Physical activity and nutrition education at the school environment aimed at preventing childhood obesity: evidence from systematic reviews

Guerra, Paulo Henrique; Silveira, Jonas Augusto Cardoso da; Salvador, Emanuel Péricles

doi:10.1016/j.jped.2015.06.005

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REVIEW ARTICLE • J. Pediatr. (Rio J.) 92 (1) • Jan-Feb 2016 • https://doi.org/10.1016/j.jped.2015.06.005 copy

Physical activity and nutrition education at the school environment aimed at preventing childhood obesity: evidence from systematic reviews ^☆ ☆ Please cite this article as: Guerra PH, Silveira JA, Salvador EP. Physical activity and nutrition education at the school environment aimed at preventing childhood obesity: evidence from systematic reviews. J Pediatr (Rio J). 2016;92:15-23.

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

OBJECTIVE:

To organize the main findings and list the most frequent recommendations from systematic reviews of interventions developed at the school environment aimed at reducing overweight in children and adolescents.

DATA SOURCE:

Searches for systematic reviews available until December 31, 2014 were conducted in five electronic databases: Cochrane, PubMed, SciELO, SPORTDiscus, and Web of Science. Manual search for cross-references were also performed.

SUMMARY OF THE FINDINGS:

Of the initial 2139 references, 33 systematic reviews adequately met the inclusion criteria and were included in the descriptive summary. In this set, interventions with periods of time greater than six months in duration (nine reviews), and parental involvement in the content and/or planned actions (six reviews) were identified as the most frequent and effective recommendations. Additionally, it was observed that boys respond more effectively to structural interventions, whereas girls respond to behavioral interventions. None of the included reviews was able to make inferences about the theoretical basis used in interventions as, apparently, those in charge of the interventions disregarded this component in their preparation.

CONCLUSIONS:

Although the summary identified evidence with important applications in terms of public health, there are still gaps to be filled in this field of knowledge, such as the effectiveness of different theoretical models, the identification of the best strategies in relation to gender and age of participants and, finally, the identification of moderating variables to maximize the benefits provided by the interventions.

Keywords:
Review; Children; Physical activity; Nutrition education; Overweight; School

Objectives	Assessment of interventions effectiveness (25):^{6, 7, 8, 10, 11, 12, 14, 15, 16, 17, 18, 20, 23, 24, 27, 30, 31, 32, 33, 34, 35, 36, 37, 38 and 39}; theoretical and methodological characteristics of interventions (3):^{13, 19 and 25}; promotion of physical activity and nutrition education (2):^{19 and 21}; promoting healthy eating habits (2):^{22 and 28}; identification of moderators (1):²⁶
Specific interventions	Only nutritional actions (5):^{8, 19, 22, 28 and 31}
Specific contexts	Continents (3): Latin America:³⁶; Europe:^{28 and 29}; Countries (6): Canada and USA⁸; China:¹⁸; USA:^{12 and 33}; USA and UK:¹⁰; Except USA:¹⁶; Income (2): Low income schools in the USA:³³; Low and middle income countries:³⁵; Ethnicity (2): Latinos living in the USA:³⁸; Ethnic minorities in the USA:³²
Included studies	Clinical trials/community (14):^{6, 7, 15, 17, 18, 20, 26, 27, 34, 35, 36, 37, 38 and 39}; clinical trials/community and cross-sectional (1):²²; clinical trials/randomized controlled community (3):^{12, 24 and 31}; unrestricted (2):^{29 and 33}
Intervention time	>three months (4):^{6, 14, 20 and 32}; >six months (1):¹⁷; >nine months (1):²⁴
Assessed age range (years)	4–14 (1):¹³; 5–18 (1):³¹; 6–12 (1):²⁴; 6–18 (5):^{21, 28, 29, 34 and 35}; 6–19 (1):¹¹; 7–19 (1):¹⁹
Number of electronic databases	5–8 (10):^{6, 15, 21, 22, 26, 28, 29, 32, 34 and 35}; >9 (3):^{31, 36 and 38}; nd (4):^{7, 8, 13 and 16}
No manual searches	(10):^{7, 8, 10, 16, 19, 24, 26, 30, 34 and 39}
Language restriction	Only publications in English (7):^{10, 16, 23, 30, 34, 37 and 39}
Samples	Heterogeneous populations (5):^{11, 17, 18, 22 and 30}; populations with overweight/obesity (1):³⁹
Others	Interventions with parental involvement (1):³⁴; studies with positive results (1):¹³

Reference	Summary N.	Main result
Story, 1999⁸	12	Among schools, the efforts to promote physical activity and healthy diet should be part of a coordinated comprehensive health program. The inclusion of both primary and secondary interventions in a large school health program is recommended.
Campbell et al., 2001⁶	7	Two of the long-term studies (one with PA + NE focus against control, and the other only NE versus control) resulted in reduction in the prevalence of obesity.
Baranowski et al., 2002⁷	20	In successful interventions, program implementers were not classroom teachers, targeting the interventions to pre-adolescents and adolescents’ groups. However, interventions were intuitively designed and developed, without a theoretical basis.
Budd & Volpe, 2006^12,a	12	Greater effectiveness observed in the samples of older children, providing new perspectives on curriculum, designed with the purpose of changing behavior. Physical education classes must be culturally appropriate to the habits practiced outside the school environment, such as active video games.
Cole et al., 2006^13,a	10	The Social Cognitive Theory of Bandura was used in eight of ten included studies. This theory and the role of social learning are useful in planning interventions to prevent and treat overweight in childhood.
Doak et al., 2006¹¹	25	17 of the 25 interventions showed statistically significant results in lowering BMI. The authors suggest that these proposals can be developed on a large scale and offered for a longer period of time.
Sharma, 2006¹⁰	11	Most interventions aimed at short-term changes immediately after the intervention. In total, the interventions resulted in modest changes in relation to behavior and mixed results on the obesity indicators. High heterogeneity in relation to the measure standards.
Flodmark et al., 2006^14,b	10 + 14	Permanent long-lasting community interventions that promote PA and NE are likely to have more powerful effects than the effects demonstrated for proposals limited to the school environment.
Lissau, 2007¹⁵	14	Half of the studies showed positive effects on reducing obesity. A wide variation in sample characteristics and in theoretical basis of the studies was observed.
Sharma, 2007¹⁶	21	Nine interventions were longer than one school year. Approaches involving parents showed positive results regarding measures of obesity.
Kropski et al., 2008¹⁷	14	Only four of the 14 studies were rated as high quality. Methodological concerns and the small number of publications limits the formulation of inferences about the effectiveness of school interventions.
Li et al., 2008¹⁸	22	Most studies showed beneficial effect of the intervention on one or more outcomes, but all studies had methodological problems. In this sense, the authors highlight the high risk of influence of publication bias.
Shaya et al., 2008¹⁹	51	13 of the 15 intervention studies reported positive results in some or all quantitative measures. This evidence raises the potential of PA as an element of prevention and reduction of obesity in children.
Brown & Summerbell, 2009^20,c	15 + 28	The results are inconsistent, but generally suggest that PA and NE interventions can control overweight in the long term.
Dobbins et al., 2009²¹	26	Four of 14 studies reported positive effects on BMI, with intervention time >nine months. The ten studies that reported no effect on BMI had similarities in combined interventions within the period of time.
Jaime & Lock 2009²²	18	Some current school policies have been effective in improving the food environment and dietary intake in schools, but there is little evaluation of their impact on BMI.
Katz, 2009²³	18	Even with great variability in the measures, methods, and populations, the evidence clearly demonstrated that school interventions had a statistically significant effect in reducing obesity.
Pérez-Moralez et al., 2009²⁴	10	Most studies did not show a statistically significant reduction in BMI. However, a positive impact on lifestyle was observed in many studies, such as increased consumption of fruits and vegetables and reduced consumption of soft drinks.
Zenzen & Kridli, 2009^25,a	16	NE was shown to be an effective method in changing eating habits at school. A program that includes the promotion of healthy lifestyle supported by strong parental influence is also crucial.
Brandt et al., 2010²⁷	22	School interventions that combine PA and NE were effective, especially in interventions lasting more than one year.
Van Cauwenberghe et al., 2010²⁸	42	Regarding the magnitude of effects in children, multicomponent interventions aiming at the intake of fruits and vegetables showed strong evidence. In adolescents, educational interventions on behavior showed moderate evidence and multicomponent programs in behavior showed limited evidence.
De Bourdeaudhuij et al., 2011²⁹	11 (27 articles)	Considering the obesity reduction in European children and adolescents, the combination of educational and environmental components may be preferable in interventions in PA and NE. Results of customized educational programs via computer in adolescents are promising.
Sharma, 2011³⁰	25	Most interventions combined PA and NE strategies, and were implemented by teachers. In terms of activities, almost all interventions had a curricular component, and sought the involvement of parents/family.
Silveira et al., 2011³¹	24	The main characteristics of interventions with positive results: duration >1 year, introduction of the proposal in regular school activities, parent involvement, permanent offer of NE in curriculum, and supply of fruits and vegetables by school food services.
Yildirim et al., 2011²⁶	6	Inconsistent results and the small number of statistically significant effects made the result inconclusive. However, gender (female) and unfavorable values at baseline are the most prominent moderators on the effects of the intervention.
Johnson et al., 2012³²	7	All studies reported benefits in health behaviors and/or anthropometric measurements. Effectiveness was observed when the program objectives were specific, with extended action into the community.
Krishnaswami et al., 2012³³	16	Seven of the 12 anthropometric studies outcomes had at least one positive result.
Van Lippevelde et al., 2012³⁴	5	Results differ as to parental involvement in health behaviors of children. Interventions that predict parental involvement should include different strategies and approach different determinants and practices.
Verstraeten et al., 2012³⁵	25	Eight of the 12 studies reported statistically positive effect in reducing BMI. The authors observed the potential of the school environment to improve feeding behavior and PA by promoting the maintenance of a healthy weight. However, the need for further reviews and better designed studies is observed.
Lobelo et al., 2013³⁶	10	The most successful interventions had primary focus, time longer than six months, involvement of teachers and health professionals, better study designs, and fewer limitations on performance.
Quitério, 2013³⁷	27	The results of the interventions in PE related to health showed positive and consistent results. However, a considerable number of these interventions did not obtain a reduction in BMI, body fat measures and %BF.
Holub et al., 2014³⁸	15	Interventions involving Latin populations had inconclusive results. Apart from the deep involvement of appropriately conducted studies, few had significant results in relation to obesity after follow-up.
Kelishadi & Azizi-Soleiman 2014³⁹	32	School-based interventions can have lasting results in larger groups. Compared to interventions conducted in other environments, the school was the most favorable place for the development of strategies aimed at reducing overweight/obesity, especially when they involve the family.

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[1] Corresponding author. E-mail:paulohguerra@usp.br (P.H. Guerra).