meetings or seminars, brochures) to students and parents - Training sessions with teachers - Sending communications and activities to parents	At 3 years follow-up, compared to CG: - ↓ odds of developing obesity or overweight - ↓ BMI (z-score) (especially for overweight and obese students)
China/2019 (Liu et al. ³⁹)	cRCT 1 year	12 1,889 (959/930) 7-11 years	- Changing rules regarding selling unhealthy foods - Not allowing SSB, unhealthy snacks, and electronic products (smartphones and tablets) in school - Providing practical suggestions to improve children’s dietary intake - Changing the regular curriculum - Hanging posters about health education knowledge - Increasing the amount of time students spend in moderate-to-vigorous physical activity - Providing sports equipment (rope jumping and shuttlecock kicking)	- Lessons about behavioral knowledge, skills, healthy eating habits, childhood obesity prevention, and physical activity with students - Training sessions with teachers - Encouraging extracurricular activities at home - Involving parents in extracurricular physical activity and discussions about intervention approaches	At 12 months follow-up, compared to CG: - ↓ percentage of children consuming SSB/day
China/2019 (Li et al. ⁴⁰)	cRCT 1 year	40 1,641 (809/832) 6-7 years	- Providing vegetables every day - Reducing the fat, sugar, and salt content of school meals - Offering smaller portion sizes - Testing school lunch improvement goals (school staff and commercial suppliers) - Creating a committee (physical activity levels) - Challenge of healthy behaviors (students, parents, teachers) - Increasing the amount of physical activity	- Lessons and workshops about healthy eating and an active lifestyle with students - Handing out program handbooks (intervention activities) to school’s principals and class teachers - Promoting fun and active family games - Involving parents in workshops (with educational leaflets)	Compared to CG: - ↓ BMI z-score, WC - ↑ consuming at least five daily portions of fruit and vegetables - ↓ weekly consumption of SSB and unhealthy snacks
Ecuador/2017 (Ochoa-Avilés et al. ⁴¹)	cRCT 2 years + 4 months	20 1,430 (728/702) 12-14 years	- Changing the regular curriculum - Training school staff (recipes, leaflets, workshops)	- Lessons and workshops about healthy eating habits (booklets, games, didactic material) with students - Preparation of a healthy breakfast with students - Involving parents in workshops at school (booklets)	Compared to baseline: - ↓ WC - ↓ unhealthy snacks, added sugar, daily fruit and vegetables intake (decreased in both groups, but lower in IG)
England/2001 (Sahota et al. ⁴²)	cRCT 1 year	10 613 (312/301) 7-11 years	- Offering healthier foods - Changing the regular curriculum - Additional sessions supplied by the project manager	- Lessons about healthy eating habits and physical activity with students - Training sessions with teachers	Compared to baseline: - ↑ vegetable intake among all children - ↓ fruit intake among obese children - ↑ consumption of high-sugar foods and drinks among overweight children
Fiji/2011 (Kremer et al. ⁴³)	QE 2 years	18 7,237 (4,567/2,670) 13-18 years	- Offering healthier meals - Training school canteen staff (offering breakfast, opening earlier) - Changing the regular curriculum - Changing school policies for a healthy canteen (guidelines) - Building school gardens - Hanging posters and distributing pamphlets about healthy snacks - Promoting events, assembly (healthy eating habits) with students - Promoting physical activity during the school day - Providing sports equipment (hoops, ropes) and water bottles	- Lessons about healthy eating habits with students and parents - Training on vegetable garden, pot plant technology, healthy meal preparation - Training sessions with teachers - Sending communications (newsletter, school website) and activities to parents	Compared to CG: - ↓ %BF - ↑ vegetable intake (at school)
German/2009 (Muckelbauer et al. ⁴⁴^,⁴⁵)	cRCT 10 months	33 3,190 (1,469/1,721) 7-8 years	- Providing water bottles for children - Installing water fountains provided cooled, filtered, plain, or optionally carbonated water	- Lessons about the importance of water for the body and the water circuit in nature with students - Training sessions with teachers	Compared to CG: - ↓ risk of overweight - ↑ water consumption
India/2010 (Singhal et al. ⁴⁶)	cRCT 6 months	2 201 (102/99) 15-17 years	- Offering healthier foods - Stopping the sale of unhealthy foods - Promoting physical activity during the school day and after school	- Lessons about healthy eating habits with students - Conducting a health camp with teachers and parents (nutritional counseling) - Counseling by phone for parents - Individual counseling by nutritionist	Compared to CG: - ↓ WC - ↓ proportion of children consumed aerated drinks, unhealthy foods (burger/pizza/French fries/noodles) - ↑ proportion of children brought tiffin (packed lunch) and brought a fruit in their tiffin
India/2011 (Singhal et al. ⁴⁷)	cRCT 6 months	2 134 (57/77) 15-17 years	- Offering healthier foods - Stopping the sale of unhealthy foods - Promoting physical activity during the school day and after school	- Lessons about healthy eating habits with students - Conducting a health camp with teachers and parents (nutritional counseling) - Counseling by phone for parents - Individual counseling with children held by a nutritionist	Compared to CG: - ↓ WC
Indonesia/2022 (Kurniawan et al. ⁴⁸)	QE 5 months	2 350 (196/164) 9-11 years	- Training canteen staff - Training students’ peer leader club	- Lessons about eating habits and physical activity with students - Promoting healthy home food weekly to be eaten together at school during recess - Training sessions with teachers - Involving parents in seminars (health promotion) - Sending communications (leaflets) to parents	Compared to baseline: ↑ BMI (both groups, but higher in CG) Compared to CG: - ↑ eating fruits and vegetables behavior
Iran/2016 (Amini et al. ⁴⁹)	cRCT 18 weeks	12 334 ^# (167/167) 10-12 years	- Offering healthier foods - Stopping the sale of unhealthy foods - Increasing the amount of physical activity	- Lessons about healthy eating habits with students - Involving parents in health classes at school	Compared to CG: - ↓ BMI (z-score) Compared to baseline: - ↑ WC (both groups, but higher in CG) - ↑ energy, fat intake
Italia/2016 (Ermetici et al. ⁵⁰)	QE 2 years	6 487 (225/262) 11-15 years	- Replacing unhealthy foods with healthy foods and beverages in vending machines - Changing the regular curriculum - Hanging posters (healthy diet, water consumption, physical activity) - Providing a reusable water bottle - Creating more opportunities for exercise during breaks (an additional hour a week of movement) - Giving a pedometer to students	- Lessons about healthy eating habits (textbook) with students - Sending communications (automated text messages) to parents and students - Involving parents in activities sent home (textbook)	Compared to CG: - ↓ BMI (z-score) - ↓ SSB, high-energy snack consumption Intervention effect in subgroup analysis: - ↓ BMI (z-score) and high-energy snacks consumption in girls with overweight/obesity
Lebanon/2014 (Habib-Mourad et al. ⁵¹)	cRCT 3 months	8 374 (181/193) 9-11 years	- Changing the regular curriculum - Training canteen staff (recommendations about healthy snacks and drinks) - Hanging posters (healthy food choices) in the school canteen	- Lessons about healthy eating habits and physical activity (fun and interactive activities) with students - Training sessions with teachers - Involving parents in meetings, school events, and activities sent home (food samples, recipes, healthy lunch boxes) - Sending communications to parents (pamphlets)	No significant differences
Malaysia/2018 (Koo et al. ⁵²)	QE 3 months	2 83 ^# (40/43) 9-11 years	- Changing availability of whole grain foods (delivered daily in school)	- Lessons about whole grains recommendations and a balanced diet - Individual diet counseling for parents (booklet and recipes with whole grain foods)	At 9 months follow-up, compared to CG: - ↓ BMI-for-age (z-score), %BF, WC At 3 months follow-up, compared to baseline: - ↓ %BF, WC
Malaysia/2021 (Teo et al. ⁵³)	QE 3 months	6 523 (272/251) 7-11 years	- Offering healthier foods - Training school canteen staff - Providing a skipping rope to students	- Lessons about health awareness, nutrition, food hygiene, and physical activity with students - Training sessions with teachers - Involving parents in monitoring the program’s implementation (visit the school canteen)	At 3 months follow-up, compared to CG: - ↓ BMI-for-age
Malaysia/2022 (Majid et al. ⁵⁴)	QE 4 weeks	6 340 ^## (93/247 ***) 14-15 years	Intervention one + two: - Training school canteen staff - Giving a “Healthy Canteen Booklet” to school canteen staff Only intervention two: - Subsidy for healthy foods (fruits, vegetables, low-energy-dense kuih - traditional cake) - Students receive coupons that subsidize the price of healthy foods weekly - Allocation of funds to prepare healthy food was given to the school - Installing water fountains	- Did not include this component	Compared to baseline: - ↓ WC in intervention two - ↓ energy in all arms - ↑ fat intake and %BF in intervention one
Mexico/2009 (Colín-Ramirez et al. ⁵⁵)	cRCT 1 year	10 619 (315/304) 8-10 years	- Offering healthier foods - Creating more opportunities for exercise during the school day	- Lessons about healthy eating habits and physical activity (classes and fun activities) with students - Training sessions with teachers - Involving parents in lectures and activities at home (menu and snack suggestions, recommendations for a healthy lifestyle)	Compared to baseline: - ↓ energy and saturated fat intakes - ↑ WC in both groups (only significant in CG)
Mexico/2012 (Bacardí-Gascon et al. ⁵⁶)	QE 6 months	4 532 (280 ^###/252) 8-9 years	- Offering healthier foods - Changing the regular curriculum	- Lessons about healthy eating habits and physical activity with students and parents - Meetings with the school board and teachers (improve school meals, snacks offered in the school canteen, and physical activity installations)	At 6 months follow-up, compared to CG: - ↓ BMI At 24 months follow-up, compared pre- to post-intervention: - ↑ BMI, BMI (z-score), WC - ↓ abdominal obesity (WC > 90th percentile) - ↑ vegetables intake, SSB - ↓ consumption of snacks high in fat and salt, availability of SSB, cookies, chocolates, candy, and vegetables at home
Mexico/2012 (Levy et al. ⁵⁷)	cRCT 6 months	60 1,019 (510/509) 10 years	- Offering healthier foods - Training school canteen staff - Hanging posters (healthy breaks) - Broadcasting of audio spots on the schools’ physical activity systems to promote the consumption of water, fruits, vegetables, and physical activity - Hanging posters (physical activity) - Providing a school guide (to support physical activity), a CD with music for established activities, and a bottle of water for the children - Organizing games during the break	- Lessons about healthy eating habits and physical activity (workshops, puppet theatre) with students - Training sessions with teachers - Participation of teachers in games during the break - Teachers performing activities before the start of classes (warm-ups, activation and relaxation) - Delivery of recipe calendars (healthy eating and physical activity) to parents	Compared to baseline: - ↓ probability of shifting from the overweight to the obesity category
Mexico/2013 (Alvirde-García et al. ⁵⁸)	cRCT 3 years	5 2,682 (755/1,927) 9 years	- Offering healthier foods - Meetings with school canteen staff - Changing the regular curriculum - Increasing the amount of time students spend in moderate-to-vigorous physical activity - Promoting physical activity during and after school (guide and activity cards)	- Lessons about healthy eating habits and physical activity (textbook and workbook) with students and parents - Training sessions with teachers - Involving parents in meetings and activities at home	At 3 years follow-up, compared to CG: - ↓ increase of BMI variation - ↓ energy, bread, fat and sugar intake At 3 years follow-up, compared to baseline: - ↓ energy in both groups (higher in IG) At 3 years follow-up, compared to 1 year follow-up: - ↑ BMI in both groups
Mexico/2013 (Safdie et al. ⁵⁹)	cRCT 1.5 years	27 860 (354/506 ***) 9-11 years	Group 1 + Group 2: - Increasing availability of healthy foods and water at school - Reducing availability of unhealthy foods - Training school canteen staff and school authorities (booklets, workshops) - Providing sports equipment - Promoting physical activity during the school day Only Group 2: - Increasing the amount of time students spend in moderate-to-vigorous physical activity - Additional financial investment and human resources (hiring physical education teachers)	Group 1 + Group 2: - Promoting workshops, mass communication, and marketing strategies targeted to students (healthy eating habits) - Training sessions with teachers - Distributing a booklet for parents (healthy lunch)	At 18 months follow-up, compared to CG: - ↓ consumption of unhealthy foods at school (only group 2) At 18 months follow-up, compared to baseline: - ↑ availability of healthy foods at school (both IG) - ↓ availability of unhealthy foods at school (both IG)
Netherlands/2007 and 2009 (Singh et al. ⁶⁰^,⁶¹)	cRCT 8 months	18 1,053 (453/600) 12-13 years	- Offering smaller portion sizes - Offering healthier foods - Changing the regular curriculum - Restricting access to vending machines - Providing financial encouragement to schools to offer additional physical activity options	- Biology and physical activity lessons with students - Training sessions with teachers	At 8 months follow-up, compared to CG: - girls: ↓ SSB consumption - boys: ↓ WC, SSB consumption At 12 months follow-up, compared to CG: - girls: ↓ SSB consumption - boys: ↓ SSB consumption
Peru/2017 (Aparco et al. ⁶²)	QE 9 months	4 824 (347/477) 6-10 years	- Training school canteen staff - Promoting physical activity during the school recess - Providing sports equipment (balls, cones, ropes)	- Lessons about healthy eating habits and physical activity (educational materials, puppet theatre) with students - Training sessions with teachers - Involving parents in lessons about healthy eating habits and physical activity and activities at home	Compared to baseline: - ↓ vegetable consumption
Sweden/2009 (Marcus et al. ⁶³)	cRCT 4 years	10 3,135 (1,465/1,670) 6-10 years	- Offering healthier foods - Changing the regular curriculum - Increasing the amount of physical activity - Increasing opportunities for physical activity	- Training sessions with teachers - Communicating with parents	Compared to baseline: - Eating habits at home were healthier (↓ sweetened cereals, high-fat dairy, and sweet products)
Thailand/2017 (Chawla et al. ⁶⁴)	QE 6 months	4 453 (227/226) 8-12 years	- Offering healthier foods - Stopping the sale of unhealthy foods - Removing vending machines - Training sessions with school staff (comic book, discussions, handbook) and teachers - Requesting vendors around the school to stop selling unhealthy food	- Lessons about healthy eating habits, obesity consequences, growing vegetables, and physical activity (presentations, gaming, gardening/planting, comic book) with students - Involving parents in workshops, activities sent home (healthy handbook), and sending communications (report cards, meetings)	Compared to CG: - ↓ sugary foods (chocolate and candies), fast foods consumption - ↑ vegetables consumption
Turkey/2011 (Sevinç et al. ⁶⁵)	cRCT 8 months	6 6,847 (2,926/3,921 ***) 7-13 years	Group 1 + Group 2: - Offering healthier foods in the school canteen - Distributing boxed milk during mealtime	Group 1 + Group 2: - Lessons about healthy eating and methods of preventing obesity Only in Group 1: - Lessons about physical activity	Group 1 and Group 2, compared to CG: - ↑ BMI (lower than CG increased) - ↓ BMI increased in boys IG compared to CG Group 1, compared to CG and group 2: - ↓ BMI increased in boys compared to girls
United States/1996 and 1999 (Luepker et al. ⁶⁶; Webber et al. ⁶⁷; Nader et al. ⁶⁸)	cRCT 3 years	96 4,019 ^# (1,653/2,366 **) 8-11 years	Group 1 + Group 2: - Training school canteen staff - Changing the regular curriculum - Increasing the amount of time students spend in moderate-to-vigorous physical activity	Group 1 + Group 2: - Lessons about healthy eating habits, cigarette smoking, and physical activity with students - Training sessions with teachers and physical education specialists Only in Group 1: - Involving parents in activities sent home and in school events	At 3 years follow-up, Group 1 + Group 2, compared to CG: - ↓ % energy from total fat, saturated fat - ↑ total daily energy intake (both groups, but lower in IG) At 6 years follow-up, Group 1 + Group 2, compared to CG: - ↓ % energy from total fat and saturated fat intake
United States/2003 (Sallis et al. ⁶⁹)	cRCT 2 years	24 1,678 (no data) 11-13 years	- Offering healthier foods - Providing financial encouragement to purchase kitchen and physical activity equipment - Health policy meetings - Creating a committee - Promoting physical activity before and after school, as well as after lunch	- Training sessions with teachers - Sending communications and involving parents in school events and meetings	Compared to CG: - ↓ BMI only in boys
United States/2003 (Caballero et al. ⁷⁰)	cRCT 3 years	41 1,704 (825/879) 8-10 years	- Reducing the fat content of school meals - Training school canteen staff - Changing the regular curriculum - Increasing the amount of time students spend in moderate-to-vigorous physical activity - Promoting physical activity in the classroom	- Lessons about healthy eating habits and physical activity with students - Training sessions with teachers - Communicating with and involving parents in school events	Compared to CG: - ↓ % energy from fat (24-hR, and direct observation), total energy intake (only 24-hR, not by direct observation)
United States/2004 (Treviño et al. ⁷¹)	cRCT 7 months	27 1,419 (706/713) 9 years	- Changing the regular curriculum - Training school canteen staff	- Lessons about healthy eating habits and physical activity with students - Training sessions with teachers - Involving parents in events, meetings, and activities at home	No significant differences
United States/2007 (Williamson et al. ⁷²)	cRCT 1.5 year	4 661 (313/348 ^§) 7-11 years	- Offering healthier foods - Eliminating vending machines - Reducing unhealthy foods - Training school canteen staff - Creating marketing materials (menu boards, buttons, place cards) and a committee - Hanging posters (physical activity) - Promoting physical activity during and after school - Providing financial encouragement to purchase physical activity equipment	- Training sessions with teachers - Sending communications, creating a website, and involving parents in committee	Compared to CG: - ↓ total calories, % of calories from total dietary fat, saturated fat
United States/2008 (Foster et al. ⁷³)	cRCT 2 years	10 1,349 (600/749) 9-11 years	- Offering healthier foods - Creating a committee - Training all school staff	- Lessons about healthy eating habits and physical activity with students - Involving parents in committees, meetings, and nutrition workshops	No significant differences
United States/2010 (Hollar et al. ⁷⁴)	QE 2 years	5 3,769 (737/3,032) 6-13 years	- Offering healthier foods - Reducing unhealthy foods - Changing the regular curriculum - Hanging health-related posters - Providing a school gardening program - Increasing opportunities for physical activity	- Lessons about healthy eating habits and physical activity with students - Training sessions with teachers - Sending communications to parents (newsletter)	At 2 years follow-up, compared to CG: - ↓ BMI (percentile)
United States/2010 (Hollar et al. ⁷⁵)	QE 2 years	5 2,494 (465/2,029) 6-13 years	- Offering healthier foods - Reducing unhealthy foods - Changing the regular curriculum - Hanging health-related posters - Providing a school gardening program - Increasing opportunities for physical activity	- Lessons about healthy eating habits and physical activity with students - Training sessions with teachers - Sending newsletters to parents	At 2 years follow-up, compared to CG: - girls: ↓ BMI (z-score)
United States/2010 (Foster et al. ⁷⁶)	cRCT 3 years	42 6,358 (3,169/3,189) 11 years	- Offering healthier foods - Reducing unhealthy foods - Increasing the amount of time students spend in moderate-to-vigorous physical activity - Providing financial encouragement to purchase physical activity equipment	- Lessons about behavioral knowledge and skills with students - Training sessions with physical education teachers - Involving parents in activities sent home and sending communications	Compared to CG: - ↓ BMI (z-score), % of students with WC (≥ percentile 90), % of students with BMI ≥ percentile 85 (both groups)
United States/2012 (Coleman et al. ⁷⁷)	cRCT 2 years	8 579 (279/300) 7-11 years	- Offering healthier foods - Reducing unhealthy foods - Training school canteen staff - Hanging health-related posters - Performing taste tests on students - School staff modeling healthy eating - Providing free meals for staff who eat school lunches with students	- Lessons about healthy eating habits with students - Participation of teachers and parents in the development of action plans to change school environment - Meetings with parents	Compared to baseline: - ↑ BMI (z-score) (both groups)
United States/2012 (Williamson et al. ⁷⁸)	cRCT 2 years + 4 months	17 2,060 (587/1,473 ***) 9-11 years	Group 1 + Group 2: - Offering healthier foods (vending machine and school canteen) - Reducing unhealthy foods - Training school canteen staff - Creating marketing materials (menu boards, buttons, place cards) - Creating a committee - Hanging posters (physical activity) - Promoting physical activity during the school day and after school - Providing financial encouragement to purchase physical activity equipment	Group 1 + Group 2: - Training sessions with teachers - Sending communications, creating a website, and involving parents in committee Only Group 2: - Lessons about healthy eating habits with students - Internet counseling for children and their parents	At 28 months follow-up, compared Group 1 + Group 2 to CG: - ↓ %BF in boys
United States/2016 (Bogart et al. ⁷⁹)	cRCT 5 weeks	10 2,439 (1,261/1,178) 12-13 years	- Offering healthier foods - Offering a greater variety of sliced/bite-sized food and freely chilled filtered water at lunch - Training with students’ peer leader club (social marketing: intervention messages at lunchtime, taste tests, short film) - Hanging health-related and physical activity posters and nutritional postings	- Lessons about healthy eating habits and physical activity with students - Sending parent-student activities - Communicating with parents	Compared to CG: - ↓ BMI (percentiles) in students who were classified as obese at baseline
United States/2021 (Davis et al. ⁸⁰)	cRCT 9 months	16 3,135 (1,723/1,412) 8-10 years	- Changing the regular curriculum - Creating a committee - Building gardens	- Lessons about nutrition, gardening, and cooking with students - Involving parents in health classes at school	Compared to CG: - ↑ vegetable intake
United States/2023 (Patel et al. ⁸¹)	cRCT 15 months	18 1,249 (572/677) 9 years	- Installing water fountains in which cups were also available - Kickoff assembly - Signage and modest prizes for students observed drinking water at lunch	- Lessons about health, fiscal, and environmental benefits of drinking water with students - Sending parent-student activities	No significant differences

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[TFN1] 24-hR: 24-hour dietary recall; %BF: body fat percentage; BMI: body mass index; CG: control group; cRCT: cluster randomized controlled trial; IG: intervention group; QE: quasi-experimental study; SSB: sugar-sweetened beverage; WC: waist circumference.

[TFN2] * Number of individuals assessed at baseline was taken into consideration;

[TFN3] ** Only outcomes with statistically significant results (p < 0.05) are reported in the “Main results” column;

[TFN4] *** Study with two intervention arms;

[TFN5] ^# Only students with overweight or obesity were included in the study;

[TFN6] ^## Included the number of students analyzed at the end of the intervention (no base data);

[TFN7] ^### After six months of intervention, the control group received the intervention, and the data were analyzed as pre- and post-intervention;

[TFN8] ^§ The study compared two interventions (no control group).