School-based opportunities to improve student healthy eating, physical activity, and prevent obesity: An inventory of evidence-supported options aligned to best practice guideline recommendations

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Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search School-based opportunities to improve student healthy eating, physical activity, and prevent obesity: An inventory of evidence-supported options aligned to best practice guideline recommendations View ORCID Profile Rebecca K Hodder , Kate M O’Brien , View ORCID Profile Nicole Nathan , Sasha Lorien , Peter Butler , Emma Ainsworth , Courtney Barnes , Ashley Blowes , View ORCID Profile Luke Wolfenden doi: https://doi.org/10.1101/2025.06.08.25329223 Rebecca K Hodder 1 Hunter New England Population Health, Hunter New England Local Health District , Newcastle, Australia 2 National Centre of Implementation Science, University of Newcastle , Newcastle, Australia 3 School of Medicine and Public Health, College of Health Medicine and Wellbeing, University of Newcastle , Newcastle, Australia 4 Hunter Medical Research Institute Population Health Research Program , Newcastle, Australia Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Rebecca K Hodder For correspondence: rebecca.hodder{at}health.nsw.gov.au Kate M O’Brien 1 Hunter New England Population Health, Hunter New England Local Health District , Newcastle, Australia 2 National Centre of Implementation Science, University of Newcastle , Newcastle, Australia 3 School of Medicine and Public Health, College of Health Medicine and Wellbeing, University of Newcastle , Newcastle, Australia 4 Hunter Medical Research Institute Population Health Research Program , Newcastle, Australia Find this author on Google Scholar Find this author on PubMed Search for this author on this site Nicole Nathan 1 Hunter New England Population Health, Hunter New England Local Health District , Newcastle, Australia 2 National Centre of Implementation Science, University of Newcastle , Newcastle, Australia 3 School of Medicine and Public Health, College of Health Medicine and Wellbeing, University of Newcastle , Newcastle, Australia 4 Hunter Medical Research Institute Population Health Research Program , Newcastle, Australia Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Nicole Nathan Sasha Lorien 5 The University of Sydney , Camperdown, Australia Find this author on Google Scholar Find this author on PubMed Search for this author on this site Peter Butler 6 Mid North Coast Local Health District , Kempsey, Australia Find this author on Google Scholar Find this author on PubMed Search for this author on this site Emma Ainsworth 7 Community Allied Health, Allied Health Service, Big Rivers Region , NT Health, Australia Find this author on Google Scholar Find this author on PubMed Search for this author on this site Courtney Barnes 1 Hunter New England Population Health, Hunter New England Local Health District , Newcastle, Australia 2 National Centre of Implementation Science, University of Newcastle , Newcastle, Australia 3 School of Medicine and Public Health, College of Health Medicine and Wellbeing, University of Newcastle , Newcastle, Australia 4 Hunter Medical Research Institute Population Health Research Program , Newcastle, Australia Find this author on Google Scholar Find this author on PubMed Search for this author on this site Ashley Blowes Find this author on Google Scholar Find this author on PubMed Search for this author on this site Luke Wolfenden 1 Hunter New England Population Health, Hunter New England Local Health District , Newcastle, Australia 2 National Centre of Implementation Science, University of Newcastle , Newcastle, Australia 3 School of Medicine and Public Health, College of Health Medicine and Wellbeing, University of Newcastle , Newcastle, Australia 4 Hunter Medical Research Institute Population Health Research Program , Newcastle, Australia Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Luke Wolfenden Abstract Full Text Info/History Metrics Data/Code Preview PDF ABSTRACT Background Schools are a valuable setting for the implementation of effective interventions to improve healthy eating, physical activity, sedentary behaviour and prevent overweight and obesity in children recommended by global guidelines. Robust evidence from systematic reviews, considered the gold standard source of evidence to inform public health policy and practice decisions, suggests school-based interventions produce modest improvement however effects across trials are heterogenous. To date no systematic reviews have sought to comprehensively consolidate the global evidence to identify the effectiveness of specific healthy eating and physical activity components of school-based interventions as aligned to current guidelines. Objective To 1) develop an inventory of global guideline-aligned recommendations of school-based healthy eating, physical activity, sedentary behaviour intervention componentry targeting children 5 to 12 years, and 2) explore their effectiveness via consolidation, and secondary data analysis, of existing systematic review evidence. Methods A mixed methods study was conducted, which incorporated: 1) an umbrella review of the global systematic review evidence to develop an inventory of individual school-based healthy eating, physical activity, and sedentary behaviour intervention components; and 2) consolidation of existing systematic review evidence and secondary data analysis of primary studies to explore the effectiveness of individual intervention components. Results Of 8745 records, 228 full texts were screened against eligibility criteria which identified 12 eligible systematic reviews of which eight isolated the effects of individual intervention components. Forty-nine individual healthy eating (n=26), physical activity or sedentary behaviour (n=22), or other obesity prevention (n=1) intervention components were included in the inventory. Beneficial components were identified in each of the seven recommended opportunities for multicomponent school-based interventions: healthy eating in the classroom (e.g. curriculum, food growing experiences, fruit and vegetable breaks), healthy food available at school (e.g. strategies to encourage selection of healthier foods, free cooled water, free fruit and vegetables), healthy food brought to school (e.g. information on healthy food to bring to school), healthy eating outside of school/involving families (e.g. interactive family programs), physical activity in the classroom (e.g. short activity breaks, curriculum, increased intensity/quality of physical education (PE) classes), physical activity outside of the classroom/during break times (e.g. teacher/student led organised physical activity at break times), physical activity outside of school/involving families (e.g. interactive family programs, information to parents on benefits of physical activity). Conclusions The study findings demonstrate the breadth of components that have been trialed as part of multi-component school-based interventions globally and identified a range of components that are likely beneficial in addressing obesity-related behaviours and could be prioritised in future school-based interventions. BACKGROUND Poor diet, physical inactivity and obesity are responsible for a considerable burden of disease internationally, 1 – 4 and the existence of these risk factors in childhood increases the risk of future chronic disease. 5 As such, developing and implementing effective interventions targeting children is recommended to improve child health and mitigate future health burdens. 1 One of the most valuable settings to do so is schools, as they provide centralised and universal access to students, for prolonged periods during a critical stage in their development. 6 Robust evidence to inform policy and practice decision making is a cornerstone of evidence-based public health paradigm 7 as it improves the impact of investments of scarce resources in public health initiatives. Rigorous systematic reviews are recommended as the ‘gold standard’ source of evidence to assess and or compare the effectiveness of different public health interventions, as they systematically search for, synthesise and appraise all relevant trial evidence. 8 A large number of systematic reviews have been published describing the effectiveness of school-based interventions to improve healthy eating and physical activity. 9 – 11 Broadly, these reviews suggest that school-based interventions produce modest improvements in these risk factors for students, however, effects across trials are heterogeneous. Despite the number of systematic reviews available, policy makers and practitioners are critical of their utility in supporting decisions regarding the development or selection of interventions suitable for their context. 12 – 14 Audits of systematic reviews in child obesity prevention, for example, have found that few (7%) have co-authors from policy-based agencies, or discuss the policy implications of their findings (29%). 15 Others have noted concerns regarding the likely generalisability of international literature across contexts. 14 , 16 This is particularly salient for school-based programs promoting healthy eating, physical activity, or obesity prevention behaviours, as school systems vary considerably across jurisdictions. Such differences are evident even between high-income countries. For example, in the United States and Canada a primary source of food consumed in schools comes from school cafeterias, while in Australia and New Zealand, food consumed at schools is primarily brought from home and packed in a lunchbox. 17 , 18 Such differences necessitate different approaches to improving healthy eating behaviours in these settings. Several frameworks and guidelines have been published to support effective promotion of student healthy eating, physical activity, and obesity prevention in this setting. These recommend comprehensive, multi-component approaches. For example, the World Health Organisation Health Promoting Schools framework suggests that approaches to improve student health that are holistic and include strategies targeting the school curriculum, ethos and/or environment and that engage families and communities can be effective in improving weight related behaviours. 19 Other best practice guidelines in Australia and internationally recommend the implementation of intervention components that target opportunities to improve healthy eating and physical activity across the school day, including within the classroom, during breaks, and at home. 20 – 22 To our knowledge, however, no systematic review has comprehensively consolidated global evidence on the effectiveness of specific healthy eating and physical activity components of school-based interventions for children 5 to 12 years, as tested to date and aligned to current guidelines. 23 – 27 Evidence regarding the benefit of individual healthy eating and physical activity intervention components is critical to guide the development of more efficient and effective school-based initiatives. For example, a range of different strategies could be employed as part of a multicomponent intervention to improve the availability or selection of healthy foods at school, such as changes to food provided or sold on site, the introduction of fruit and vegetable breaks for students, or introducing labelling nudges that support healthy food selection. 9 – 11 An inventory of the types of strategies that have been employed, and an assessment of their effectiveness would aid the selection of more potent and contextually relevant intervention components. The absence of such information and analyses is an important gap in the literature. In this context, the aim of this study is to 1) develop an inventory of global guideline-aligned recommendations of school-based healthy eating, physical activity intervention componentry targeting children 5 to 12 years, and 2) explore their effectiveness via consolidation, and secondary data analysis, of existing systematic review evidence. METHODS A mixed methods study was conducted, which incorporated: 1) an umbrella review of the global systematic review evidence to develop an inventory of individual school-based healthy eating and physical activity intervention components; and 2) consolidation of systematic review evidence and secondary data analysis of primary studies to explore the effectiveness of individual intervention components. 1. Umbrella review of the global systematic review evidence to develop an inventory of individual school-based healthy eating and physical activity intervention components We conducted an umbrella review of the global review evidence to develop an inventory of individual healthy eating and physical activity components that have previously been trialed. The review was conducted in line with Cochrane recommendations for umbrella reviews. 28 Study inclusion criteria We sought systematic reviews published in the last five years that implemented a comprehensive search strategy and synthesised the effects of randomised controlled trials (RCTs) (individual or cluster) on healthy eating, physical activity or obesity prevention interventions targeting healthy eating and/or physical activity in school-based interventions for children aged 5 to 12 years. Eligible systematic reviews had to report a synthesis of RCTs, with or without meta-analysis, and could be either a review of primary studies or an umbrella review of systematic reviews of RCTs. Based on Cochrane guidelines, we defined systematic and umbrella reviews high-quality if they included explicit reproducible methodology i.e., included a comprehensive search with explicit criteria for including or excluding studies, and acceptable methods for assessing the quality of included studies (i.e. using an existing tool or reporting the criteria used to make assessments on the quality of the included studies). Reviews that did not specifically synthesise the effects of school-based RCTs (either in meta-analysis or narratively) were excluded. Reviews including a combination of RCTs and other study designs (e.g. non-randomised trials) were included if the results were reported separately for RCTs. Eligible review outcomes for each outcome category included any measure of healthy eating, physical activity and child weight status Search strategy and review selection A Medline search was conducted from inception up to end 2023 to identify potentially eligible systematic or umbrella reviews of systematic reviews published in the last 5 years that synthesised the effects of school-based healthy eating, physical activity or obesity prevention interventions on healthy eating, physical activity, or child weight ( Appendix A ). Review selection Records were de-duplicated, uploaded and screened using Covidence software. 29 One reviewer conducted an initial screening of titles only to discard irrelevant titles. Pairs of review authors then independently screened titles, abstracts, and full text articles of all identified reviews in duplicate for eligibility. Disagreements for title, abstract, and full text screening were resolved by discussion and consensus, or by consultation with a third review author. To develop the inventory, we extracted details of primary studies included in the most recent, high-quality and comprehensive reviews targeting each of the following outcome categories: child healthy eating; child physical activity; and child obesity prevention. We defined a comprehensive and high-quality review as one that adopted methods consistent with the Cochrane handbook. We prioritised systematic reviews of primary studies (RCTs) that synthesised findings using meta-analysis, and if no such reviews were available, we included umbrella reviews of systematic reviews that included RCTs. Data extraction for inventory development Interventions and their components of each primary study extracted from the selected reviews were independently coded by pairs of health promotion practitioners with experience in the implementation of healthy eating and physical activity interventions in schools. An inventory of each discrete healthy eating or physical activity intervention component was iteratively developed during this process, which included consensus-based definitions. Discrepancies between coders were resolved via discussion or via consultation with a third reviewer. Intervention components were then coded against current recommendations of existing International 19 – 21 , 30 – 43 and Australian 22 , 44 – 46 best-practice guidelines regarding school-based healthy eating, physical activity and obesity prevention strategies. To do so, we reviewed and consolidated current recommendations into a framework of seven commonly recommended school-based opportunities to improve healthy eating or physical activity, and one other opportunity targeting child weight status. The framework is described in table 1 and includes citation details demonstrating concordance of the framework with current guidelines ( Appendix B ). View this table: View inline View popup Table 1. Consolidated framework of school-based healthy eating and physical activity opportunities 2. Systematic review evidence and secondary analysis of primary studies to explore the effectiveness of individual intervention components To assess the effectiveness of discrete intervention components, we first sought to examine the findings of systematic reviews of RCTs that reported the effects of individual school-based interventions. This involved screening the citations of the umbrella review Medline search (described above) using the same eligibility criteria to identify eligible reviews that reported the effectiveness of individual healthy eating or physical activity intervention components. Second, to explore the effectiveness of individual intervention components that were not isolated in any eligible systematic reviews, we conducted a secondary analysis of the primary studies included in the reviews used to develop the intervention component inventory. Data extraction, synthesis and analysis Systematic review evidence Where an eligible systematic review reported the effects of intervention components in isolation (narratively or via meta-analysis), we reported this effect. We extracted and reported the full citation details and review characteristics of all reviews from which we draw findings regarding intervention component effects. Quality assessments of the included systematic reviews were assessed by two independent review authors using Assessing the Methodology Quality of Systematic Reviews tool 2 (AMSTAR2). 47 Of the 16 tool domains, we identified the following six critical domains according to the tool guidance that weighted more heavily when rating the overall confidence in results for each review: protocol registration; adequacy of literature search; performing risk of bias assessment; appropriateness of meta-analytical method; consideration of risk of bias when interpreting the results; and assessment of publication bias. Review authors assessed each according to the tool as: ‘yes’, ‘partial yes’, ‘no’, or ‘no meta-analysis conducted’ and disagreements were resolved by discussion and consensus. Secondary analysis of primary studies The individual study characteristics and study results (healthy eating, physical activity, sedentary behaviour or weight) for each primary study in the reviews used to develop the intervention component inventory were extracted. These included estimates reported for each individual study in meta-analysis results from online repositories (where available e.g. Cochrane reviews), data from study authors, or data extracted from individual studies. To estimate the effectiveness of multicomponent interventions that have adopted each individual component, meta-analyses were conducted where possible, using primary study data using the generic inverse variance method in a random effects model with Review Manager 5 software. We calculated mean differences or standardised mean differences, and 95% confidence intervals when two or more studies reported the same outcome. For meta-analysis, an intervention including a specific component was classified as having a beneficial impact when confidence intervals of the effect estimate did not include zero effect (i.e. did not cross 0). Meta-analysis was not performed to assess the effects of healthy eating focused intervention components, given the substantial heterogeneity of healthy eating measures included in primary studies. Instead, we calculated the proportion of primary studies reporting statistically significant beneficial effects on one or more of the eligible outcomes that included the individual component. To aid communication of the results, a cut point of ≥75% of trials was used to indicate an overall beneficial effect. RESULTS Search results A total of 8745 records were identified in the database search, of which 228 full texts were screened against eligibility criteria and 12 systematic reviews were included ( Figure 1 ). This included three reviews for the intervention component inventory development ( Table 2 ) and eight reviews that reported isolated effects of individual intervention components ( Table 3 ). Download figure Open in new tab Figure 1. Flow diagram View this table: View inline View popup Download powerpoint Table 2. Characteristics of three reviews for the intervention component inventory development View this table: View inline View popup Table 3. Characteristics of eight reviews that reported isolated effects of individual intervention components Umbrella review and inventory of individual healthy eating and physical activity intervention components Three reviews were used to develop the intervention component inventory, one for each outcome category ( Table 2 ). This included a review of childhood obesity prevention interventions that reported an overall effect of 71 school-based RCTs on child weight (AMSTAR2: high quality); a review of school-based physical activity interventions that reported an overall effect of 18 RCTs on moderate-to-vigorous physical activity (MVPA) and sedentary behavior (AMSTAR2: high quality); and an umbrella review of school-based healthy eating interventions that reported an overall effect of 97 RCTs from 13 systematic reviews on healthy eating outcomes (AMSTAR2: two high, one moderate, three low, and seven critically low quality). There were 155 discrete RCTs included across the three reviews, which were primarily conducted in high-income countries (83%) and published between 1996 and 2021. Further details of the critical appraisal can be found in supplementary Appendix C . Across all interventions tested in the 155 primary studies within systematic reviews, 49 individual healthy eating (n=26), physical activity or sedentary behaviour (n=22) or other obesity prevention (n=1) intervention components were included in the inventory. Each individual intervention component was coded to one of the seven recommended opportunities for school-based interventions to improve student healthy eating or physical activity or other ( Table 1 ). The majority of interventions (95%) tested within the primary studies were multicomponent and tested various different combinations of healthy eating and/or physical activity intervention components (range: 1-17 individual intervention components). Effectiveness of individual intervention components Systematic review evidence The eight included reviews reported the isolated effects of eight individual healthy eating or physical activity intervention components ( Table 4 ) and included studies published between 1991 and 2021. Of the eight reviews, the quality according to AMSTAR2 of one review was rated as high quality, and the remainder were rates as critically low quality. Further details of the critical appraisal can be found in Appendix C . View this table: View inline View popup Table 4. Systematic review evidence for individual healthy eating and physical activity intervention components A beneficial impact on either healthy eating, physical activity and/or weight was found for three of the nine individual intervention components. The effects of four healthy eating components were isolated in two systematic reviews which reported a beneficial impact of “curriculum learning experiences, curriculum or lessons regarding healthy eating” on both weight and healthy eating, and “food growing experiences or food gardens” on healthy eating, but no beneficial impact of “healthy cooking programs/healthy eating experiences” or “healthy canteen policies” on weight ( Table 4 ). The effects of five physical activity components were isolated in the other seven systematic reviews, which reported a beneficial impact of “strategies to increase the intensity or quality of physical education classes “ and “Short physical activity breaks” on MVPA, but no beneficial impact of “physical activity embedded into subject areas other than PE classes”, “teacher or student led organised physical activity at break time”, “safe active travel encouraged and promoted to children and their families” on MVPA or sedentary behaviour. Secondary analysis of primary studies Meta-analyses data of primary studies examining the effect interventions of physical activity and weight was available that contributed to one of 82 separate meta-analyses for each individual intervention component tested within the primary studies. This included separate meta-analyses examined the impact of 45 healthy eating or physical activity intervention components on weight, and 20 physical activity intervention components on MVPA, and 17 physical activity intervention components on sedentary behaviour. The proportion of studies reporting a beneficial impact on child healthy eating was calculated for 24 individual healthy eating components (no meta-analysis data of primary studies was available). Healthy eating intervention components A beneficial impact on a measure of student healthy eating or weight was reported for 16 of the 26 healthy eating intervention components. Beneficial ‘healthy eating in the classroom’ components included: curriculum lessons on healthy eating (healthy eating only), healthy eating homework (weight only), role modelling of healthy eating by school community members (healthy eating only), fruit and vegetable breaks (healthy eating only), food growing experiences/school gardens (healthy eating only), healthy cooking programs (healthy eating only), healthy eating embedded into other subjects (healthy eating only), and supporting children to increase their motivation for healthy eating (healthy eating only). Beneficial ‘healthy food available at school’ components included: choice architecture strategies to encourage students to purchase/select healthier items from canteen/cafeteria (healthy eating only), incentives for selecting/purchasing healthy food and drinks (healthy eating only), school-wide events to promote healthy eating (healthy eating only), providing free fruit and vegetables to children (healthy eating only), free access to cooled or carbonated water (healthy eating only), and providing students free healthy school lunches (healthy eating only). Beneficial ‘healthy food brought to school’ intervention components included: information to families on healthy eating (weight only). Beneficial ‘healthy eating outside the school involving families’ components included: interactive healthy eating or cooking programs with students and families (weight only). Physical activity intervention components A beneficial impact on student physical activity, sedentary behaviour or weight was reported for 8 of the 22 physical activity intervention components. Beneficial ‘physical activity in the classroom’ intervention components included: curriculum lessons targeting physical activity (weight only) or sedentary behaviour (weight only), physical activity ‘homework’ (weight only), and implementing short activity breaks (weight and MVPA). Beneficial ‘physical activity outside of the classroom and during break times’ intervention components included: structured break time activities (weight only), and increasing time spent doing physical activity outside of class (weight only). Beneficial ‘physical activity outside of school or involving families’ intervention components included physical activity information to parents (weight only), and interactive physical activity programs for students and families outside of school (weight only). Other A beneficial impact on child weight and healthy eating was also identified for: height and weight screening. DISCUSSION This study sought to develop an inventory of school-based healthy eating, physical activity and obesity prevention intervention componentry targeting children aged 5 to 12 years aligned to global guideline recommendations and consolidate global evidence to explore their effectiveness. This work yielded an inventory of 49 components of interventions targeting healthy eating, physical activity, sedentary behavior, or obesity utilised across 155 primary studies, and spanned each opportunity recommended by guidelines to promote physical activity among school students. Of these we found beneficial impacts on these outcomes for 26 intervention components. The findings demonstrate the breadth of components that have been trialed as part of multicomponent school-based interventions and will facilitate the design of more effective approaches to improve student health. Beneficial impacts on healthy eating, physical activity, sedentary behaviour, or obesity were found for intervention components across each of the three guideline-aligned opportunities. Components suggested as effective were most common for obesity and healthy eating outcomes. For these components such as “Teacher or student led organised physical activity for students at break time” and “Curriculum learning experiences, curriculum or lessons regarding healthy eating” appear likely to be beneficial. While meta-analyses inclusive of all eligible studies suggests that school based physical activity interventions are, on average, effective in improving MVPA, secondary subgroup analyses examining individual components identified just one to be statistically significant - “short physical activity breaks (e.g. energisers) implemented across the school day”. The findings suggests that comprehensive interventions inclusive of multiple components may be required to improve student activity. Examination of point estimates of secondary subgroup analyses may help to identify a package of components that may maximise potential effects. The absence of existing comprehensive syntheses of school-based studies determining the impact of individual healthy eating and physical activity components limits the ability to compare the findings of this study to previous research. Nonetheless the findings suggest a broad range of intervention components are likely beneficial in addressing obesity related behaviours. We found broad consistency between the umbrella review and secondary data syntheses approach utilised in this study. For six of the intervention components, both individual systematic reviews were identified, and secondary data analysis was possible. Of the physical activity intervention components, the findings were consistent between the two synthesis methods for three of four intervention components examined. For example, both individual systematic reviews and secondary data analyses consistently found no evidence of effect for active travel and embedding physical activity into non-physical education lessons on child MVPA. Whereas inconsistent evidence was found for short activity breaks, with secondary data analysis suggesting a beneficial impact on time in sedentary behaviour but not MVPA, and systematic reviews reporting no significant impact on either outcome. A similar pattern of results was found for healthy eating intervention components. While differences in the studies included in the syntheses likely explain the inconsistent findings, nonetheless, the findings of systematic reviews designed explicitly to assess the effects of discrete interventions are likely less biassed than secondary subgroup analyses. Despite the exploratory nature of this study, the findings are particularly useful for policymakers and practitioners given the absence of any comprehensive evidence examining effectiveness of individual components. Identification of those healthy eating and physical activity intervention components that may be the most effective provides important guidance regarding which components should be prioritised within multicomponent interventions to optimise their impact. Importantly the study also highlights those intervention components where there is little evidence of a beneficial impact and could be replaced in multicomponent interventions for other more effective components. The study also highlights a number of healthy eating and physical activity intervention components where their impact on child outcomes have not been synthesised as yet and could be prioritised in future research. This study has several methodological strengths that enhance its contribution to the existing evidence base. It is the first to systematically consolidate and explore the effectiveness of the discrete intervention components of school-based healthy eating, physical activity and obesity prevention interventions. The intervention component inventory was informed by the most recent and comprehensive systematic reviews targeting the relevant outcomes, to ensure all potential components tested in global studies to date would be captured. Finally, the study employed a rigorous approach to identifying and categorising intervention components, according to internationally recognised guidelines and implementation of iterative coding and consensus process to maximise methodological robustness and validity. The study also has a number of limitations that should be considered when interpretating the results. Of the primary studies included in the secondary data analysis, 95% were multicomponent interventions and the exploratory subgroup analysis approach adopted to explore effectiveness, cannot isolate the effects of intervention components within multicomponent interventions. As a result, the findings of the secondary data analyses report the effects interventions that included a specific component, and not the effects of that component in isolation. More sophisticated analysis methods that have been developed recently may offer more robust methods for determining the effectiveness of individual intervention components within complex interventions, however these were beyond the scope of the present study. The evidence base used to explore the impact of healthy eating interventions was drawn from an umbrella review and use vote counting, rather than synthesis of primary RCTs. While vote counting can help to capture the frequency of the direction of effect, it doesn’t not quantify the effect size. Additionally, the study considered syntheses of RCTs only, and beneficial impacts of other initiatives synthesised with, or more suited to, non-randomised study designs, or where only single RCTs have been synthesised in reviews conducted to date, were omitted and not considered in determining beneficial impact, and could be investigated in future research. While the findings of this study provide useful insights , evidence of effectiveness alone is insufficient to make well informed decisions regarding investments in school health initiatives. For example, evidence to decision frameworks suggest policy makers should weigh this with evidence of any unintended adverse effects, considerations of feasibility, cost, and acceptability. 60 Other factors related to the local context and potential scalability of intervention components should be considered including equity impacts and whether the infrastructure required for implementation is available and the likelihood that any implementation could be sustained. Future research to assess these factors and its integration with the review findings will help better inform the design of impactful and appropriate school-based initiatives. Funding This research was supported by a National Health and Medical Research Council Centre for Research Excellence Grant (APP153479). RKH is supported by a National Health and Medical Research Council Early Career Fellowship (APP1160419). Conflict of interest The authors report no conflicts of interest Data Availability All data produced in the present work are contained in the manuscript Appendices View this table: View inline View popup Download powerpoint Appendix A: Search strategy View this table: View inline View popup Appendix B: Opportunities for healthy eating and physical activity aligned to global guidelines and frameworks View this table: View inline View popup Download powerpoint Appendix C: Methodological quality assessment for each systematic review, according to the AMSTAR2 scale References 1. ↵ Rock CL , Thomson C , Gansler T , et al. American Cancer Society guideline for diet and physical activity for cancer prevention . CA: A Cancer Journal for Clinicians 2020 ; 70 ( 4 ): 245 – 71 . OpenUrl CrossRef PubMed 2. Scott-Sheldon LAJ , Hedges LV , Cyr C , et al. Childhood Obesity Evidence Base Project: A Systematic Review and Meta-Analysis of a New Taxonomy of Intervention Components to Improve Weight Status in Children 2-5 Years of Age, 2005-2019 . Child Obes 2020 ; 16 ( S2 ): S221 – s48 . OpenUrl PubMed 3. Murray CJL , Aravkin AY , Zheng P , et al. Global burden of 87 risk factors in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019 . The Lancet 2020 ; 396 ( 10258 ): 1223 – 49 . OpenUrl CrossRef PubMed 4. ↵ Afshin A , Sur PJ , Fay KA , et al. Health effects of dietary risks in 195 countries, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017 . The Lancet 2019 ; 393 ( 10184 ): 1958 – 72 . OpenUrl 5. ↵ Alves JGB , Alves LV . Early-life nutrition and adult-life outcomes . J Pediatr (Rio J) 2024 ; 100 ( Suppl 1 ): S4 – 9 . OpenUrl PubMed 6. ↵ Naylor P , McKay H . Prevention in the first place: schools a setting for action on physical inactivity . British Journal of Sports Medicine 2009 ; 43 ( 1 ): 10 – 3 . OpenUrl Abstract / FREE Full Text 7. ↵ Lhachimi SK , Bala MM , Vanagas G . Evidence-Based Public Health . Biomed Res Int 2016 : 5681409 . 8. ↵ Khoi Quan N , Liamputtong P . Systematic Review and Evidence Synthesis in Public Health. In: Liamputtong P, ed. Handbook of Social Sciences and Global Public Health . Cham : Springer International Publishing ; 2023 : 1045-69. 9. ↵ Jones M , Defever E , Letsinger A , Steele J , Mackintosh KA . A mixed-studies systematic review and meta-analysis of school-based interventions to promote physical activity and/or reduce sedentary time in children . Journal of Sport and Health Science 2020 ; 9 ( 1 ): 3 – 17 . OpenUrl 10. Hodder RK , O’Brien KM , Lorien S , et al. Interventions to prevent obesity in school-aged children 6-18 years: An update of a Cochrane systematic review and meta-analysis including studies from 2015-2021 . EClinicalMedicine 2022 ; 54 : 101635 . 11. ↵ O’Brien KM , Barnes C , Yoong S , et al. School-Based Nutrition Interventions in Children Aged 6 to 18 Years: An Umbrella Review of Systematic Reviews . Nutrients 2021 ; 13 ( 11 ): 17 . OpenUrl 12. ↵ Wolfenden L , Movsisyan A , McCrabb S , Stratil JM , Yoong SL . Selecting Review Outcomes for Systematic Reviews of Public Health Interventions . Am J Public Health 2021 ; 111 ( 3 ): 465 – 70 . OpenUrl PubMed 13. Powell JT , Koelemay MJW . Systematic Reviews of the Literature Are Not Always Either Useful Or the Best Way To Add To Science . EJVES Vasc Forum 2022 ; 54 : 2 – 6 . OpenUrl PubMed 14. ↵ Wolfenden L , Wiggers J , Tursan d’Espaignet E , Bell AC . How useful are systematic reviews of child obesity interventions? Obes Rev 2010 ; 11 ( 2 ): 159 – 65 . OpenUrl PubMed 15. ↵ Kite J , Indig D , Mihrshahi S , Milat A , Bauman A . Assessing the usefulness of systematic reviews for policymakers in public health: A case study of overweight and obesity prevention interventions . Prev Med 2015 ; 81 : 99 – 107 . OpenUrl PubMed 16. ↵ Ahmad N , Boutron I , Dechartres A , Durieux P , Ravaud P . Applicability and generalisability of the results of systematic reviews to public health practice and policy: a systematic review . Trials 2010 ; 11 : 20 . 17. ↵ Briefel RR , Wilson A , Gleason PM . Consumption of Low-Nutrient, Energy-Dense Foods and Beverages at School, Home, and Other Locations among School Lunch Participants and Nonparticipants . Journal of the American Dietetic Association 2009 ; 109 ( 2, Supplement ): S79 – S90 . OpenUrl CrossRef PubMed Web of Science 18. ↵ Sutherland R , Nathan N , Brown A , et al. A cross-sectional study to determine the energy density and nutritional quality of primary-school children’s lunchboxes . Public Health Nutrition 2020 ; 23 ( 6 ): 1108 – 16 . OpenUrl PubMed 19. ↵ Langford R , Bonell C , Jones H , et al. The World Health Organization’s Health Promoting Schools framework: a Cochrane systematic review and meta-analysis . BMC Public Health 2015 ; 15 : 130 . 20. ↵ Boonen A , de Vries N , de Ruiter S , Bowker S , Buijs G. HEPS Guidelines . Guidelines on Promoting Healthy Eating and Physical Activity in Schools . NIGZ, Woerden, The Netherlands 2009 . 21. ↵ World Health Organization . Report of the commission on ending childhood obesity . Geneva : WHO , 2016 . 22. ↵ NSW Department of Education . Student health and wellbeing policy . 2025 . https://education.nsw.gov.au/policy-library/policies/pd-2004-0034 . 23. ↵ Cornett K , Murfay K , Fulton JE . Physical Activity Interventions During the School Day: Reviewing Policies, Practices, and Benefits . J Sch Health 2023 ; 93 ( 9 ): 778 – 87 . OpenUrl PubMed 24. Davies AL , Spiga F , Caldwell DM , et al. Factors associated with effectiveness of interventions to prevent obesity in children: a synthesis of evidence from 204 randomized trials . medRxiv 2024 : 2024.06.19.24309160. 25. Merlo C , Smarsh BL , Xiao X . School Nutrition Environment and Services: Policies and Practices That Promote Healthy Eating Among K-12 Students . J Sch Health 2023 ; 93 ( 9 ): 762 – 77 . OpenUrl PubMed 26. Partridge SR , Reece L , Sim KA , et al. An analysis of current obesity strategies for adolescents in NSW against best practice recommendations: Implications for researchers, policymakers and practitioners . Health Promot J Austr 2023 ; 34 ( 2 ): 390 – 7 . OpenUrl PubMed 27. ↵ Bandeira ADS , Ravagnani FCP , Barbosa Filho VC , et al. Mapping recommended strategies to promote active and healthy lifestyles through physical education classes: a scoping review . Int J Behav Nutr Phys Act 2022 ; 19 ( 1 ): 36 . OpenUrl PubMed 28. ↵ Pollock M FR , Becker LA , Pieper D , Hartling L . Chapter V: Overviews of Reviews [last updated August 2023] . In: Higgins JPT TJ , Chandler J , Cumpston M , Li T , Page MJ , Welch VA , ed. Cochrane Handbook for Systematic Reviews of Interventions version 65: Cochrane ; 2024 . 29. ↵ Covidence systematic review software, Veritas Health Innovation, Melbourne, Australia . Available at www.covidence.org . 30. ↵ The Community Guide Community Preventive Services Task Force findings, 2019 . 31. Canadian Paediatric Society. School nutrition: Support for providing healthy food and beverage choices in schools 2020 . 32. Centers for Disease Control and Prevention. Comprehensive framework for addressing the school nutrition environment and services CDC, US Dept of Health and Human Services, 2016 . 33. Centers for Disease Control and Prevention. Increasing Physical Education and Physical Activity: A Framework for Schools. Atlanta, GA : CDC, US Dept of Health and Human Services , 2019 . 34. Centers for Disease Control Prevention. School health guidelines to promote healthy eating and physical activity: CDC, US Dept of Health and Human Services , 2011 . 35. Centers for Disease Control Prevention. Local School Wellness Policy: CDC, US Dept of Health and Human Services , 2024 . 36. Centers for Disease Control Prevention. Whole School, Whole Community, Whole Child (WSCC): CDC, US Dept of Health and Human Services , 2024 . 37. Lipnowski S , LeBlanc CM , Canadian Paediatric Society , Healthy Active Living , Sports Medicine Committee . Healthy active living: Physical activity guidelines for children and adolescents . Paediatrics & child health 2012 ; 17 ( 4 ): 209 – 10 . OpenUrl PubMed 38. New Zealand Ministry of Health. Healthy food and drink guidance - schools . Wellington : Ministry of Health , 2020 . 39. New Zealand Office of the Children’s Commissioner . Guidelines for school food programmes: best practice guidance for your school, 2014 . 40. Public Health England . What works in schools and colleges to increase physical activity? London, UK : PHE publications 2020 . 41. UK Department for Children Schools and Families . Autumn performance report , 2007 . 42. UK Department for Education . Healthy schools rating scheme: Guidance for schools , 2022 . 43. ↵ UK Department of Education . Food in schools policy , 2013 . 44. ↵ NSW Department of Education . Healthy school canteens , 2024 . 45. Queensland Department of Education . Physical activity in state schools . 2019 . https://education.qld.gov.au/student/Pages/physicalActivityInStateSchools.aspx . 46. ↵ South Australia Department for Education . Healthy eating in schools and preschools , 2024 . 47. ↵ Shea BJ , Reeves BC , Wells G , et al. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both . BMJ 2017 ; 358 : j4008 . 48. Neil-Sztramko SE , Caldwell H , Dobbins M . School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6 to 18 . Cochrane Database of Systematic Reviews 2021 ; ( 9 ). 49. Lonsdale C , Rosenkranz RR , Peralta LR , Bennie A , Fahey P , Lubans DR . A systematic review and meta-analysis of interventions designed to increase moderate-to-vigorous physical activity in school physical education lessons . Preventive Medicine 2013 ; 56 ( 2 ): 152 – 61 . OpenUrl CrossRef PubMed 50. Masini A , Marini S , Gori D , Leoni E , Rochira A , Dallolio L . Evaluation of school-based interventions of active breaks in primary schools: A systematic review and meta-analysis . J Sci Med Sport 2020 ; 23 ( 4 ): 377 – 84 . OpenUrl PubMed 51. Norris E , van Steen T , Direito A , Stamatakis E . Physically active lessons in schools and their impact on physical activity, educational, health and cognition outcomes: a systematic review and meta-analysis . Br J Sports Med 2020 ; 54 ( 14 ): 826 – 38 . OpenUrl Abstract / FREE Full Text 52. Nury E , Stadelmaier J , Morze J , et al. Effects of nutritional intervention strategies in the primary prevention of overweight and obesity in school settings: systematic review and network meta-analysis . BMJ Med 2022 ; 1 ( 1 ): e000346 . OpenUrl 53. Ohly H , Gentry S , Wigglesworth R , Bethel A , Lovell R , Garside R . A systematic review of the health and well-being impacts of school gardening: synthesis of quantitative and qualitative evidence . BMC Public Health 2016 ; 16 : 286 . 54. Peiris D , Duan Y , Vandelanotte C , Liang W , Yang M , Baker JS . Effects of In-Classroom Physical Activity Breaks on Children’s Academic Performance, Cognition, Health Behaviours and Health Outcomes: A Systematic Review and Meta-Analysis of Randomised Controlled Trials . Int J Environ Res Public Health 2022 ; 19 ( 15 ). 55. Pulido Sánchez S , Iglesias Gallego D . Evidence-Based Overview of Accelerometer-Measured Physical Activity during School Recess: An Updated Systematic Review . Int J Environ Res Public Health 2021 ; 18 ( 2 ). 56. Vetter M , Orr R , O’Dwyer N, O’Connor H. Effectiveness of Active Learning that Combines Physical Activity and Math in Schoolchildren: A Systematic Review . J Sch Health 2020 ; 90 ( 4 ): 306 – 18 . OpenUrl PubMed 57. Konnyu KJ , Grimshaw JM , Trikalinos TA , Ivers NM , Moher D , Dahabreh IJ . Evidence Synthesis for Complex Interventions Using Meta-Regression Models . Am J Epidemiol 2024 ; 193 ( 2 ): 323 – 38 . OpenUrl PubMed 58. Nathan N , Janssen L , Sutherland R , et al. The effectiveness of lunchbox interventions on improving the foods and beverages packed and consumed by children at centre-based care or school: a systematic review and meta-analysis . International Journal of Behavioral Nutrition and Physical Activity 2019 ; 16 ( 1 ): 1 – 15 . OpenUrl 59. Pang B , Kubacki K , Rundle-Thiele S . Promoting active travel to school: a systematic review (2010-2016) . BMC Public Health 2017 ; 17 ( 1 ): 638 . OpenUrl PubMed 60. ↵ Rehfuess EA , Stratil JM , Scheel IB , Portela A , Norris SL , Baltussen R . The WHO-INTEGRATE evidence to decision framework version 1.0: integrating WHO norms and values and a complexity perspective . BMJ Glob Health 2019 ; 4 ( Suppl 1 ): e000844 . OpenUrl Abstract / FREE Full Text View the discussion thread. Back to top Previous Next Posted June 09, 2025. Download PDF Data/Code Email Thank you for your interest in spreading the word about medRxiv. NOTE: Your email address is requested solely to identify you as the sender of this article. Your Email * Your Name * Send To * Enter multiple addresses on separate lines or separate them with commas. 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