SciELO - Scientific Electronic Library Online

 
vol.17 issue4Functional fitness in older women from southern brazil: normative scores and comparison with different countriesCan leucine supplementation attenuate muscle atrophy? A literature review author indexsubject indexarticles search
Home Pagealphabetic serial listing  

Services on Demand

Journal

Article

Indicators

Related links

Share


Revista Brasileira de Cineantropometria & Desempenho Humano

Print version ISSN 1415-8426On-line version ISSN 1980-0037

Rev. bras. cineantropom. desempenho hum. vol.17 no.4 Florianópolis July/Aug. 2015

https://doi.org/10.5007/1980-0037.2015v17n4p485 

Review Article

Effectiveness of intervention programs in schools to reduce health risk factors in adolescents: a systematic review

Roseane de Fátima Guimarães1 

Raquel David Langer1 

Gil Guerra-Júnior1 

Ezequiel Moreira Gonçalves1 

1State University of Campinas. Faculty of Medical Sciences. Graduate Program in Health of Children and Adolescents. Campinas, SP. Brazil


Abstract

The aim of this study was to systematically review studies on intervention programs involving physical activity promotion and/or nutritional education to reduce health-related risk factors (overweight/obesity and metabolic profilealterations) in Brazilian adolescent students. A search was performed in the following electronic databases: Medline (PubMed), Lilacs, Embase, Scielo and Capes Thesis Database. A total of 1,568 studies were identified, of which 21 full papers were analyzed and 5 were included in the systematic review. The majority of the studies involved physical activity practice combined with nutritional education in Brazilian adolescent students and all interventions showed positive effect on reducing health-related risk factors among Brazilian adolescents.It was concluded that all studies included in this review showed positive alterations in health-related risk factors after interventions, reinforcing the importance of intervention programs to promote a healthier lifestyle and reduce health-related risk factors in adolescents.

Key words: Adolescents; Eating behavior; Intervention studies; Motor activity; Students' health

Resumo

O objetivo do estudo foi realizar uma revisão sistemática sobre os programas de intervenção, com ações de atividades físicas e/ou educação nutricional, na redução de fatores de risco à saúde (sobrepeso/obesidade e alterações no perfil metabólico), em adolescentes escolares brasileiros. Foi realizada busca nas bases de dados eletrônicas Medline (PubMed), Lilacs, Embase, Scielo e Banco de Teses da Capes. Identificaram-se 1.568 estudos e 21 textos completos foram analisados, dos quais, cinco foram incluídos na revisão. A maioria dos estudos envolveu a prática de atividades físicas combinada à educação nutricional em diferentes regiões do país e todas as intervenções mostraram efeitos positivos na redução de fatores de risco à saúde. Conclui-se que todos os estudos nesta revisão demonstraram alterações positivas após as intervenções, mesmo que não significativas estatisticamente, reforçando a importância de programas de intervenção para a promoção de uma vida mais saudável e para reduzir os fatores de risco à saúde, em adolescentes.

Palavras-chave: Adolescentes; Atividade motora;; Comportamento alimentar; Estudos de intervenção; Saúde escolar

INTRODUCTION

Population studies have demonstrated an increased prevalence of obesity among adolescents1-5, as well as the early appearance of a series of risk factors for the development of cardiovascular and metabolic diseases such as type-2 diabetes, hypertension and dyslipidemia3,6,7. Studies conducted in Brazil also showed the same results in the last decade, a high percentage of individuals in adolescence presenting several health risk factors such as abdominal obesity (32%), hypertension (15%), metabolic syndrome (7, 7%)8-10.

Childhood and adolescence are important stages for the development of a healthy lifestyle, since most habits acquired during this period of life are perpetuated into adulthood 11. However, decreased levels of physical activity and increased sedentary behavior have been observed at this stage, both national and internationally12-15. Acquiring healthy habits in this age group should be a priority for the educational and social sectors, particularly schools, because they are privileged spaces for the development of interventions towards health, since they gather most adolescents in the country, which are over 30 million students enrolled in the Elementary and High-School public school system16.

There is evidence that physical activity interventions performed in schools are capable of promoting increased levels of physical activity and combat sedentary behavior11, but the beneficial effects of these actions on cardiometabolic risk factors remain inconsistent. Recent review studies have shown that interventions in schools in different countries, with different models of physical activity practices were effective in reducing cardiometabolic risk factors17,18, increase the level of physical activity and cardiorespiratory fitness, increase the active time during Physical Education classes and active transport to school19, and indicate that these interventions should focus both on promoting physical activity and nutrition education11.

In Brazil, few school interventions on physical and / or nutritional activities have been performed in order to reduce health risk factors20-24, moreover, little is known about the methodology of the studies, types of intervention, evidence of effects and results on the health of adolescents. Thus, this review study will assist in explaining the differences among studies, being useful for the systematization, planning and implementation of school intervention programs in order to define a favorable health policy in this environment.

In this context, the aim of the study was to conduct a systematic review of intervention programs with planned physical activity and / or nutrition education actions to reduce health-related risk factors (overweight / obesity and metabolic profile alterations) in Brazilian adolescent students aged 10-19 years.

METHODOLOGICAL PROCEDURES

A systematic review was conducted in August and September 2014 that aimed to identify articles published in the last 10 years in order to highlight the scope of the most recent studies in Medline (PubMed), Lilacs, Embase, Scieloelectronic databases and also the portal of dissertations and theses of the Coordination for the Improvement of Higher Education Personnel - CAPES (http://capesdw.capes.gov.br/capesdw/), using keywords and combinations in Portuguese and English with Boolean operators "and" and"or": Intervention, Students, Adolescents, Physical Activity, Sedentary Lifestyle, Sedentary Behavior, Eating Behavior, Nutrition, Risk Factors, Overweight and Obesity. A search through the reference lists of relevant studies and systematic reviews that addressed the topic of interest was also conducted. Consultation to journals to ensure that there was peer review and conference of methods described by the authors through the search and reading of articles to verify their methodological quality were used as strategies to reduce bias.

The following inclusion criteria for the selection of studies were used: (i) studies published in journals, dissertations and theses available in selected databases, as well as in the references of the selected studies; (ii) samples that include adolescents aged 10-19 years; and (iii) programmed physical activity and / or nutrition interventions conducted in public and / or private schools in order to reduce health risk factors (overweight / obesity and metabolic profile alterations) regardless of duration; (iv) interventions conducted in Brazil; (v) articles containing pre- and post-test data.

The review study excluded articles with sample of adolescents in specific health conditions (hypertension, diabetes, hyperlipidemia or other chronic diseases); sample with children (<10 years) or adults only (> 19 years); interventions performed totally outside the school environment (clubs, communities, clinics, hospitals, laboratories) or actions involving families or community; interventions carried out only with teachers / school staff; articles with exclusive description of the methodological design of intervention programs and / or transversal studies; Brazilian articles with international data; systematic review articles or meta-analysis.

After the search for studies in electronic databases, the selection started from the analysis of titles and abstracts by two independent reviewers in accordance with the inclusion and exclusion criteria. In the case of lack of information in the abstract, the study was evaluated by the full text. The results were crossed to verify agreements, and disagreements were resolved by consensus and with the presence of a third appraiser, and at the end of the search, and data extracted were checked. The assessment by reviewers was unmasked as for the authors and the study results.

The methodological quality of studies selected was evaluated by the scale proposed by Downs & Black25. This scale aims to evaluate both studies that have randomized clinical trial design and those who are not random, including five sub-items related to: the way results are reported (if the information presented in the study allows the reader to interpret data and results without bias), external validity, biases, confounding factors and study power. The maximum score to be achieved through the 27 items is 31 points25. From this, the evaluators classified the articles with scores greater than 20 points as high methodological quality, 10 to 20 points, moderate, and below 10 points low methodological quality.

The articles selected are shown in the tables in increasing order of year of publication and, when in the same year, in alphabetical order considering the first author. This study followed the PRISMA recommendations for systematic reviews26.

RESULTS

Figure 1 shows the flowchart of the study selection process. Overall, 1,568 studies were found and of these, 1,515 were excluded after thorough analysis of titles and then 32 by reading the abstracts for not meeting the inclusion criteria. After the first stage, 21 original articles were selected for reading the full text, of these, 16 were excluded for not meeting the inclusion criteria. A search in the reference list of articles read in full was also performed and 1 article was selected. Finally, five studies were chosen for the quality verification step according to the scale proposed by Downs & Black25.

Figure 1 Selection process. 

Two studies were conducted in the southeastern21,22, one in the midwestern23, one in the northern20 in one in the southern regions of Brazil24. All interventions were conducted with boys and girls at the same time, and the age group ranged from 7 to 17 years, the sample size from 34 to 416 students and the duration of interventions from 10 weeks to 1 academic year. It was observed that all interventions, with the exception of only one study 20 occurred in public schools.

As for the sample selection, all studies20-24 showed selection of participants for convenience. It was found that all studies used body mass index (BMI) as the dependent variable, as well as some skin folds to estimate body fat percentage (% BF)20,21,24, anthropometric girth20,21,23, body composition through bioelectrical impedance (BIA)22, blood variables21,23, blood pressure measurement23and physical fitness control23,24 (Table 1).

Table 1 Characteristics of the intervention studies included in the systematic review. 

Some results should be highlighted such as the significant body fat reduction observed in all studies, positive changes in blood parameters21,23, improvement in physical abilities23,24 and blood pressure23. The effect size was calculated from the results obtained after the intervention programs of the main variables that showed significant pre- and post-test differences according to the equation of Cohen27. According to Cohen27, values greater than or equal to 0.8 represent large effect size; values between 0.8 to 0.2 are considered intermediate effect size and less than 0.2 small effect size, and positive values correspond to a higher average in the intervention group and negative values to a higher average in the control group (Table 1).

Table 2 Characteristics of intervention programs 

When observing the aims, all studies focused on the effects of programmed physical activity and / or nutrition education in school about health risk factors such as changes in body composition20-24 and / or metabolic profile21,23 in adolescents.

After assessing the methodological quality of studies, it was found that only one article23 had excellent methodological quality and the others had moderate. The items that most studies have not achieved refer to the sample randomization or the intervention groups, as well as the control of confounding variables25.

DISCUSSION

The first fact that drew attention in this systematic review was the limited number of available studies who developed intervention programs in Brazil promoting physical activity and / or nutrition education aiming to reduce health-related risk factors among adolescent students20-24. Another highlight is the occurrence of positive effects in all studies found, regardless of type of intervention (physical activity, nutrition or both), duration (10 weeks to 1 academic year) or nutritional status of participants (overweight / obesity or normal weight; overweight and obese included in the same sample).

The inclusion criteria of this study were selected due to the high prevalence of overweight and obesity, as well as to the poor health-related habits in this phase, as we believe that this phase is of utmost importance for the development of a healthy lifestyle. Thus, there are gaps in this area of study, making it possible for future investigations using a reliable methodology using methods of better accuracy and validity.

Improvement in the body composition of participants was observed after intervention20-24; however, all studies used BMI or methods for assessing body composition considered doubly indirect (developed from an indirect assessment method) as skinfold thickness20,22-24 or bioelectrical impedance21. Despite being correlated with cardiometabolic risk factors in adolescents28,29 and easy to be used in the field with a high number of individuals, as in the school environment, these methods may have some limitations related to the lack of accuracy, especially in individuals with higher body fat30.

Among the interventions protocols applied, three studies involved controlled exercise, using heart rate as a parameter for the monitoring physical exercise intensity20,22,23, and this variable is considered valid as an indicator of physical activity intensity in adolescents 31. Most of them added education programs20,23,24 to physical activity intervention nutrition and only one study used nutritional intervention and also demonstrated positive changes in body proportions and effectiveness in reducing BMI21, as previously observed in a systematic review32, where most of the studies showed a decrease in the prevalence of overweight and obesity among participants.

Analyzing the intervention period of the selected studies, it was observed that even programs with shorter duration (12 and 10 weeks)20,23 demonstrated positive changes in variables. Sun et al.18claim that higher intervention periods provide greater health benefits and a high adhesion to physical activity practices in the daily lives of adolescents; in the studies analyzed, it was not possible to verify the influence of intervention duration on the health risk factors of students, because based on the findings, it was found that the effectiveness of interventions was independent of the duration of interventions.

The lack of control of the level of physical activity and nutrition intake of participants is also a point to be considered after the evaluation of the quality of studies25. Only two studies evaluated physical activity and eating habits, one of them using previously validated questionnaires and classifying adolescents by TEM / week (considering the resting metabolic equivalent of 3.5 mL • kg-1 • min-1) and the frequency of the consumption of different types of food23, and the other through a recall of time spent in physical and sedentary activities, classifying them according to the intensity of reported activity24.

Physical activity questionnaires and recalls are subjective instruments well accepted and widely used in population studies, and generally present good correlation with objective physical activity measures such as accelerometers, being valid to estimate the level of physical activity in adolescents33. Furthermore, the lack of criterion-methods to measure physical activity in adolescents can be considered a limitation of these studies, since self-reports can present significant bias associated with the outcomes34-36.

Another important aspect to be considered is the fact that the changes do not always occur in a sensitive way due to metabolic adaptations during the intervention process and mainly due to growth changes and body composition of the growth spurt and sexual maturation22, and most interventions included in this review did not control this variable. Therefore, some of the positive results presented by intervention programs can be related to body changes. Another fact observed in most studies was that adolescent males and females are equally compared within groups, but there are differences between them at the end of puberty such as the fact that girls present proportionately twice as much fat than boys, which may cause bias the interpretation of the reported findings37. Similarly to the inclusion of subjects with different nutritional status in the same group, differences in body composition after interventions tend to be higher in overweight and obese adolescents compared to those with normal weight18.

Furthermore, the limitations of these studies were not clearly described by the authors, except by Silva et al.24, who reported that the design adopted by the authors (quasi-experimental and sample not randomized for convenience) was chosen due to operability reasons and to the presence of complex programs with extracurricular activities twice a week, making it impractical to move participants from the intervention group to places far from their homes to participate in activities. The low score obtained by studies in item related to the intervention design in the assessment of the methodological quality should also be emphasized.

The inclusion of a control group can minimize this limitation, ensuring similarities among gender, age and nutritional status; however, there was a study20 that did not include it, dividing participants only into different intervention groups and presenting a very small number of individuals in the sample. Another limitation is the lack of generalization of results to populations with similar characteristics, because none of them is characterized as randomized clinical trial, considered the gold standard for interventions, and so little representative to the population in question.

The results presented here can assist in the planning of future intervention studies. Thus, even considering that some studies have shown medium and small effects, it could be inferred that the regular practice of physical activity along with nutrition education contributes to the improvement of health-related risk factors in adolescents. In addition, it is essential to consider that school is critical in the formation and actuation of people in all fields of social life, playing a decisive role in the development of students, the perception and construction of citizenship and access to public policies. Thus, school is the best place to carry out health promotion activities for children, adolescents and young adults38,39.

FINAL COMMENTS

The increased incidence of obesity and the early onset of a number of risk factors for the development of cardiometabolic diseases in adolescents are stimulating factors for carrying out actions to improve health in this population, but there are few intervention studies in Brazil that are often not properly documented and evaluated.

Thus, the few studies involving students and methodological differences between them, as well as the observed biases, made it difficult to assess the effectiveness of these actions. However all studies in this review showed positive changes after intervention, even if some are not statistically significant, reinforcing the importance of intervention programs to promote a healthier lifestyle and reduce health-related risk factors in adolescents.

It is believed that the results and criticisms presented in this systematic review can assist in improving the methodological quality of intervention programs aimed at students, enriching the scientific evidence for improving the quality of life and health in adolescents.

REFERENCES

1 Wang Y, Monteiro C, Popkin BM. Trends of obesity and underweight in older children and adolescents in the United States, Brazil, China, and Russia. Am J Clin Nutr 2002;75(6):971-7. [ Links ]

2 Bergmann GG, Bergmann MLdA, Pinheiro EdS, Moreira RB, Marques AC, Garlipp DC, et al. Body mass index: secular trends in children and adolescents from Brazil. Rev Bras Cineantropom Desempenho Hum 2011;11(3):280-5 [ Links ]

3 Freedman DS, Goodman A, Contreras OA, DasMahapatra P, Srinivasan SR, Berenson GS. Secular trends in BMI and blood pressure among children and adolescents: the Bogalusa Heart Study. Pediatrics 2012;130(1):e159-66. [ Links ]

4 Ng M, Fleming T, Robinson M, Thomson B, Graetz N, Margono C, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014;384(9945):766-81. [ Links ]

5 Rivera JA, de Cossio TG, Pedraza LS, Aburto TC, Sanchez TG, Martorell R. Childhood and adolescent overweight and obesity in Latin America: a systematic review. Lancet Diabetes Endocrinol 2014;2(4):321-32. [ Links ]

6 Williams DE, Cadwell BL, Cheng YJ, Cowie CC, Gregg EW, Geiss LS, et al. Prevalence of impaired fasting glucose and its relationship with cardiovascular disease risk factors in US adolescents, 1999-2000. Pediatrics 2005;116(5):1122-6. [ Links ]

7 May AL, Kuklina EV, Yoon PW. Prevalence of cardiovascular disease risk factors among US adolescents, 1999-2008. Pediatrics 2012;129(6):1035-41. [ Links ]

8 Stabelini Neto A, Sasaki JE, Mascarenhas LP, Boguszewski MC, Bozza R, Ulbrich AZ, et al. Physical activity, cardiorespiratory fitness, and metabolic syndrome in adolescents: a cross-sectional study. BMC Public Health 2011;11:674. [ Links ]

9 Christofaro DG, Fernandes RA, Oliveira AR, Freitas Junior IF, Barros MV, Ritti-Dias RM. The association between cardiovascular risk factors and high blood pressure in adolescents: a school-based study. Am J Hum Biol 2014;26(4):518-22. [ Links ]

10 Moraes AC, Musso C, Graffigna MN, Soutelo J, Migliano M, Carvalho HB, et al. Prevalence of cardiovascular risk factors among Latin American adolescents: a multilevel analysis. J Hum Hypertens 2014;28(3):206-9. [ Links ]

11 Friedrich RR, Polet JP, Schuch I, Wagner MB. Effect of intervention programs in schools to reduce screen time: a meta-analysis. J Pediatr (Rio J). 2014;90(3):232-41. [ Links ]

12 Nader PR, Bradley RH, Houts RM, McRitchie SL, O'Brien M. Moderate-to-vigorous physical activity from ages 9 to 15 years. JAMA. 2008;300(3):295-305. [ Links ]

13 Dumith SC, Gigante DP, Domingues MR, Hallal PC, Menezes AM, Kohl HW, 3rd. A longitudinal evaluation of physical activity in Brazilian adolescents: tracking, change and predictors. Pediatr Exerc Sci 2012;24(1):58-71. [ Links ]

14 Hallal PC, Andersen LB, Bull FC, Guthold R, Haskell W, Ekelund U. Global physical activity levels: surveillance progress, pitfalls, and prospects. Lancet 2012;380(9838):247-57. [ Links ]

15 Silva KS, Lopes AS, Hardman CM, Cabral LG, da Silva SG, Nahas MV. Commuting to school and to work among high school students in Santa Catarina state, Brazil: a comparative analysis between 2001 and 2011. J Phys Act Health 2014;11(8):1458-67. [ Links ]

16 Censo Escolar - Inep 2015. Available from: http://portal.inep.gov.br/basica-censo. [2015 Jan 10]. [ Links ]

17 Guerra PH, Nobre MR, Silveira JA, Taddei JA. The effect of school-based physical activity interventions on body mass index: a meta-analysis of randomized trials. Clinics (Sao Paulo) 2013;68(9):1263-73. [ Links ]

18 Sun C, Pezic A, Tikellis G, Ponsonby AL, Wake M, Carlin JB, et al. Effects of school-based interventions for direct delivery of physical activity on fitness and cardiometabolic markers in children and adolescents: a systematic review of randomized controlled trials. Obes Rev 2013;14(10):818-38. [ Links ]

19 Ribeiro IC, Parra DC, Hoehner CM, Soares J, Torres A, Pratt M, et al. School-based physical education programs: evidence-based physical activity interventions for youth in Latin America. Global Health Promotion 2010;17(2):5-15. [ Links ]

20 Farias ES, Paula F, Carvalho WRG, Gonçalves EM, Baldin AD, Guerra-Júnior G. Influence of programmed physical activity on body composition among adolescent students. J Pediatr (Rio J) 2009;85(1):28-34. [ Links ]

21 Martelo S. Effects of nutritional ducation associated with exercise on body composition and biochemical parameters in adolescents with excess weight. Nutrire: Rev. Soc. Bras. Alim. Nutr 2009;34(3):31-44. [ Links ]

22 Feferbaum R, Leone C, Nogueira RC, Cavalcanti PN, Cardoso EB, Serra MA. Avaliação antropométrica e por bioimpedância de um programa de educação nutricional para escolares na faixa etária de 7-14 anos durante o período de 10 meses. Rev Bras Crescimento Desenvolv Hum 2012;22(3):283-90. [ Links ]

23 Militao AG, Karnikowski MGO, da Silva FR, Militao ESG, Pereira RMS, Campbell CS. Effects of a recreational physical activity and healthy habits orientation program, using an illustrated diary, on the cardiovascular risk profile of overweight and obese schoolchildren: a pilot study in a public school in Brasilia, Federal District, Brazil. Diabetes Metab Syndr Obes 2013;6:445-51. [ Links ]

24 da Silva LS, Fisberg M, de Souza Pires MM, Nassar SM, Sottovia CB. The effectiveness of a physical activity and nutrition education program in the prevention of overweight in schoolchildren in Criciuma, Brazil. Eur J Clin Nutr 2013;67(11):1200-4. [ Links ]

25 Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health 1998;52(6):377-84. [ Links ]

26 Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg 2010;8(5):336-41. [ Links ]

27 Cohen J. Statistical Power analysis for the behavioral sciences. 2nd ed. Hillsdale, NJ: Erlbaum; 1988. [ Links ]

28 Steinberger J, Jacobs DR, Raatz S, Moran A, Hong CP, Sinaiko AR. Comparison of body fatness measurements by BMI and skinfolds vs dual energy X-ray absorptiometry and their relation to cardiovascular risk factors in adolescents. Int J Obes (Lond) 2005;29(11):1346-52. [ Links ]

29 Goncalves VS, Faria ER, Franceschini C, Priore SE. Predictive capacity of different bioelectrical impedance analysis devices, with and without protocol, in the evaluation of adolescents. J Pediatr (Rio J) 2013;89(6):567-74. [ Links ]

30 Freedman DS, Horlick M, Berenson GS. A comparison of the Slaughter skinfoldthickness equations and BMI in predicting body fatness and cardiovascular disease risk factor levels in children. Am J Clin Nutr 2013;98(6):1417-24. [ Links ]

31 Ekelund U, Poortvliet E, Yngve A, Hurtig-Wennlov A, Nilsson A, Sjostrom M. Heart rate as an indicator of the intensity of physical activity in human adolescents. Eur J Appl Physiol 2001;85(3-4):244-9. [ Links ]

32 Silveira JA, Taddei JA, Guerra PH, Nobre MR. Effectiveness of school-based nutrition education interventions to prevent and reduce excessive weight gain in children and adolescents: a systematic review. J Pediatr (Rio J) 2011;87(5):382-92. [ Links ]

33 Martínez-Gómez D, Martínez-De-Haro V, Del-Campo J, Zapatera B, Welk GJ, Villagra A, et al. Validez de cuatro cuestionarios para valorar la actividad física en adolescentes españoles. Gaceta Sanitaria 2009;23(6):512-7. [ Links ]

34 Puyau MR, Adolph AL, Vohra FA, Butte NF. Validation and calibration of physical activity monitors in children. Obes Res. 2002;10(3):150-7. [ Links ]

35 Schmitz KH, Treuth M, Hannan P, McMurray R, Ring KB, Catellier D, et al. Predicting energy expenditure from accelerometry counts in adolescent girls. Med Sci Sports Exerc 2005;37(1):155-61. [ Links ]

36 Taber DR, Stevens J, Murray DM, Elder JP, Webber LS, Jobe JB, et al. The effect of a physical activity intervention on bias in self-reported activity. Ann Epidemiol 2009;19(5):316-22. [ Links ]

37 Castilho SD, Barros-Filho AA. Anthropometry in Relation to Sexual Maturation. In: Preedy VR, editor. Handbook of Anthropometry: Physical Measures of Human Form in Health and Disease. New York: Springer; 2012. p.1385-1403. [ Links ]

38 Ministério da Saúde. Escolas promotoras de saúde: experiências do Brasil. 6 ed: Brasília: Ministério da Saúde; 2006. 333 p. [ Links ]

39 Kopp D, Prat I, Azevedo M. Intervenções escolares de médio e longo prazo para promoção de atividade física: Revisão sistemática. Rev Bras Ativ Fis Saúde 2014;19(2):142-52. [ Links ]

Received: January 05, 2015; Accepted: April 21, 2015

Creative Commons License This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.