INTRODUCTION. Prior Studies Analyzing Schoolbased Nutrition Interventions

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1 Research Article A Content Analysis of Kindergarten-12th Grade School-based Nutrition Interventions: Taking Advantage of Past Learning Mary G. Roseman, PhD, RD, LD 1 ; Martha C. Riddell, DrPH, RD 2 ; Jessica N. Haynes, MS, RD, LD 3 ABSTRACT Objective: To review the literature, identifying proposed recommendations for school-based nutrition interventions, and evaluate kindergarten through 12th grade school-based nutrition interventions conducted from Design: Proposed recommendations from school-based intervention reviews were developed and used in conducting a content analysis of 26 interventions. Participants: Twenty-six school-based nutrition interventions in the United States first published in peer-reviewed journals from Variable Measured: Ten proposed recommendations based on prior analyses of school-based nutrition interventions: (1) behaviorally focused, (2) multicomponents, (3) healthful food/school environment, (4) family involvement, (5) self-assessments, (6) quantitative evaluation, (7) community involvement, (8) ethnic/heterogeneous groups, (9) multimedia technology, and (10) sequential and sufficient duration. Analysis: Descriptive statistics. Results: The most frequent recommendations used were: (1) behaviorally focused components (100%) and (2) quantitative evaluation of food behaviors (96%). Only 15% of the interventions included community involvement or ethnic/heterogeneous groups, whereas 31% included anthropometric measures. Five of the 10 proposed recommendations were included in over 50% of the interventions. Conclusions and Implications: Rising trend of overweight children warrants the need to synthesize findings from previous studies to inform research and program development and assist in identification of high-impact strategies and tactics. Key Words: school interventions, child, adolescent, overweight, nutrition (J Nutr Educ Behav. 2011;43:2-18.) INTRODUCTION Childhood obesity is a major epidemic in the United States (US). The prevalence of overweight children and adolescents in the US has more than doubled over the past 20 years, and an estimated 17% of today s youth ages 2-19 years are considered overweight. 1 Overweight children are more at risk for associated adult health problems, including cardiovascular disease, type 2 diabetes, stroke, hypertension, several types of cancer, and osteoporosis. 2 Moreover, the probability that childhood weight problems will continue into adulthood increases from approximately 20% at age 4 years to between 40%-80% by adolescence. 3 A 2005 Institute of Medicine report presented a strong argument in favor of addressing childhood obesity as a collective responsibility involving many different sectors, including federal, state, and local governments; communities; schools; industries; media; and families. 4 Specifically, schools are an excellent environment to efficiently promote positive health 1 Department of Nutrition and Hospitality Management, University of Mississippi, University, MS 2 Department of Health Services Management, University of Kentucky, Lexington, KY 3 Cincinnati Health Department, Cincinnati, OH Address for correspondence: Mary Roseman, PhD, RD, LD, Department of Nutrition and Hospitality Management, 214 Lenoir Hall, Sorority Row, University, MS 38677; Phone: (662) ; mroseman@olemiss.edu Ó2011 SOCIETY FOR NUTRITION EDUCATION doi: /j.jneb behavior modifications, since schools reach more than 95% of all US children 5-17 years of age. 5 No other institution has as much continuous and intensive contact with children during their first 2 decades of life. 6 Schools continue to be an important location for childhood obesity prevention interventions. However, it is imperative that school-based interventions be developed and implemented to achieve maximum results. A periodic review of research on school-based nutrition interventions provides the opportunity to examine previous research and identify successful strategies and tactics for future studies that will lead to improved health outcomes in children. Prior Studies Analyzing Schoolbased Nutrition Interventions Since 1995, 15 school-based nutrition intervention reviews have been published in the literature One review 2 Journal of Nutrition Education and Behavior Volume 43, Number 1, 2011

2 Journal of Nutrition Education and Behavior Volume 43, Number 1, 2011 Roseman et al 3 had a broad inclusion of school-based interventions between , 7 whereas a second analysis described intervention studies between specifically within the context of different types of evaluation measures used. 8 Another study reviewed only interventions with at least a 6-month duration, 9 whereas 2 studies focused on interventions for the prevention or treatment of obesity. 10,11 Four of the 15 analyses focused on specific types of interventions or specific components of the intervention, such as measuring program implementation 12 or increasing fruit and vegetable consumption Two articles reviewed only adolescent nutrition interventions, 16,17 and 6 reviews were limited to school-based interventions with weight-related measures as outcomes (body mass index, body weight, skinfolds, or other anthropometric measures). 9,17-21 Recommendations from Prior School-based Nutrition Intervention Analyses Twelve of the 15 analyses 7-11,13,16-21 of school-based nutrition interventions contained in the literature offered recommendations for future programs. In distilling these recommendations, the authors of this study propose that 10 suggestions are prevalent when developing school-based interventions. 1. Nutrition interventions are most effective when they are behaviorally focused; studies focusing on specific behaviors resulted in more behavioral change than general nutrition education programs. 7,16 2. The use of multicomponent interventions that address multiple influences on health behavior such as family norms, nutrition knowledge, accessibility of healthful food options, and the social environment 22,23 is important. Multicomponent programs often include a combination of elements within the overall school-based intervention. 3. Healthful changes in the food and school environment (ie, National School Breakfast and Lunch Programs, a la carte food, vending machines, school stores, marketing, and advertising) can improve behavior changes at the population level. 10,11,18 Intervention effectiveness has been found to increase through food environmental changes such as increased availability and familiarity of healthful food, social learning, and reinforcement. 7,16 4. Family involvement enhances the effectiveness of school-based programs, 9,13,17 especially in changing the behavior of younger children. 7,18 Particular attention is needed on how best to engage the family 21 and make healthful changes in the home. 8 Less evidence supports the usefulness of parental involvement in middle school and high school children Incorporation of student self-assessments containing a feedback component is effective in middle school or older students. Selfassessments often include food records, diaries, frequencies, checklists, and 24-hour recalls. 7,16 However, food recalls and records can be labor intensive, analytically exhaustive, and costly, whereas scannable food frequency forms may be more appealing Inclusion of quantitative evaluation measures that capture food-related behaviors, eating patterns, 8 and anthropometric measures 17,19 is important. Quantitative measures remain more desirable than qualitative measures; 19 however, the inclusion of qualitative measures is integral in determining the success of an intervention in other areas such as efficacy and adoption of educational protocols by students, along with satisfaction and cultural suitability of the intervention Interventions with links to the larger community can enhance school nutrition interventions. 7,11,13,18 8. More studies should include ethnic/cultural groups to determine effective strategies and approaches for specific groups versus using entire school populations. 7,9,16 In addition, greater attention should be given to the difficulty of targeting 17 and measuring 9 a heterogeneous group. 9. Usage of innovative multimedia technology tools such as multimedia games, video, and Web-based instruction may enhance children s engagement in the intervention when delivered in formats easily tailored to the audience, 21 providing positive benefits over traditional media approaches. 18 This approach is relevant to children today, most of whom are familiar with technology from an early age and easily adapt to the incorporation of new technology into nutrition education Nutrition education should be sequential, with sufficient duration and intensity, and include developmentally appropriate strategies. 7,20 Short-term interventions with a duration of less than 6 months have experienced positively significant results, whereas the continuation of positive results long-term has not been observed; 19 therefore, the incorporation of long-term follow-up measurements is critical. Comprehensive planning from kindergarten (K)-12th grade is needed instead of sporadic approaches, including appropriate decision-making skills integrated across a variety of subject areas. 7,16 The purpose of this study was to explore and analyze K-12th grade school-based nutrition interventions by performing a comprehensive content analysis. Content analysis is an observational research method that is used to systematically evaluate the symbolic content of all forms of recorded communications, 24 or simply, ameansofanalyzingtexts. 25 This research summarized and compared school-based nutrition interventions recorded in the literature from Unique to this study, the program components were then compared to the authors 10 proposed recommendations for school-based interventions based on 12 prior content analyses. 7-11,13,16-21 METHODS Bos and Tarnai s model provided a framework of methodological steps that were followed in the content analysis. 25 The data collection steps included a comprehensive search of peer-reviewed journal databases using the following keywords: school, elementary school, middle school, high

3 4 Roseman et al Journal of Nutrition Education and Behavior Volume 43, Number 1, 2011 school, nutrition, intervention, childhood obesity, childhood overweight, and adolescent overweight. Databases searched included PubMed, ERIC, Academic Search Premier, and Ovid SP Medline. Studies were selected for inclusion based on the following criteria: (1) publication in English; (2) implementation of the intervention in a school setting; (3) location of the intervention in the US; (3) first publication in peer-reviewed journals between 2000 and 2008; (4) obesity- or nutritionrelated health intervention with quantitative measures; and (6) study participants in K-12th grade. Studies excluded from this analysis were those that were clinically oriented or focused only on a specific subpopulation, such as pregnant teenagers, overweight children, or youth at risk for diabetes. Also, physical activity interventions, foodservice/vending interventions, or before- and after-school programs were excluded except when the activities were part of the overall school nutrition education program; however, interventions that focused only on general nutrition education were included. Multiple publications from the same study were counted as only 1 intervention. Based on previous work, 7 the intervention components were then analyzed to determine whether a study was behaviorally focused, knowledge based, or both. Behaviorally focused interventions were defined as programs that provided a theoretical framework or addressed personal factors, environmental factors, and the behavioral change process through the nature of the intervention. Knowledge-based interventions contained curricula generally provided by teachers or trainers with dissemination of information and measurement of knowledge. For example, foodservice and parental involvement components were considered behaviorally focused, whereas classroom nutrition education was considered knowledge based. Additional investigation included examining each study to determine its usage of the 10 recommendations proposed in this study from previous school-based intervention analyses. Findings were summarized and frequencies were tabulated for comparison across studies. Each intervention was numbered 1-26 by increasing age of the target population; for example, program 1 included kindergarteners and programs included 12thgraders. Specific to this study, for recommendation 7, community involvement was defined as public and private businesses, organizations, and individuals involved in a school-based program that did not have a common association or routine involvement with the school. RESULTS Table 1 shows that of the 26 studies, 17 (65%) targeted elementary-aged children (K-5th grade), 6 studies (23%) targeted middle school-aged children (6th through 9th grade), and 3 studies (12%) targeted high school students (9th-12th grade). [Note: grade levels for middle school vary in the US: 6th through 8th grade, 7th and 8th grade, or 7th through 9th grade. In this study, 6th grade was considered elementary school when the study sample included lower grades, whereas 9th grade was considered middle school when the study sample included lower grades.] The sample sizes, which are listed as stated in the literature, varied in terms of measurement. Some studies quantified the number of students, whereas others stated the number of schools or classes or included a combination of measurements. Interventions ranged from 36 students to 2,883 students and from 1 school to as many as 41 schools. The sample selection methods also varied; 17 studies (65%) were randomized, 24 studies (92%) were controlled, and 4 studies (15%) used matched pairs. Studies used a variety of evaluation measures; over half of the studies included pre- and poststudy questionnaires and surveys. Other evaluation measures are provided in Table 1. Studies were conducted in 16 states, and 4 states were involved in 42% of the interventions: Minnesota (4), Florida (3), North Carolina (2), and California (2). The results and conclusions reported in each study are presented in Table 2. An analysis of the components of school-based nutrition interventions (Table 3) found that the majority (85%) of programs used both knowledgebased and behaviorally focused components, whereas 4 studies focused on behavior modification only. Establishing a specific curriculum for classroom nutrition education (85%) was the highest frequency component. The secondhighest frequency component was parental involvement at home (62%), followed by training teachers as an element of classroom nutrition education (42%), disseminating physical education materials (42%), increasing fruits and vegetables in school food service (38%), and providing incentives for students or families (38%). Lessfrequent components included involvement of parents at school (8%), establishment of foodservice guidelines (15%), and inclusion of incentives for schools (12%). Table 4 summarizes the analysis of the usage of this study s 10proposed recommendations for K-12th grade nutrition interventions. The recommendations used most often were the incorporation of behaviorally focused interventions (100%) and quantitative evaluation of food behaviors and eating patterns (96%), followed by interventions involving multiple components (88%) and families involved in the program (62%). Another recommendation frequently employed was the incorporation of healthful changes in the food and school environment (54%). Based on previous literature, 10,19 interventions that were at least 6 months in duration (42%) were counted as meeting the proposed recommendation of providing nutrition education that was sufficient in duration and intensity. Multimedia technology was incorporated in slightly more than one third of the interventions (35%). Other proposed recommendations such as usage of anthropometric evaluation measures (31%), inclusion of ethnic/cultural groups (15%), and involvement with the community (15%) were not used as frequently in school-based interventions. Self-assessments, a recommendation that applied to middle school and high school interventions only, were present in 33% of studies targeting that population. DISCUSSION Ten Proposed Recommendations for School-based Interventions Behaviorally focused nutrition interventions. All of the studies in this analysis included behaviorally

4 Table 1. Study Design Components of K-12 School School-Based Nutrition Interventions in the United States by Target Population Grade (January 2000-December 2008) Program Target Grade Goal Sample Size a Race/ ethnicity Sample Selection Evaluation Measures Duration and Intensity b ID # Name R C M Overall Classroom Nutrition Education 1 Multi-component Elementary Nutrition Education Program 53 K-1 Increase F/V knowledge and consumption during school lunch 6 classrooms, 150 students P - Black U U Pre/post-test knowledge change and follow-up, plate waste assessments during lunch periods 5 wk 10 lessons NP 2 Shape Up Somerville 33, Prevent weight gain through a community-based environmental change intervention 3 Kids Choice 44 1,2,4 Increase F/V consumption and preference ratings using token reinforcement, food choice, and peer participation 4 Cafeteria Power Plus Increase F/V consumption at lunch 5 Effects of Social Cognitive 2-3 Determine effects of Social Theory 52 Cognitive Theory-based nutrition education program on dietary behavior, nutrition knowledge 6 Wise Mind Pilot Project Weight gain prevention (particularly in children with BMI $85th percentile) focused on modification of eating habits and physical activity 7 Gimme Impact F/V consumption and psychosocial variables 30 schools, 1,178 students MC U Ht/wt, BMI z scores (pre/post), Substudy included formative research focus groups, direct observation, survey (pre/post) 188 students P - White U U Direct observation, student interviews (pre/post) Location (state) 1 school yr 30-min lesson/wk MA 6 wk No classroom education PA 26 schools, 1,668 students P - White U U Direct observation 2 school yr No classroom education MN 1,100 students P - White U Game and questionnaire 8 wk 6 weekly classes AL (pre/post) 4 schools, 586 students 16 schools, 1,172 students 8 High 5 46, Influence F/V consumption 28 schools P - White U U Observations, self-reported checklists, surveys, 24-h dietary recall interviews (pre-post) P - White U U Ht/wt, % body fat, weight gain prevention, food selection, plate waste, selfadministered physical activity assessment and psychosocial variables 2 school yr NP NP P - White U U U 7-day food record, parent 2 school yr NP NP telephone interview, observations 1 school yr; 3 booster sessions the next year 14 lessons NP (Continued) Journal of Nutrition Education and Behavior Volume 43, Number 1, 2011 Roseman et al 5

5 Table 1. (Continued) Program Target Grade Goal Sample Size a Race/ ethnicity Sample Selection Evaluation Measures Duration and Intensity b ID # Name R C M Overall Classroom Nutrition Education 9 Pathways Promote healthful eating, increase physical activity, and reduce percentage of body fat 41 schools, 1,704 students P-American Indian U U Anthropometry, motion sensors, self-reported activity questionnaires, Knowledge, Attitudes & Behaviors (KAB) questionnaires, direct observation, 24-h recall 3 yr 48 hr over 3 yr AZ, NM, SD 3-5 Develop more healthful 4 Improve nutrition knowledge 10 Jump Into Foods and Fitness (JIFF) 60 lifestyles (improve nutrition and physical activity knowledge and behavior) 11 Garden Enhanced Nutrition Curriculum 49 and vegetable preferences 130 students P - Black U Knowledge and behavior questionnaire (pre/post test, follow-up) Location (state) 14 wk Seven 1-h lessons SC 213 students P - White U Student questionnaire and 17 wk 9 lessons semi-weekly CA preference survey (pre-post) 12 Squire s Quest 62 4 Increase F/FJ/V intake 26 schools, MC U U U Student pre/post 24-h dietary 5 wk Ten 25-min sessions TX 1,578 students intakes 13 Improving Meals and Physical Activity in Children and Teens (IMPACT) 63 4 Improve nutrition and physical activity knowledge, attitudes, and behaviors 75 students, 4 classes P - White U U Texas School Physical Activity and Nutrition (SPAN) questionnaire (pre/post); BMI percentile for age (pre/post) 12 wk 1-h lesson/wk NC 14 Wellness, Academics, and You (WAY) Healthy Whole Grain Choices: A multicomponent pilot intervention Evaluate effectiveness of multidisciplinary intervention on BMI, consumption of F/V, and physical activity 4-5 Increase consumption of whole grains 4-5 Improve nutrition and 4-6 Examine effect 16 Healthy Lifestyle Program 68 healthful lifestyle knowledge 17 School Nutrition Policy Initiative 43 on prevention of obesity/ overweight by a multicomponent School Nutrition Policy Initiative 1,013 students, 69 classes, 4 states 2 schools, 150 students NP U U BMI calculated on ht/wt measurements (pre-post) and individual student surveys (pre-post) MC U Pre/post meal observations, knowledge questionnaire for children, questionnaire for parents 4-5 mo NP DE, FL, KS, NC 3 mo Five 45-min lessons MN 36 students P - White Pre/post test 5 wk Five 35-min lessons NP 10 schools, 1,349 students MC U U U Ht/wt, BMI z scores, dietary intake (Youth/Adolescent Questionnaire), physical activity and sedentary behavior (Youth/Adolescent Activity Questionnaire), body image (Eating Disorder Inventory-2) pre/post, incidence of overweight and obesity 2 yr Average 92 h/yr NP 6 Roseman et al Journal of Nutrition Education and Behavior Volume 43, Number 1, 2011

6 6 Increase F/V consumption 18 Garden-Based Nutrition Education 50 through garden-based nutrition education 19 Project Healthy Schools 42 6 Determine impact of multidisciplinary education program on atherosclerosis risk factors 20 Middle School Physical Activity and Nutrition (M-SPAN) 35, Increase physical activity at school and decrease total saturated fat purchased or brought to school 6-9 Determine impact of Michigan 21 Michigan Model (MM) Nutrition Curriculum 65 Model Nutrition Curriculum on nutrition knowledge, eating behaviors, and efficacy expectations 22 Teens Eating for Energy and Nutrition at School (TEENS) Using technology to promote healthful eating Trying Alternative Cafeteria Options in Schools (TACOS) Increase consumption of healthier foods 7-9 Increase self-efficacy and healthful eating among adolescents through classroom and Web interventions 9-12 Increase sales and choices of lower-fat a la carte food in school cafeterias through increased availability and studentbased promotions. 99 students NP U U 24-h food recall workbooks (pre/post) 287 students P - White Pre/post ht/wt, BP, BMI, school physical activity and nutrition survey (SPAN), cholesterol panel, random blood glucose 24 schools MC U U Direct observation, existing records, 7-d recall survey, cafeteria sales 576 students P - Black U Questionnaire of eating habits, nutrition knowledge, and efficacy expectations regarding healthful eating (pre/post-test) 16 schools, 2,883 students 2 schools, 121 students P - White U U U 24-h dietary recall, student survey, parent survey MC U U Pre/post test, 3 sections of the Health Behavior Questionnaire: dietary self efficacy for Y fat and sodium, usual food choices, and which is better for health. F/V consumption SE scale, Youth and Adolescent Food Frequency Questionnaire, and Gimme 5 Dietary knowledge for F/V questionnaire 10 schools P - White U U Computerized a la carte sales data on percentage of Yfat food sales, collection of promotional activity 12 wk 12-wk curriculum ID 1 school yr 10 classroom modules NP 2 school yr No classroom education CA 1 mo 8 lessons (8-10 h total) MI 2 yr 10 lessons/yr MN 1 mo 5 h Web-based and 10 h classroom NP 2 school yr NP MN (Continued) Journal of Nutrition Education and Behavior Volume 43, Number 1, 2011 Roseman et al 7

7 8 Roseman et al Journal of Nutrition Education and Behavior Volume 43, Number 1, 2011 Table 1. (Continued) Duration Location and Intensity b (state) Evaluation Measures Sample Selection Goal Sample Race/ Size a ethnicity Program Target Grade ID # Name R C M Overall NP Five 45-min sessions FL Classroom Nutrition Education 3 schools MC U BMI calculation, 24-h recall, food frequency questionnaire, nutrition knowledge questionnaire, physical activity questionnaire for adolescents, dietary and exercise confidence survey, and social support survey (pre/post) 9-12 Determine whether method of delivery of education influences behavior change in adolescents 25 Method of delivery of nutrition and physical activity information 64 1 wk Two 30-min presentations FL P - White U U Pre/post test evaluation instrument 14 schools, 880 students 9-12 Improve nutrition knowledge and develop positive attitudes to avoid overweight and obesity 26 Present and Prevent minimal intervention teen obesity prevention program 67 Y indicates decrease; [, increase; A, attitudes; B, behavior; BMI, body mass index; BP, blood pressure; C, controlled; F, fruit; FJ, fruit juice; F/V, fruit/vegetable; h, hours; Ht/wt, height/weight; K, knowledge; M, matched; MC, multicultural/heterogeneous population; mo, months; NP, information not provided; P, predominant race/ethnicity (60% or >); R, randomized; SE, self-efficacy; V, vegetable; wk, weeks; y, years. a Terms of measurement for sample size are listed as stated in the publication. Some quantified the number of students, whereas others stated the number of schools or classes or included a combination of these measurements; b Overall denotes length of the entire intervention. Classroom Nutrition Education denotes length of nutrition education component of the intervention. focused interventions. This finding is encouraging documentation that recommendations by previous researchers are being incorporated into practice. 7,16 Multicomponent interventions. The second proposed recommendation dealt with the development of multicomponent interventions. This study categorizedschool-basednutritioninterventions as multicomponent if they contained 2 or more elements, such as food service, classroom nutrition education, physical activity, parental involvement, or peer involvement. Almost all of the interventions included multicomponents in the intervention. In agreement with earlier analyses, future studies examining the optimal and most effective blend of interventional components are needed. 9,18 The classroom nutrition education component, which generally encompassed implementation of curriculum and teacher training, was included in a majority of the interventions. In contrast, fewer of the interventions included physical activity or peer involvement as components. Though this study excluded interventions solely focused on physical activity, it is encouraging to note the inclusion of physical activity in some school-based nutrition interventions. Research has noted that the extent to which physical activity has contributed to weight reduction is minimal; however, lack of evidence of effectivenessisnotthesameasevidence of ineffectiveness. 9 One intervention extensively incorporated multiple components: physical activity, the establishment of curriculum, training of foodservice workers, and parental/ family and community involvement Healthful changes in the food and school environment. The third proposed recommendation addressed healthful changes in the food and school environment, including the National School Breakfast and Lunch Programs, a la carte food, vending machines, school stores, and marketing and advertising. Many of the programs included elements of environmental change. For example, interventions included lowering fat, increasing the number of fruit and vegetable offerings, 27,33-36,38,40-42,44-47

8 Journal of Nutrition Education and Behavior Volume 43, Number 1, 2011 Roseman et al 9 or increasing intake of whole-grain food. 48 An innovative environmental change included gardening activities incorporated into nutrition educational programs. 49,50 Reinforcements of behavioral changes in the food and school environment were used in several studies. A former professional athlete supported an intervention through videotaped messagestoparents, 51 and foodservice staff reinforced and encouraged children to try healthful or new food. 45 In 1 study, nutrition educators served as role models by eating with the children, 52 whereas classroom assistants rewarded healthful choices through stickers and praise 53 and tokens were awarded weekly based on fruit or vegetable lunch consumption. 44 Family involvement. Previous analyses have recommended incorporating parents and family in school-based interventions. The family can shape children s dietary and physical activity patterns through decisions they make with regard to availability of food, opportunities for recreation and exercise, and control of resources. 54 Research has found that parent involvement in school-based nutrition education does make a difference in younger children, 55 whereas other research has discovered difficulty in getting families involved and demonstrating the effectiveness of family participation in student-level outcomes To increase participation, incentives and services to address conflicts with work, challenges with transportation, and other barriers that hinder family involvement have been recommended. 59 This study found a variety of methods were employed to educate or remind family members of desired nutrition behaviors. The most common method was newsletters sent home, 34,35,38,41,48,49,51,53,60,62 whereas other methods included sending home brochures, 46,47 video tapes emphasizing modeling of desired behaviors, 51 and trinkets such as magnets. 46,47 Other activities that focused on involving family included creation of a Web site, 61 usage of Parent- Teacher Association meetings, 35,43 classroom role playing on how to talk to parents about health issues, 61 family member interviews about family health history, 61 discussions of meals and physical activity with parents, 61 and development of a cookbook using caregivers contributions. 53 One intervention educated children on selecting after-school snacks and vegetables at grocery stores while encouraging children to ask for favorite fruits and vegetables at home. 62 Another intervention included educating the family on ways to incorporate more vegetables into the dinner meal and providing fruit and vegetable behavioral coupons to reward serving fruits and vegetables at home. 38 Family participation was encouraged through a kickoff event, 46 parent forums, 34 parent-child homework, 38,46,47,63 recipes of food to prepare at home, 46,47 and bakery, milling museum, and grocery store tours. 48 Families were also involved in different forms of intervention evaluation through surveys regarding impact, 35 food availability at home, 38,39 and perceived social support to children s health-related eating and exercise behaviors. 64 Student self-assessments. This study proposed the use of feedback through food diaries, self-assessments, and goal measurements as a worthwhile component of school-based nutrition interventions involving middle and high school students. Various feedback components were incorporated, such as food recall workbooks for a pre-post intervention 50 and a student self-assessment survey. 40 One intervention included assessments by students of a typical day s diet followed by development of an improved diet plan, 65 whereas another incorporated a food record activity to teach students how to assess their diet and make appropriate changes The Youth and Adolescent Food Frequency Questionnaire was used to measure consumption of fruit, vegetables, and fat, 66 whereas the Goals for Health Questionnaire, a shortened version of the Youth and Adolescent Food Frequency Questionnaire instrument, along with 24-hour recalls were also used. 64 Quantitative evaluation measures of food-related behaviors and anthropometric measures. One criterion for inclusion in this review was the presence of a quantitative measurement of the nutrition intervention; therefore, all studies contained this recommendation. Although other reviews have limited analysis to only those studies with anthropometric measurements, 9,17,19-21 food-related behaviors and eating patterns can be assessed through surveys, direct observation, dietary recalls, food-purchasing records, and other means to provide valid outcome data. However, like a previous review, 13 this analysis continues to show a lack of standardized methodology for dietary assessment. Pre- and post-surveys were used frequently to assess knowledge and behavior change. 26,33,41-43,48,49,52,53,60-68 For younger children, direct observation was a common measurement method ,41,44-48,51,53 Food recall records were often included as sources of data, 35-39,42,50,51,53,62,64,68 with several noting recalls in formats specific for the age of the school children. Anthropometric measures were included in a minority of interventions, 26-32,34,41-43,61,63,64, possibly owing to difficulty and cost to administer. A few interventions reviewed cafeteria and a la carte sales or production data for pre and post changes. 35,36,39,40 In addition to quantitative evaluations, several interventions incorporated qualitative evaluations in their methods. Interviews with students, staff, parents, or key informants 34,44,51 and focus groups 33,34 are examples of qualitative approaches used. One study was an exception and did not include anthropometric measurements or measurements of food behaviors/patterns, but it did include a quantitative evaluation focusing on nutrition and healthful lifestyle knowledge. 68 Community involvement. The National Institutes of Health have called for the development and evaluation of trans-site interventions for the prevention and control of obesity. 69 Trans-site interventions attempt to connect different organizations that are involved with children and families, potentially providing continuity, reinforcement, and synergy in promoting and maximizing health behavior change. 18 Although the Centers for Disease Control and Prevention have developed a model, the Coordinated

9 10 Roseman et al Journal of Nutrition Education and Behavior Volume 43, Number 1, 2011 Table 2. Reported Results and Conclusions from K-12 School-based Nutrition Interventions in the United States (January December 2008) Program ID # Results Conclusion 1 Students in the intervention group demonstrated significantly increased nutrition knowledge compared to the C group (P <.001). This increased knowledge was maintained at the 1-month follow-up. Vegetable consumption did not show an increase for the original intervention group. However, the delayed intervention group did show a significant increase in consumption of vegetables following the intervention (P <.001). The study highlights the importance of implementing nutrition education programs that include knowledge and behavior change components. The study illustrates the role school psychologists can play in health promotion in schools. 2 BMI z score in the intervention community decreased significantly (P ¼.001) compared to C communities. A substudy using public address messages to promote new low-fat, high-fiber entrees found no significant change in menu choice for all schools combined, but choice was significantly higher in school compared to matched C school with highest dose of intervention (P <.001). 3 F/V consumption increased throughout reinforcement conditions and was maintained 2 weeks postprogram. 7 months post, F/V preference returned to baseline. 4 Students in test group significantly increased total fruit intake (P <.001). Verbal encouragement from foodservice staff was associated with outcomes. 5 T group exhibited significantly greater improvement (P <.001) in overall dietary behavior and nutrition knowledge vs C group. 6 Weight gain prevention program participants showed reduced caloric and dietary fat intake, Y protein intake, [ physical activity compared to C and to baseline. No difference between program and C in weight gain prevention. 7 Improved F/FJ/V combined consumption, F/FJ/V at weekday lunch, eating F/FJ/V self-efficacy, social norms, asking behaviors and knowledge. 8 Significant increase (P <.001) of F/V consumption by intervention group compared to C at Follow-up 1 and 2, high student willingness to participate in classroom activities, moderate parental involvement, high cafeteria staff participation. 9 Reduced % energy from fat at lunch in intervention schools (P ¼.005). Reduced total energy intake in the intervention schools as measured by 24-h recall (P ¼.003). Significantly positive changes in food choice intentions (P ¼.001) and in health-related knowledge for 3 rd -5 th grade schoolchildren (3 rd grade P ¼.001; 4 th grade P ¼.013; 5th grade P ¼.001). A multifaceted intervention approach that included the community, schools, students, and families significantly decreased the BMI z score in children at high risk of obesity. Public address announcement substudy showed promise as effective and appropriate communication channel, but only in schools able to play message frequently, which suggests a dose/response relationship. There is need for ongoing program to keep preferences high. Multicomponent interventions are more powerful than cafeteria programs alone in elementary school age. Nutrition education programs that teach positive dietary messages can potentially improve dietary behavior and increase nutrition knowledge. Behavioral changes of more healthful eating and increased physical activity compared to C were recorded by participants in the weight gain prevention program. Significant changes in body weight were not recorded. Theory-based school nutrition education program can help change children s F/FJ/V consumption and influence factors at home that predispose to F/FJ/V consumption; persistence is unknown. Strong effects were found for F/V consumption, macro-and micronutrients, and psychosocial variables. Multicomponent program is feasible for American Indian elementary schoolchildren. Intense and/or longer intervention may be beneficial in modifying the trend in American Indian schoolchildren of higher adiposity. (continued)

10 Journal of Nutrition Education and Behavior Volume 43, Number 1, 2011 Roseman et al 11 Table 2. (Continued) Program ID # Results Conclusion 10 Intervention group significantly improved pre/post test on all food and nutrition behaviors and fitness activities. Follow-up data indicated intervention group maintained improvement in all behaviors (P <.005) after 5 months. 11 Intervention significantly improved student nutrition knowledge (P <.001) for both the nutrition-only intervention and for the nutrition intervention with garden sites compared to the C. These results were maintained at the 6-month follow-up. Preference scores for vegetables were significantly higher posttest by the nutrition-only intervention group and the nutrition intervention with garden sites for carrots (P <.005) and broccoli (P <.01). The nutrition intervention with garden sites also had significantly greater scores than the C group and the nutrition only group for snow peas (P <.005) and zucchini (P <.001). The results for broccoli, snow peas, and zucchini were retained at 6-month follow-up. 12 F/FJ/V consumption increased by 1.0 serving for T group compared to C group following a psychoeducational multimedia training game intervention. 13 Intervention group reported increased F/V (þ0.85 servings/d compared with C; P <.05) and improved knowledge of food group required servings (P <.01). Increased consumption of calcium-rich food and grains were also reported by the intervention group. 14 The intervention group showed significant positive change (P ¼.01) compared to the comparison group in BMI. Increases in F/V consumption and physical activity were also reported by the intervention group. 15 Consumption of whole-grain food during school lunch increased by 1 serving (P <.001), whereas consumption of refined-grain food significantly decreased by 1 serving (P <.001) for T group compared to C group. Intervention schools significantly increased availability of whole grain food (P <.001) and parenting scores for role modeling (P <.001), and enabling behaviors (P <.05) were significantly higher post-intervention in the intervention group versus the C group. 16 The program resulted in a significant (P <.001) increase in the scores from pre-test to post-test knowledge for nutrition and healthful lifestyles. 17 Significantly fewer children became overweight in the intervention schools (7.5%) than in the C schools (14.9%) after 2 years. The predicted odds of incidence of overweight in the intervention schools was approximately 33% lower than the C schools after controlling for sex, age, and race/ethnicity (P <.05). The intervention was significantly related to positive changes in food consumption, knowledge, foodrelated behaviors, and physical activity behaviors, and these changes were maintained at the 5-month follow-up. Vegetable gardens are effective in enhancing student nutrition education. This psychoeducational multimedia training game resulted in positive changes in dietary behavior among elementary school students. Elementary schoolchildren reported improved dietary behaviors and knowledge following the Improving Meals and Physical Activity in Children and Teens (IMPACT) intervention. This study indicates that reduction of overweight through school-based programs is possible. This school-based program, which incorporated classroom curriculum components, school cafeteria menu changes, and a family component, increased the intake of whole-grains in elementary schoolchildren. The program focused on increasing knowledge to address the increasing problem of overweight children. A comprehensive program that includes interventions to change behavior and attitudes may increase impact. A multicomponent intervention in children in grades 4-6 can be effective in slowing the development of overweight. Additional studies on effect, dose, and range of intervention are recommended, along with implementation of prevention programs in earlier elementary grades. (continued)

11 12 Roseman et al Journal of Nutrition Education and Behavior Volume 43, Number 1, 2011 Table 2. (Continued) Program ID # Results Conclusion Inactivity in intervention group was 4% lower than the C group (P <.01), whereas weekday television viewing was 5% lower in the intervention group (P <.001) than the C group. 18 Adolescents participating in the garden-based nutrition intervention increased F/V consumption (P <.001). Significant increases were also found in vitamin A intake (P ¼.004), vitamin C (P ¼.016), and fiber intake (P ¼.001). 19 Decreases reported in mean total cholesterol value, (P <.001), low density lipoprotein (P ¼.01), highdensity lipoprotein (P <.001), random blood glucose value (P ¼.01), and diastolic blood pressure (P ¼.01). No significant change in reported intake of high-fat or fried protein food or in high-intensity aerobic activity. Intake of F/V increased. Intake of F/V increased. 20 Intervention showed significant effect for physical activity in the total group (P <.009) and for boys (P <.001). Survey data reported a reduced BMI for boys (P <.05) following the intervention. 21 The T group showed significant improvement pre to post and were significantly higher at post in consumption of F (P ¼.047), V (P ¼.018), and other (P ¼.025); demonstrated significant improvement in nutrition knowledge pre to post and compared to the C group, and more confidence they could eat more healthfully. 22 Positive significant effects were seen only for food choice score post-intervention. The intervention schools offered on an a la carte basis a significantly higher number of more healthful menu options than C schools (P ¼.04). A significantly higher number of parents (P ¼.01) of students in the intervention schools reported purchasing more healthful food items as compared to parents of students in the C schools. 23 Significant increase in SE for Healthful Eating (P <.01) was seen in the intervention group for fruits and vegetables and for lower fat (P <.001). The intervention group also showed significant change in usual food choices (P <.001) and dietary knowledge of fat (P <.05) when compared to the C group. The difference between groups for consumption of fruit, vegetables, and fat was not statistically significant. 24 In year 1, total number of promotions was significantly associated with sales of lower-fat food items. In year 2, duration of promotions was significantly associated with sales of lower-fat food items. This study documented increased consumption of F/V by schoolchildren following garden-based nutrition education. This school based program is feasible & appears effective in improving risk factors for atherosclerosis. School environment and policy interventions have the potential to improve student health behavior, but barriers to school food environment and policy changes need further study. Curriculum resulted in significant positive changes in nutrition knowledge and behavior in a pilot study. Recommendations include use of peer leaders, expanded training for teachers, increased targeting of environmental factors in schools, approaches to change the food environment in homes, and development of validated measures for assessing school food environments. The intervention in this study was effective for increasing self-efficacy for healthful eating. Collaborations of foodservice personnel, students, and research staff can be effective in developing promotional activities to increase consumption of lower-fat food. (continued)

12 Journal of Nutrition Education and Behavior Volume 43, Number 1, 2011 Roseman et al 13 Table 2. (Continued) Program ID # Results Conclusion 25 The computer-based intervention group showed more positive behavior change than the traditional education group and the C group. Increased knowledge (P <.001), physical activity (P ¼.001), SE (P <.001), social support (P <.001), and decreased meals skipped (P <.001) all showed significantly positive changes for the computerbased intervention group. 26 The intervention group showed significant improvement posttest on nutrition knowledge (P <.001), intention to maintain healthful weight because it is important to my friends (P <.001) and intention to eat fewer fried food items and sweets, read food labels, and restrict TV watching (all P <.001). The computer-based intervention group showed more positive behavior changes than the traditional education group and the C group. Suggested additions to the computer-based intervention include group discussion and individual feedback. This minimal nutrition education intervention improved nutrition knowledge along with positive behavioral intentions in only 2 class sessions. BMI indicates body mass index; C, control; F, fruit; FJ, fruit juice; F/V, fruit/vegetable; SE, self-efficacy; T, treatment; V, vegetable. Note: Information provided here was extracted from published research articles. Program ID numbers are described in Table 1. School Health Program, to encourage interventions to reach beyond the school boundaries and include health care workers, the media, religious organizations, and community organizations, 70 few interventions in this analysis involved community groups in their efforts. However, Pathways developed a collaborative relationship with the American Indian communities that included participation or leadership in all aspects of the development and implementation of their program. 32 Shape Up Somerville also developed collaborations with ethnic-minority groups by involving community champions and engaging ethnicminority community members and advisory councils throughout the intervention. 34 Bakery, milling museum, and grocery store tours for students and families were included in an intervention focusing on whole grains, 48 and point-of-purchase education regarding fresh produce on family nights at local grocery stores was included in another intervention. 51 A focus on ethnic/cultural or heterogeneous groups. In this analysis, although some studies were conducted in heterogeneous populations, only a few interventions included an ethnic or heterogeneous component/ focus in the intervention. The Pathways study involving American Indian schoolchildren was the only study to focus strictly on an ethnic group. 26 The Jump Into Foods and Fitness intervention was conducted in schools with a high minority population (70% African American/ black), 60 whereas all participants in another study 53 were from an urban, African American school. Innovative multimedia tools. Innovative use of multimedia tools may enhance children s engagement, since it offers a natural point of intervention in itself or enhances other intervention components. 18 A multimedia dietary education game used computer-based psychoeducational multimedia training, which facilitated goal setting by students to increase fruit, juice, and vegetable consumption. 62 One intervention with student-led promotion campaigns incorporated the development of media, TV, and Web-based information spots and public service announcements focusing on healthful nutrition messages, 40 and another intervention 61 used videos to present baseline exercise routines to students. In 3 studies of junior and senior high students, computer-based educational lessons 64 were used in 1 intervention, and the other 2 interventions incorporated Web-based instruction with a trained classroom teacher. 66,67 The use of media to support health education is also an element of innovative multimedia communication. The Gimme 5 intervention included videotapes as a format for parent outreach. 51 To reinforce educational messages, these Music Television (ie, MTV)-like videotapes used a professional basketball player as the spokesperson for the program. Sequential, sufficient duration, and sufficient intensity of nutrition education. The recommendation to provide nutrition education interventions of sufficient duration and intensity creates several assessment challenges for this study. It has been suggested that an average of 50 hours of instruction is necessary to change behavior. 71 As noted in a previous analysis, 16 many of the interventions reviewed did not provide the exactamountoftimeincorporatedin the intervention inhibiting assessment of duration. In contrast, 1 study 43 reported an average of 92 hours of nutrition education per year during a 2-year period. Additionally, the sequential nature of the interventions was difficult to ascertain from most articles. Based on reporting, the Pathways intervention