School-Based Interventions for Healthy Lifestyle Behaviors in Children: Comparison
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Please note this is a comparison between Version 2 by Jason Zhu and Version 1 by Archontoula Drouka.

Diet and physical activity interventions had favorable effects on a series of health outcomes, including anthropometric parameters, biomarkers, eating behavior and self-efficacy. Diet-only interventions had a positive impact specifically on eating habits, mostly on water consumption. Most successful interventions lasted for 1 school year, and they were characterized by parental involvement and teachers’ training.

  • primary school
  • nutrition
  • physical activity
  • children
  • obesity

1. Introduction

Childhood is one of the critical periods for good health and development in human life. During childhood, physiological needs for nutrients increase and the adoption and maintenance of high-quality eating habits is particularly important [1]. A healthful diet during childhood promotes growth and cognitive development of children and may contribute to the prevention of chronic diseases in later life [2,3][2][3]. Similarly, regular physical activity is associated with physiological and mental health benefits, including a low risk of adiposity, improved fitness and optimal cardiometabolic health [4,5][4][5]. Evidence suggests that both eating and physical activity habits adopted early in life track to some extent into adulthood [6,7][6][7]. It is therefore important to establish healthy lifestyle behaviors as early as possible during lifetime. However, dietary consumption surveys show that most children in Europe do not meet these guidelines [8,9][8][9] and a great proportion of children spend less than the recommended 60 min of moderate-to-vigorous physical activity per day [10].
Recent figures also show alarming and increasing numbers of children with overweight or obesity in Europe. Childhood obesity is associated with several short-term physical health consequences, such as adverse blood lipid profile, altered glucose metabolism and obstructive sleep apnea, as well as long-term effects, i.e., higher risk for hypertension, diabetes mellitus, cardiovascular disease, gallbladder disease and osteoarthritis in adulthood [11,12,13,14][11][12][13][14]. The presence of overweight and obesity during childhood has also been linked with psychosocial adverse consequences, including poor self-image, low self-esteem, higher risk for eating disorders and poor quality of life [15]. The increasing prevalence of childhood obesity can be linked to social and lifestyle changes in Europe occurring over the last three decades with the development of unhealthy eating habits (characterized by a high intake of unhealthy lipids and added sugars, as well as by low consumption of complex carbohydrates and fiber) and sedentary way of living (high screen time and low engagement in lifestyle physical activities) [11]. To date, many programs have been developed to promote healthy lifestyle and prevent obesity in children. The vast majority of these programs use schools as the optimal setting for the implementation of interventions targeting school-aged children [16].
Schools are a crucial social environment for children and many attempts have been made to utilize this environment to promote healthful behaviors in youth, including eating and physical activity habits [17,18,19][17][18][19]. School-based interventions have the potential to reach almost 100% of children of diverse ethnic and socio-economic groups. Other influencing factors of eating behaviors in the school environment are the availability of food and beverages, apart from meals served in many countries (e.g., foods provided in vending machines and school stores), and the provision of nutrition education classes. Additionally, schools can promote physical activity as structured physical activity, while sports education is a mandatory part of the school curriculum, and, in many cases, children have to walk from and to school on week days [20]. Thus, schools represent an ideal setting to promote and provide both healthy nutrition and physical activity education [17,21][17][21].

2. Diet-Only Interventions

Most of the successful diet-only interventions examined the potential association of a series of school-based interventions that included and targeted only water intake (two studies) [23,24][22][23] or water intake and nutrition education (one study) [25][24] with relevant environmental changes in order to increase children’s water consumption and decrease their sugar-sweetened beverage consumption. These programs exhibited a good potential for public health impact as they documented improvements in dietary behaviors, such as increased water consumption, decreased free sugar intake and improvement in nutrition-related knowledge. Three interventions were based on the health promotion model [23[22][23][24],24,25], and one of them was also based on the ecological model [24][23]. In addition, mixed modes of intervention delivery were found: one study involved teachers’ training and participation of children’s parents [23][22], another study involved teachers’ training [25][24], and in the third intervention, only children’s parents participated and there was no teachers’ training [24][23]. The DIATROFI program was conducted by directly comparing two different intervention approaches, namely food-voucher approach or free daily meal distribution, and found that the meal distribution intervention was considered more effective than the food voucher one, not only because of its pedagogical benefits, but most importantly because it appeared to improve dietary habits, alleviate food insecurity and break stereotypes for parents and children through universal student participation [26][25]. In the DIATROFI intervention, children’s parents participated without teachers’ training. Four unsuccessful diet-only interventions were identified. All of them were developed without using a specific theoretical framework. One study involved teacher’s training and parents’ involvement [27][26]. Three of the unsuccessful studies had a duration of 6 months [27,28[26][27][28],29], while 1 lasted for only 3 days [30][29]. Even though the three studies reported food knowledge improvement [28[27][28][29],29,30], these results were not translated into lifestyle changes in 2 studies [28[27][29],30], whereas in the fourth study, both positive and negative dietary changes were observed (higher consumption of both healthy and unhealthy foods) [29][28].

3. Diet and Physical Activity Interventions

Among the successful diet and physical activity interventions, three involved teachers’ training and participation of children’s parents [31,32[30][31][32][33],33,34], one involved teachers’ training [35][34] and one involved participation of children’s parents [36][35]. Teachers’ training was conducted through workshops concerning healthy habits for school children and/or through teaching materials (re-printed posters for drinking rules or pre-prints to record children’s fluid intake). In one program, teachers delivered specific education contents (overweight and obesity prevention; concepts of food and nutrition, and dietary guidelines for children and families; hydration and the importance of water; strategies to encourage fruit and vegetable consumption and to reduce intake of low-nutrition, energy-dense foods; appropriate physical activity levels and strategies to reduce screen time; healthy cooking activities), and then they further developed creative and engaging classroom activities on the addressed topics. Themed games and modified sports were performed under the following thematic areas: fun, inclusion and cooperation, and safety. The intervention program of one study was based on the health promotion model and the social cognitive theory [35][34], and the intervention program of another one was based only on the social cognitive theory [33][32]. Both interventions improved children’s dietary behavior, and the intervention that lasted for 2 years had beneficial effects on anthropometric measurements and biomarkers, even though this result concerned children of a specific age (10 years of age). Three studies had a benefit on anthropometric measurements [31,32,33,36][30][31][32][35]. Specifically, one study showed a reduction in the incidence of obesity [31[30][31],32], another one showed an increase in the % of children of healthy body weight [33][32], and one found a reduction in the waist-to-height ratio, but this reduction was recorded only in 10-year-old children [36][35]. Furthermore, two studies had a beneficial effect on biomarkers and blood pressure (BP) [33,36][32][35]. Specifically, blood glucose and triacylglyceride (TAG) concentrations were reduced following the intervention [33][32]. Five studies found favorable change for at least one dietary behavior outcome [33,35,36,37,38,39][32][34][35][36][37][38]. These behaviors included regular breakfast consumption [33[32][36],37], adequate vegetable consumption, moderation in sodium intake [35][34] and adequate fiber intake (shown only in 6-year-old boys) [36][35], and better diet quality [33,39][32][38]. When it came to physical activity behavior, one study showed positive effects on physical fitness and motor skills (speed, coordination, strength, mobility and endurance) [34][33], and another one found decreased time spent on sedentary activities [38,39][37][38]. Finally, one study showed improvement in the self-efficacy of children [37][36].

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