Lead Article

Factors that contribute to effective nutrition education

interventions in children: a systematic review
Mary W. Murimi, Ana Florencia Moyeda-Carabaza, Bong Nguyen, Sanjoy Saha, Ruhul Amin, and
Valentine Njike

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Context: Establishing healthy dietary practices at an early age is crucial, as dietary
behaviors in childhood track to adulthood. Objective: The purpose of this system-
atic review was to identify factors associated with successful nutrition education
interventions conducted in children and published between 2009 and 2016. Data
Sources: Using the PRISMA (Preferred Reporting Items for Systematic Review and
Meta-Analysis) guidelines, relevant studies were identified through the PubMed,
Web of Science, ScienceDirect, and ERIC (Educational Resources Information Center)
databases. Study Selection: Studies published in English between 2009 and 2016
that included a nutrition education intervention among children aged 2 to 19 years
were included. Review articles, abstracts, qualitative or cross-sectional studies, and
studies targeting children with special nutritional needs were excluded. Data
Extraction: Four authors screened and determined the quality of the studies using
the GRADE (Grading of Recommendations Assessment, Development, and
Evaluation) system and extracted the data from the articles. Data Analysis: Forty-
one studies were included: 7 targeted preschool children, 26 targeted elementary
school children, and 8 targeted secondary school children. A total of 46% met their
primary objectives of nutrition education intervention, while the rest either partially
achieved or did not achieve their stated objectives. Results: Successful interventions
targeting school children engaged parents by means of face-to-face sessions, identi-
fied specific behaviors to be modified, and assured fidelity by training teachers or
recruiting trained experts to deliver the intervention. In addition, they allowed ade-
quate dosage, with an intervention duration of at least 6 months, and used age-
appropriate activities. Conclusions: Interventions with a multicomponent approach
that were age appropriate and of adequate duration ( 6 months), that engaged
parents, and that ensured fidelity and proper alignment between the stated objec-
tives, the intervention, and the desired outcomes were more likely to succeed.

INTRODUCTION by nutritional intake.1 A balanced and nutrient-dense

diet provides children with essential nutrients for opti-
Development and growth during childhood, which sets mal growth and development, while diets with imbal-
the trajectory for lifelong health, is heavily influenced anced or inadequate nutrients may lead to insufficient

Affiliation: M.W. Murimi, A.F. Moyeda-Carabaza, B. Nguyen, and S. Saha are with the Department of Nutritional Sciences, College of Human
Sciences, Texas Tech University, Lubbock, Texas, USA. R. Amin is with the Institute of Nutrition and Food Science, Dhaka University, Dhaka,
Bangladesh. V. Njike is with the Yale-Griffin Prevention Research Center, Derby, Connecticut, USA.
Correspondence: M.W. Murimi, College of Human Sciences, Department of Nutritional Sciences, Texas Tech University, PO Box 41270,
Lubbock, TX 79409, USA. Email: [Link]@[Link].
Key words: children, interventions, nutrition education.
C The Author(s) 2018. Published by Oxford University Press on behalf of the International Life Sciences Institute.
V
All rights reserved. For permissions, please e-mail: [Link]@[Link].

doi: 10.1093/nutrit/nuy020
Nutrition ReviewsV Vol. 76(8):553–580
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nutrient intake or overweight, which affects health and characteristics associated with successful nutrition edu-
performance in childhood as well as in adulthood.1 cation interventions in children, as evidenced by the
More importantly, children’s dietary practices and achievement of stated objectives in 3 different age
behaviors may track to adulthood, potentially influenc- groups: preschool children, elementary school children,
ing health status during adulthood.2,3 Therefore, it is and secondary school students. This review followed
important to establish healthy dietary practices and the PRISMA (Preferred Reporting Items for Systematic
behaviors at an early age, which in turn may lead to op- Review and Meta-Analysis) guidelines.21
timal growth and development and healthier dietary
choices later in life.3 METHODS
Contento4 defined nutrition education as “any
combination of educational strategies, accompanied by Age categorization of children

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environmental supports, designed to facilitate voluntary
adoption of food choices and other food- and nutrition- Building on the work of a prior systematic review on
related behaviors conducive to health and well-being.” factors that contribute to successful intervention in nu-
Nutrition education is a critical component in the de- trition education for adults,22 this review aims to iden-
velopment of healthy eating practices and behaviors,5 as tify factors associated with successful nutrition
it enhances the knowledge and skills children need to education interventions among children. To account
make healthful dietary choices.6–8 For example, a nutri- for the wide range in the age (2–19 years) and cognitive
tion education intervention study by Dunton et al6 development of children, the review and the subsequent
among primary school children showed significant im- analysis were based on developmental stages catego-
provement in children’s knowledge and intake of fruit rized into preschool, elementary, and secondary school
and vegetables as well as decreased consumption of children in order to identify key strategies associated
soda and high-energy foods post intervention. with successful interventions in the context of each age
Similarly, a properly designed nutrition education pro- category.
gram has the potential to enhance motivation and pref-
erence for eating healthful food and to facilitate the Research team
implementation of appropriate dietary practices.8,9 In
addition, healthy dietary practices are associated with The research team consisted of 6 members. The lead in-
improved academic performance.10,11 For example, af- vestigator and 5 graduate students conducted the
ter attending the nutrition education intervention search, screened the articles for quality and relevance
EatFit, which aimed to increase the frequency and qual- on basis of the established criteria, and extracted infor-
ity of morning meals, the consumption of iron-rich mation on a spreadsheet. Authors independently ana-
food, and the level of physical activity, school-aged chil- lyzed the findings and identified the factors that
dren showed significantly improved academic perfor- characterized successful interventions. Afterward,
mance, specifically in mathematics and English.10 results were discussed and a consensus was reached.
Despite convincing evidence that nutrition educa-
tion has the potential to influence children’s dietary Literature search strategy
choices, improve health, and enhance academic perfor-
mance, the specific characteristics of effective nutrition This review followed the recommendations and criteria
education programs for children are not clearly de- established in the PRISMA statement (see Appendix S1
fined.12–14 Effectiveness of nutrition education for chil- in the Supporting Information online).21 Articles pub-
dren is further complicated by the wide variance in age, lished between 2009 and 2016 were obtained from elec-
physical growth, and cognitive development during tronic searches of 4 databases, namely PubMed, Web of
childhood, which ranges from preschool age to high Science, Science Direct, and ERIC (Education
school age. For example, the approaches needed to cap- Resources Information Center) from 2009 to 2016.
ture the cognitive capability and attention span of pre- Keywords entered in varying combinations included
school children are different from those needed for “nutrition education,” “nutrition education inter-
elementary or high school children.15–18 Active parental vention,” “children,” and “dietary behavior.”
participation might be key for effective nutrition educa-
tion for one age group, but not the other.19,20 It is there- Inclusion and exclusion criteria
fore critical to identify the aspects of nutrition
education that are essential for each age group and to Research articles were evaluated using the PICOS
differentiate those that are essential for all categories. (Population, Intervention, Comparators, Outcome, and
The purpose of this systematic review is to identify the Study design) model (Table 1).21 The following

554 Nutrition ReviewsV Vol. 76(8):553–580

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 Table 1 PICOS criteria for inclusion and exclusion of studiesa
Category Inclusion Exclusion
Participants Children aged 2–19 y, alone or accompanied by parents and/or Children aged < 2 y; children with spe-
teachers and/or those who prepared meals cial nutritional needs; parents or
caregivers only; teachers only; those
who prepared meals only
Intervention Face-to-face nutrition education interventions Online nutrition education
interventions
Comparator With or without control group; nutrition education intervention None
only, physical activity intervention only; similar intervention
Outcomes Nutrition-related outcomes such as anthropometric measure- No nutrition-related outcomes; out-
ments (eg, body mass index, waist circumference, etc); bio- comes measured only in children
chemical measurements (eg, glycemia, lipid profile, etc); with pre-existing medical conditions

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dietary intakes, knowledge, preferences, attitudes, behaviors,
self-efficacy; cultural nutrition awareness factor; dietary diver-
sity score; physical activity (time, attitudes, behaviors); or food
and beverage availability at schools
Study design Randomized controlled trials, pre-post design quasi-experimental Meta-analyses and systematic reviews;
studies reviews; qualitative studies; cross-sec-
English language tional studies; abstracts; gray litera-
Published from 2009 to December 2016 ture; book chapters
a
Elaborated according to the description of PICOS criteria as provided by Liberati et al (2009).21

inclusion criteria were applied: (1) studies were pub- reviewing authors exchanged the articles without shar-
lished between 2009 and 2016, (2) publications were ing the results of assessment. In addition, all authors
available in English, and (3) articles described nutrition discussed each article as a group and either confirmed
education interventions conducted among children or added to the findings of the 2 reviewing authors. The
aged 2 to 19 years. The following were excluded: (1) re- group made the final decision on whether to include or
view articles, abstracts, or qualitative or cross-sectional exclude each article, and a quality score for each study
studies, (2) studies targeting populations with special was assigned by the 2 reviewing authors.
nutritional needs (eg, hospitalized children), (3) nutri- Determination of the quality of the studies was
tion education interventions targeting caregivers or guided by the GRADE (Grading of Recommendations
parents exclusively, and (4) publications based on the Assessment, Development, and Evaluation) system of
same data set used in an already-included study, in rating the quality of evidence.23 A thorough assessment
which case only the most recently published study was of the study’s description, design, measurements, data
included. After the initial abstract screening, articles se- analysis, interpretation of results, and power and out-
lected were divided between 4 trained research team comes formed the basis for quality assessment. Each
members who evaluated whether articles met the inclu- factor scored 0 points if the article lacked a complete
sion criteria and determined the quality of each study. description of the factor analyzed or 1 point if the arti-
The lead investigator systematically trained the research cle provided a complete description of such factor. The
team about the methods of systematic review, step by quality score was calculated by summing all the compo-
step. nent scores. Studies were rated and categorized as hav-
A total of 351 original studies published between ing low risk of bias (5–6 points), moderate risk of bias
2009 and 2016 on nutrition education interventions in (3–4 points), or high risk of bias (1–2 points). Once the
children without preexisting medical conditions were 2 reviewing authors established the scores, the 4 re-
evaluated. Of the 351 studies evaluated, 303 (86%) did search members and the leader of the research team dis-
not meet the inclusion criteria (Figure 121). For the pur- cussed any discrepancies until consensus was reached.
poses of this systematic review, 48 studies qualified for Of the 48 studies that met the inclusion criteria, 7
inclusion. articles categorized as having a high risk of bias were ex-
cluded from this review (Figure 121).
Assessment of study quality and risk of bias
Approach to analysis
To minimize bias, reviewing authors were trained to as-
sess quality on the basis of PRISMA recommenda- Reviewing authors independently extracted data from
tions,21 and 2 authors independently assessed each 41 published articles and transferred them to a spread-
included article. After the initial assessment, the sheet for analysis. Table 2,3,8,24–47 Table 3,48–55 and

Nutrition ReviewsV Vol. 76(8):553–580

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555
 Idenficaon
Records idenfied through Addional records idenfied
database searching through other sources
(n = 351) (n = 0)

Records aer duplicates removed

(n = 14)

Records excluded
Screening

(n = 284)
No nutrion educaon intervenons (n=139)

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Study protocol, pilot study or methodology (n = 37)
Evaluaon of nutrion educaon intervenons (n = 29)
Records screened Children with pre-exisng health condions (n=27)
(n = 337) Nutrion educaon for parents or caregivers (n = 19)
Online/wrien intervenon (n = 11)
Abstracts/book chapter (n = 9)
Meta-analysis or systemac review (n = 8)
Review arcles (n = 4)
Qualitave study (n = 1)
Eligibility

Full-text arcles excluded

Full-text arcles assessed (n = 12)
Low quality (n = 7)
for eligibility Mulple studies on the same data (n = 2)
(n = 53) Same intervenon (n = 2)
Outcome unrelated to nutrion (n = 1)
Included

Studies included in
qualitave synthesis
(n = 41)

Figure 1 Flow diagram of the literature search process.

Table 456–62 summarize key information from the ana- duration was considered long if a study lasted for a total
lyzed studies. The primary analytic goal was to deter- of 5 months or more. This classification of duration was
mine the overall effectiveness of nutrition education deemed appropriate on the basis of the descriptions
interventions in modifying dietary and physical activity used by the authors of the original studies. It is note-
behaviors in children and adolescents aged 2 to 19 years. worthy that the included studies rarely reported the
To determine whether an intervention was successful, dosage and frequency of the intervention. Therefore, it
the outcome of the study was compared with the stated was reasonable to report the total amount of time spent
purpose or objectives of the study. Once a study was in intervention in months. Fidelity as a factor in this
classified as achieving its intended purpose on the basis systematic review was assessed on the basis of (1) the
of the results, the following contributing factors were authors’ declaration in the limitation section and (2) the
analyzed: (1) study design; (2) type of intervention and description of who conducted the intervention and how
activities implemented; (3) duration and dosage of the the intervention was implemented.
intervention; (4) number of objectives in the study; (5) A semiquantitative approach was used to summa-
fidelity in implementing the intervention; and (6) use of rize the findings from nutrition education interven-
theory in directing the study. These factors were identi- tions. Results from nutrition education interventions
fied through systematic review of the 41 published nu- were dichotomized on the basis of whether they
trition education interventions. The duration of reported a statistically significant (P < 0.05) improve-
intervention was categorized as short if the study had a ment in dietary intakes, physical activity, or other re-
cumulative duration of less than 5 months. The lated risk factors for obesity and diet-related chronic

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 Table 2 Nutrition education interventions at the elementary school level
Reference Study sample Objective of Study design Length and Behavioral Achievement Risk of Major findings
intervention frequency of theory/ of objectives bias
intervention construct
Battjes-Fries 1183 children in To assess the effect of Quasi- One school year No theory Partially Moderate There were no significant differences be-
et al. grades 5–8 the Dutch school- experimental (2011–2012). achieved tween IG and CG in expected positive

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(2015)24 based education pro- Teachers imple- taste or willingness to taste unfamiliar
gram Taste Lessons mented lessons in foods at either follow-up measurement.
on children’s behav- a flexible way At the first follow-up, participants in IG
ioral determinants showed a significantly higher positive
toward tasting unfa- change in knowledge than those in CG
miliar foods and eat- (P < 0.01). This remained significant at

Nutrition ReviewsV Vol. 76(8):553–580

ing a variety of the second follow-up (P < 0.05)
healthy foods Children in grades 5 and 6 from IG
showed a significant change in number
of foods tasted and a significantly
higher positive change in subjective
norm of their parents at the first follow-
up (P < 0.05)
Cunningham- 237 children in 4th To assess the effect of RCT 10 wk total, with a No theory Achieved Moderate Fruit preferences significantly increased
Sabo & grade CWK on students’ FV 1-h introductory in IG from baseline to follow-up
Lohse preferences, cooking lesson, three 2- (P ¼ 0.012). Within IG, fruit preferences
(2013)25 attitude, and cooking h cooking classes, were greater in those with preinterven-
self-efficacy in a and three 1-h FV tion cooking experience at both base-
mostly non-Hispanic tasting sessions line and follow-up (P < 0.05)
white sample that (10 h total) Vegetable preferences were significantly
assured no previous higher in IG than in CG at follow-up
CWK exposure (P ¼ 0.001)
The IG showed significantly greater im-
provement in cooking attitudes than
the CG (P ¼ 0.02)
Francis et al. 579 children in 6th To evaluate the effec- RCT 1 mo (frequency not Bloom’s mastery Partially Moderate There was a significant change in the
(2010)26 grade tiveness of a short- mentioned) learning achieved proportion of students in IG report-
term, school-based, model ing fruit consumption levels of 2
multicomponent edu- servings a day (P < 0.01). The propor-
cation intervention tion of students in IG reporting vege-
on improving the table consumption within the past
knowledge, attitudes, 24 h significantly increased from
and behavior of pri- baseline to postintervention assess-
mary school children ment (P < 0.01). Students in IG
toward better dietary showed significant changes in their
and activity habits knowledge scores vs those in CG
(P < 0.01). There was a significant de-
cline in reported fried food intake in
IG from baseline to post intervention
(P < 0.01). The proportion of students
reporting regular PA at school at
least 3 times per week significantly

557
increased in IG (P < 0.01)
(continued)
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 Table 2 Continued

558
Reference Study sample Objective of Study design Length and Behavioral Achievement Risk of Major findings
intervention frequency of theory/ of objectives bias
intervention construct
Gallotta et al. 230 children aged To assess the effect of a Cluster RCT 5 mo total. NE ad- No theory Partially Low Weekly PA level significantly increased af-
(2016)27 8–11 y 5-mo PE and NE in- ministrated once achieved ter the intervention in the 2 IGs
tervention on body per month. Fruit (P < 0.0001). Sedentary time signifi-
composition, PA level, or vegetable pro- cantly decreased in children in all
time spent on seden- vided once per groups, from 565.7 to 492.1 min/wk
tary activities, and week. 1-h PA ses- (P < 0.0001).
eating habits of pri- sion administered There was a significant increase in con-
mary school children twice per week sumption (times per week) of vegeta-
bles (3.97 vs 4.29, P < 0.05) and fruits
(4.30 vs 4.85, P < 0.05) post interven-
tion. Consumption of bread signifi-
cantly decreased post intervention in
children with normal fat (4.72 times/wk
vs 4.08 times/wk, P < 0.05), while the
consumption of snacks significantly de-
creased post intervention in both chil-
dren with normal fat (3.20 times/wk vs
1.94 times/wk) and in obese children
(3.07 times/wk vs 2.24 times/wk)
Gibbs et al. 764 children in To evaluate the Pre-post 2.5 y total, with 45– SEM and princi- Achieved Moderate At follow-up, after adjusting for base-
(2013)28 grades 3–6 achievement of the 60 min of garden- ples of effec- line and grade, children showed a
SAKG Program in in- ing class and tive health significant increase in willingness to
creasing children’s 90 min of kitchen promotion try new foods if they had never tried
appreciation of di- class administered it (OR ¼ 1.95; 95%CI, 1.06–3.58;
verse, healthy foods every week P ¼ 0.03), if they had cooked it
(OR ¼ 2.37; 95%CI, 1.45–3.90;
P ¼ 0.001), and if they had grown it
(OR ¼ 2.25; 95%CI, 1.47–3.47;
P < 0.001)
Herbert et al. 104 children aged To evaluate the effec- Quasi- 1-h weekly session SCT, TRA, and Partially Low There was a significant difference be-
(2013)29 7–11 y tiveness of the experimental for 12 wk HBM achieved tween groups in the post-test score
Energize program for for consumption of french fries and
changing dietary and chips after controlling for the pre-test
PA habits compared score (P ¼ 0.044). The Energize group
with a CG of children consumed significantly less french
not participating in fries and chips compared with the

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the program CG. A marginally significant
(P < 0.10) increase in vegetable con-
sumption was detected for the
Energize group as compared with
the CG over time (P ¼ 0.068). PA hab-
its were not significantly different be-
tween the Energize and CG groups at

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post-test follow-up (P>0.05)
(continued)
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 Table 2 Continued
Reference Study sample Objective of Study design Length and Behavioral Achievement Risk of Major findings
intervention frequency of theory/ of objectives bias
intervention construct
Katz et al. 1180 children aged To enhance the ability RCT Five 20-min lessons SEM Partially Low Nutrition knowledge in both students

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(2011)30 7–9 y, grades 2–4 of both students and achieved and the parents of students in IG im-
their parents to dis- proved significantly (18.1% 6 26.9%;
tinguish more health- P < 0.01; and 7.9% 6 19.9%;
ful from less healthful P < 0.01) compared with baseline. No
options among a statistically significant improvements
wide variety of food observed in dietary patterns from

Nutrition ReviewsV Vol. 76(8):553–580

choices baseline between the IG and CG of
both students and parents in terms
of calories, protein, total fat, carbohy-
drates, iron, saturated fat, monoun-
saturated fat, polyunsaturated fat,
cholesterol, sodium, or folate intake
Keihner et al. 1154 children aged To encourage children RCT One 50-min lesson Resiliency Theory Achieved Low Children in IG were significantly more
(2011)31 8–12 y to eat the recom- per week for 8 wk and SCT likely than those in CG to improve
mended amount of their knowledge about the total
FVs and get at least number of daily servings of FVs
60 min of PA daily in (P < 0.05) and the number of daily
order to promote servings of vegetables needed for
healthful growth, de- good health (P < 0.001), as well as
velopment, and aca- the vitamin C obtained from eating
demic achievement FVs (P < 0.05). In both 4th and 5th
grades, children in IG showed
improvements in FV asking and
shopping self-efficacy (P ¼ 0.04) and
in FV eating self-efficacy (P < 0.001).
They were significantly more likely
than CG children to improve their
knowledge about the number of
minutes of PA needed daily for good
health (P < 0.001) and the health
benefits of PA (P < 0.01)
(continued)

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 Table 2 Continued

560
Reference Study sample Objective of Study design Length and Behavioral Achievement Risk of Major findings
intervention frequency of theory/ of objectives bias
intervention construct
Kipping et al. 2242 children aged To investigate the effec- Cluster RCT 16 lessons over a SCT Not achieved Moderate None of the 3 primary outcomes (time
(2014)32 9–10 y tiveness of a school- period of 6–7 mo. spent per day in MVPA, time spent in
based intervention to Teachers imple- sedentary behavior, and servings of
increase PA, reduce mented lessons in FVs) differed between children in
sedentary behavior, a flexible way schools allocated to IG and those al-
and increase FV con- located to CG. The intervention was
sumption in children effective for 3 of 9 secondary out-
comes after multiple testing was
taken into account: self-reported
time spent in screen viewing on
weekends (21 min/d [95%CI, 37
to 4; P ¼ 0.01]), self-reported serv-
ings of snacks (0.22/d [95%CI,
038 to 0.05; P ¼ 0.01]), and serv-
ings of high-energy drinks (0.26/d
[95%CI, 0.43 to 0.10; P ¼ 0.002])
were all reduced
Kristjansdottir 265 children aged To increase FV intake in Pre-post 2 y (frequency not No theory Achieved Moderate At follow-up, intakes of raw vegetables
et al. 7–9 y the IG by at least 20% mentioned) (P < 0.001), cooked vegetables
(2010)33 (P < 0.05), and total vegetables
(P < 0.001) and total intake of FVs
(P < 0.05) and fish (P < 0.001) were
higher in IG compared with CG, and
intake of candy was lower (P < 0.05).
Percentage of energy from MUFAs
(P ¼ 0.029) and the intakes of fiber
(P ¼ 0.013), potassium (P ¼ 0.005),
magnesium (P ¼ 0.012), copper
(P ¼ 0.035), and b-carotene increased
significantly in IG compared with CG,
and increase in vitamin C intake was
of borderline significance (P ¼ 0.056)
Mittman et al. 1376 children and To investigate the Pre-post 135 min for 1 time No theory Not achieved Low No steady increase could be observed
(2016)34 adolescents aged effects of the Cancer for intake of FVs throughout the day,
7–14 y Society of Lower neither at follow-up 1 nor at follow-
Saxony’s school- up 2. In contrast, intakes of vegeta-

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based NE program bles and fruit juice, as well as total in-
“5-a-Day for kids,” take of fruit/vegetables/juice,
designed to increase showed a significant decline between
children’s FV baseline and follow-up 1 and be-
consumption tween baseline and follow-up 2. Only
fruit consumption rose temporarily
between baseline and follow-up 2,

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though not significantly
(continued)
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 Table 2 Continued
Reference Study sample Objective of Study design Length and Behavioral Achievement Risk of Major findings
intervention frequency of theory/ of objectives bias
intervention construct
Morgan et al. 127 children aged To measure the effects Quasi- Three 1-h NE ses- SCT Partially Moderate Students in NE&G and NE groups were

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(2010)35 11–12 y of a garden-based NE experimental sions over 10 wk achieved significantly more willing to taste vege-
program on FV and one 45-min tables and rated the tastes more highly
knowledge, willing- session 4 times than did students in CG (P < 0.001).
ness to taste, food per week There was a significant difference
preferences, and per- (P ¼ 0.02) in FV knowledge between
ceived quality of NE&G group and CG, but only among

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school life in upper those students who started with lower
primary school chil- FV knowledge. For willingness to taste,
dren vs in a control there was a significant between-group
group difference for 4 vegetables: capsicum
(P ¼ 0.04), broccoli (P ¼ 0.01), tomatoes
(P < 0.001), and peas (P ¼ 0.02), with
NE&G students being significantly more
willing to taste these than students in
NE group or CG
Moss et al. 65 children in 3rd To introduce the CATCH Quasi- Two 30-min NE les- SEM Partially Moderate Significant differences in knowledge of
(2013)36 grade nutrition curriculum experimental sons and a 2- achieved fiber were found (P < 0.001).
and Farm to School h farm tour over a Differences in knowledge of vitamins
program to assess nu- 4-wk period and minerals, reported vegetable
trition knowledge of consumption behavior at school, and
3rd-grade students, farm exposure were also significant
and increase their FV (P < 0.05). No significant relation-
consumption ships were found between self-
behavior reported FV consumption and partici-
pation in the farm tour
Muros et al. 134 children aged To investigate the Pre-post 6-mo intervention, No theory Achieved Low Students in groups receiving PA re-
(2015)37 10–11 y effects of 4 experi- with 60-min ses- duced their fat percentage (P0.05)
mental conditions sions of PA twice and increased their muscle mass post
and 1 CG on health- a week, 2 1-h NE intervention (P0.05). The lipid pro-
related parameters, classes for chil- file improved in all IGs post interven-
such as the lipid, dren, and 6 2- tion. The proportion of
physiological, and an- h NE classes for macronutrients and dietary choles-
thropometric profiles parents terol improved (P0.001) in groups
of children receiving NE. The post-test compari-
son showed significantly lower fat
percentage, sum of skinfolds, waist
circumference, and PA in NE group
relative to CG
(continued)

561
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 Table 2 Continued

562
Reference Study sample Objective of Study design Length and Behavioral Achievement Risk of Major findings
intervention frequency of theory/ of objectives bias
intervention construct
Parmer et al. 115 children in 2nd To examine the effects Pre-post 28 wk, with a bi- No theory Achieved Low Participants in NE&G and NE groups
(2009)38 grade of a school garden on weekly 1-h ses- exhibited significantly greater
children’s FV knowl- sions of NE and improvements in nutrition knowl-
edge, preference, and biweekly 1-h ses- edge and taste ratings than those in
consumption sions of CG (P0.001). Moreover, NE&G
gardening group was more likely to choose and
consume vegetables in a lunchroom
setting post assessment than either
the NE group or the CG (P0.01)
Prelip et al. 399 children aged To assess the impact of Quasi- One school year. SCT and TPB Partially Moderate The intervention with 4 components
(2012)8 9–11 y a multicomponent NE experimental Teachers had free- achieved (program, nutrition curriculum,
program on student dom to develop teacher training, and parent work-
knowledge, attitudes, their own lesson shop) resulted in a positive change in
and behaviors related plans but were re- knowledge (P < 0.05) and in atti-
to consumption of quired to com- tudes and beliefs toward vegetables
FVs plete at least 10 h (P < 0.01). There were significant
over a 3-mo effects of teacher influence on stu-
period dents’ FVs attitudes in both the inter-
vention with 4 components and the
intervention with 2 components (pro-
gram and teacher’s training)
(P < 0.05). However, there was no
significant increase in students’ FV
consumption
Rosario et al. 464 children in To assess the impact of RCT Twelve 3-h NE ses- HPM and SCT Partially Moderate In IG, the increase in BMI z score was
(2012)39 grades 1–4 a 6-mo nutrition pro- sions over a 6-mo achieved significantly lower than that in CG
gram, delivered and period (P ¼ 0.009); fewer proportion of chil-
taught by classroom dren became overweight in IG vs CG
teachers with in-ser- (5.6% vs 18.4%; P ¼ 0.037).
vice nutrition train- Significantly fewer children in IG
ing, on prevention of (5.6%) than in CG (18.4%) became
overweight and obe- overweight after the intervention.
sity among children After controlling for confounders, the
in grades 1–4 predicted odds of overweight inci-
dence were 75% lower for IG
(OR ¼ 0.25; 95%CI, 0.07–0.92;

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P < 0.05)
(continued)

Nutrition ReviewsV Vol. 76(8):553–580

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 Table 2 Continued
Reference Study sample Objective of Study design Length and Behavioral Achievement Risk of Major findings
intervention frequency of theory/ of objectives bias
intervention construct
Rosi et al. 8165 children in To improve nutritional Pre-post Three 3-h NE classes No theory Achieved Moderate Children’s nutritional knowledge signifi-

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(2016)40 grades 3–5 knowledge of chil- over 2 academic cantly increased (P < 0.001) in all
dren participating to years school grades. The integrated
the Giocampus “learning through playing” approach,
Program which included educational figures,
tools, and games, was successful in
improving children’s nutritional

Nutrition ReviewsV Vol. 76(8):553–580

knowledge
Safdie et al. 830 children in To evaluate the effec- RCT 18-mo intervention No theory Partially Low In intervention schools, availability of
(2013)41 grades 4–5 tiveness of an ecolog- (frequency not achieved healthy foods increased with a con-
ically based program mentioned) comitant decrease in availability of
aimed at promoting unhealthy foods (P < 0.05). Food in-
healthy eating and take showed the same trend, but the
PA in selected Mexico difference was not statistically signifi-
City schools to opti- cant. In intervention schools, children
mize to overall en- did not engage in more MVPA during
ergy balance in PE class or recess but increased their
childhood as a strat- number of steps taken
egy for obesity
prevention
Saraf et al. 2384 children in To assess the effective- RCT 45-min NE sessions No theory Achieved Low Knowledge about PA, diet, and tobacco
(2015)42 grades 6–7 ness of a multicom- and a 20-min flip- improved significantly (P < 0.05) in
ponent school-based chart demonstra- IG vs CG. Proportion of students at-
intervention in im- tion over a 9-mo tending PT classes for 5 d/wk in-
proving knowledge period. Frequency creased significantly (17.8%;
and behavioral practi- not mentioned P < 0.01) in IG vs CG. Proportion of
ces related to diet, students consuming fruits increased
PA, and tobacco use (10%; P < 0.01) in IG vs CG. Pre-post
in middle school chil- decrease in prevalence of current
dren of rural smoking was significantly greater
Ballabgarh, North (7.7%; P < 0.01) in IG vs CG
India
(continued)

563
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 Table 2 Continued

564
Reference Study sample Objective of Study design Length and Behavioral Achievement Risk of Major findings
intervention frequency of theory/ of objectives bias
intervention construct
Sevinç et al. 6771 children and To (1) determine the ef- RCT 8-mo intervention. No theory Achieved Low Increase in BMI between the 2 measure-
(2011)43 adolescents aged fect of applying both 3-h PE sessions ments was 0.51 6 0.98 in the CG, which
7–13 y PA and healthy nutri- per week plus NE was significantly (P ¼ 0.000) higher
tion programs vs a program for stu- than that in both the intervention 1
healthy nutrition pro- dents, parents, (0.37 6 1.08) and the intervention 2
gram only for pre- and teachers. (0.35 6 1.13) groups. However, there
venting obesity in Frequency and was no significant difference between
primary school stu- duration of NE the intervention groups
dents in Denizli, session not When each group was compared, there
Turkey; (2) to deter- mentioned was a significantly lower BMI increase
mine the relationship in males (0.25 6 0.90) vs females
of this effect with (0.48 6 1.21) in IG 1 (P ¼ 0.000)
possible variables;
and (3) to construct
an obesity-control
program aimed at the
students
Shah et al. 3128 children and To assess the impact of Pre-post Weekly 60-min les- No theory Achieved Low After the intervention, knowledge and
(2010)44 adolescents aged a controlled educa- son over a 6-mo behavior scores improved in all chil-
8–18 y tive intervention on period dren except 15- to 18-year-olds from
health- and nutrition- private schools (P < 0.001). A signifi-
related knowledge cantly higher improvement in knowl-
and behavior of ur- edge and behavior was observed in
ban Asian Indian chil- younger children (aged 8–11 y) vs
dren and adolescents those aged 12–18 y, in females vs
males, and in government schools vs
private schools (P < 0.05 for all)
Steyn et al. 998 children in To promote healthy eat- RCT 3-y intervention. No theory Not achieved Moderate The intervention effect was not signifi-
(2015)45 grades 4–6 ing habits and regular Frequency not cant in consumption of food items
PA in learners, mentioned (fried potato chips, fried food, pies, po-
parents, and educa- tato crisps, take-away foods, processed
tors and to promote meat, table sugar, chocolate, sweets,
the development of a cakes/biscuits, squashes/cordials) at fol-
school environment low-up 1 or at follow-up 2. Moreover,
that would foster a in intervention schools, there was a
healthy lifestyle via >10% increase in children who con-

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an HK intervention sumed potato crisps, processed meat,
sweets, and carbonated beverages be-
tween 2009 and 2011. The mean DDS
for intervention schools increased from
4.56 in 2009 to 5.03 in 2010 to 4.91 in
2011. There were no significant inter-
vention effects at either of the 2 time

Nutrition ReviewsV Vol. 76(8):553–580

points (2009, 2011) for DDS, fat intake
score, and sugar intake score
(continued)
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 Table 2 Continued
Reference Study sample Objective of Study design Length and Behavioral Achievement Risk of Major findings
intervention frequency of theory/ of objectives bias
intervention construct
Toruner et al. 1105 children in To evaluate the effec- RCT Four 40-min sessions No theory Partially Moderate Neither before nor after the program was
(2015)46 grades 3–7 tiveness of a school- over a 6-mo achieved there any statistically significant differ-
based healthy life period ence found within or between the IG

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program on healthy and the CG with respect to daily meals,
life habits (eating eating breakfast, and time spent in
breakfast and exercis- front of a television or personal com-
ing), knowledge, BMI, puter (P>0.05). The percentage of chil-
and blood pressure dren who reported daily exercise
duration as 1 h increased from 58.8%
to 67.8% (P ¼ 0.006)

Nutrition ReviewsV Vol. 76(8):553–580

Post-test knowledge scores of IG children
significantly increased from 21.98 to
24.27 (P ¼ 0.001). No statistically signifi-
cant (P>0.05) difference was observed
in the initial or the final BMI or in the
blood pressure of IG children
Wall et al. 2231 children in 4th To assess impact of a Pre-post 3–5 wk No theory Achieved Moderate Students in IG improved in vegetable-
(2012)47 grade classroom-based, related attitude, self-efficacy, prefer-
standardized inter- ence, and knowledge scores
vention to address (P < 0.001)
limited vegetable
consumption
Zhou et al. 1023 children in To assess the effective- Pre-post 50-min sessions. No theory Partially Moderate Nutrition knowledge scores of students
(2013)3 grades 5–8 ness of a school- Neither total dura- achieved in IG increased significantly, from a
based nutrition and tion of interven- mean of 9.03 points before the inter-
food-safety education tion nor vention to 14.70 points immediately af-
program among pri- frequency of ses- ter the intervention (P < 0.01). The
mary school and ju- sions was long-term knowledge score in IG was
nior high school mentioned 12.35, which was lower than the score
students in China. The immediately after the intervention
assessment focused (P < 0.01) but higher than the baseline
on change in scores score (P < 0.01) and higher than the
for nutrition and food baseline and long-term scores in CG
safety knowledge, at- (P < 0.01)
titude, and practices There was a statistically significant differ-
(KAP) at pre-post in- ence between scores immediately after
tervention and at 9- interventions and long-term scores in
mo follow-up terms of having unhealthy food prefer-
ences and picky eating habits (P < 0.05)
Food safety scores of the IG post inter-
vention were higher (P < 0.01) than
those of the CG both preintervention
and at 9-mo follow-up

Abbreviations: BMI, body mass index; CATCH, Coordinated Approach to Child Health; CG, control group; CWK, Cooking with Kids; DDS, dietary diversity score; HBM, Health Belief Model; HK,

565
Healthy Kick; HPM, Health Promotion Model; IG, intervention group; FV, fruit and vegetable; MUFAs, monounsaturated fatty acids; MVPA, moderate to vigorous physical activity; NE, nutrition edu-
cation; NE&G, nutrition education and gardening; OR, odds ratio; PA, physical activity; PE, physical education; PT, physical training; RCT, randomized control trial; SAKG, Stephanie Alexander
Kitchen Garden; SCT, Social Cognitive Theory; SEM, Socio-Ecological Model; TPB, Theory of Planned Behavior; TRA, Theory of Reasoned Action.
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 Table 3 Nutrition education interventions at the secondary school level

566
Reference Study sample Objective of Study design Length and Behavioral Achievement of Risk of Major findings
intervention frequency of theory/construct objectives bias
intervention
Campos Pastor 263 children and To assess the repercus- Pre-post 45-min session every No theory Achieved Moderate At end of school year, the percentage
et al. adolescents sion of an NE pro- 2 wk for a school of male and female adolescents with
(2012)48 aged 12–16 y gram on year overweight or obesity in IG was sig-
anthropometric varia- nificantly lower (overweight from
bles, eating habits, 31.5% to 21.3% in males and 21.7%
and metabolic syn- to 14% in females (P < 0.001); obe-
drome components sity from 7.9% to 5.5% in males and
in adolescents 4.7% to 3.9% in females (P < 0.001).
Percentage of students with bio-
chemical data suggestive of meta-
bolic syndrome was significantly
lower (32.2% vs 19.7%, P < 0.001)
Dehdari et al. 100 girls aged To examine the effect Quasi- Weekly 60-min ses- Pender’s HPM Achieved Moderate IG reported a significant increase
(2014)49 13 y of an NE intervention experimental sion for 4 wk (P < 0.05) in perceived benefit, self-
based on Pender’s efficacy, positive activity-related ef-
HPM in improving fect, interpersonal influences, situa-
the frequency and tional influences, commitment to a
nutrient content of plan of action, and weekly frequency
breakfast among fe- of breakfast consumption compared
male Iranian students with CG. There were significant
reductions (P < 0.05) in immediate
competing demands and preferen-
ces, perceived barriers, and negative
activity-related effect constructs in IG
compared with CG
Maatoug et al. 4003 children To evaluate the effec- Quasi- On the majority of No theory Partially Low There was no significant change in the
(2015)50 and adoles- tiveness of Schools in experimental the days, school achieved BMI of IG, while the percentage of
cents aged Health, a school- children leaders obese school children in CG increased
11–16 y based PA and nutri- motivated their significantly, from 4.5% to 6.9%
tional behavior inter- peers to adopt (P < 0.001).
vention, in reducing healthy eating Percentage of children who consumed
rates of overweight behaviors recommended amounts of FVs in-
and obesity among One PA session and creased significantly, from 30% to
school children in 1 session to pro- 33.2% in IG (P ¼ 0.03), while it de-
Sousse, Tunisia mote a healthy creased significantly in CG, from 40.2%
diet; frequency of to 35.0% (P ¼ 0.001)

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sessions was not In the IG, there was a significant decrease
mentioned in school children who completed the
Duration of each recommended amount of PA, dropping
session was not from 29.1% to 25.5% (P ¼ 0.01)
mentioned
Total duration of in-
tervention was 3 y

Nutrition ReviewsV Vol. 76(8):553–580

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 Table 3 Continued
Reference Study sample Objective of Study design Length and Behavioral Achievement of Risk of Major findings
intervention frequency of theory/construct objectives bias
intervention
Murimi et al. 233 children and To examine the effects Longitudinal Each student re- No theory Partially Moderate High-density lipoprotein levels signifi-

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(2015)51 adolescents of a school-based ceived a weekly 1- achieved cantly increased between the 2nd
aged 11–19 y point-of-testing h counseling ses- and 4th visits (P < 0.05). Participants
counseling and NE in- sion for 12 wk who attended the intervention at
tervention on age- Total duration of in- least 4 times showed stabilized or im-
and gender-specific tervention: 3 y proved blood values and anthropo-
BMI percentile, blood metric measurements. Significant

Nutrition ReviewsV Vol. 76(8):553–580

lipid profile, and blood increases in nutrition knowledge
pressure among stu- were documented for students in
dents in grades 6–12 grades 7 and 8 but not for those in
in a rural community other grades (P < 0.01)
and to examine
changes in students’
nutrition knowledge
over a 3-y period
Rani et al. 181 adolescents To assess the knowl- Pre-post Weekly 1-h session HBM Partially Moderate Following the NE program, satisfactory
(2013)52 in grades 8–9 edge and practices of for 10 wk achieved dietary knowledge significantly im-
high school students proved from 37% to 67% (P < 0.001).
with respect to Similarly, students showing a positive
healthy diets before attitude toward healthy diet increased
and after an NE from 18% to 40% (P < 0.001)
program Proportion of students choosing soft
drinks declined from 20% to 10%
(P < 0.01), and consumption of fast
food items through fast food restau-
rants declined significantly
Singhal et al. 510 adolescents To assess the effective- RCT Weekly 30-min NE No theory Achieved Low Significant increase seen in proportion of
(2010)53 aged 15–17 y ness of a school- session for 10 wk IG having knowledge of the following:
based low-cost nutri- 30-min PA session 5 simple and complex carbohydrates
tion and lifestyle edu- times per week for (P ¼ 0.003), concept of empty calories
cation intervention 8 wk (P < 0.001), sources and adverse
on behavior modifica- Weekly 1-h individ- effects of trans fats (P < 0.001), high-
tion and risk profile ual counseling fat milk products (P ¼ 0.002), refined
of Asian Indian ado- session cereals (P ¼ 0.003), importance of fiber
lescents in a metro- Monthly 7-min in the diet (P ¼ 0.02), and causes and
politan city in North counseling session types of diabetes (P < 0.001).
India for parents and Significantly lower proportion of IG
monthly 1-h train- consumed aerated drinks (P < 0.001)
ing session for vol- and energy-dense unhealthy foods
unteer students such as burgers, pizzas, and french
from the 11th fries at follow-up (P ¼ 0.03). Significant
grade decrease in mean waist circumference
Total duration of in- (P ¼ 0.02), sagittal abdominal diameter

567
tervention: 9 mo (P < 0.001), waist-to-hip ratio
(P ¼ 0.02), and fasting blood glucose
(P ¼ 0.05) in IG compared with CG
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(continued)
 Table 3 Continued

568
Reference Study sample Objective of Study design Length and Behavioral Achievement of Risk of Major findings
intervention frequency of theory/construct objectives bias
intervention
Somsri et al. 131 adolescents To examine and com- Quasi- Weekly 50-min NE SCT Achieved Low FV-related knowledge scores increased
(2016)54 aged 16 y pare the effectiveness experimental session for 4 wk significantly (P < 0.001) in all 3 groups
of a CCBNEd program post test
and an HCBNEd pro- Attitude toward FV consumption im-
gram on the promo- proved significantly, from 70 to 82
tion of FV points in CCBNEd and from 72 to 74
consumption points in HCBNEd (P < 0.01). Post test,
an increase in eating FVs was observed
in CCBNEd. Amounts of FVs consumed
increased significantly (P < 0.001) in
CCBNEd, 3-fold (from 40 g to 120 g) for
fruit and 2-fold (from 65 g to 123 g) for
vegetables, compared with baseline
values
Viggiano et al. 3110 children To confirm the effec- Cluster RCT Weekly 30-min ses- No theory Achieved Moderate At first postintervention assessment
(2014)55 and adoles- tiveness of Kaledo (a sion for 20 wk (6 mo), IG had significantly higher
cents aged board game) in im- scores than CG (14.4 vs 10.9,
9–19 y proving nutrition P < 0.001) on AFHC
knowledge and in In addition, there was a significant dif-
promoting long-term ference between IG and CG in mean
healthy dietary values of nutritional knowledge ad-
behavior in a large justed for score at baseline (6.5 vs
cohort study 4.6, P < 0.001). At the same assess-
ment, for the section “healthy and
unhealthy diet and food,” there was
a significant difference between IG
and the CG in mean values adjusted
for score at baseline (11.2 vs 10.4,
P < 0.001). There was a significantly
higher moderator effect difference
between IG and CG in high schools
(11.8 vs 10.4, P ¼ 0.023) compared
with middle schools (10.7 vs 10.9,
P ¼ 0.571)
Abbreviations: AFHC, Adolescent Food Habit Checklist; BMI, body mass index; CCBNEd, Cosmetic Content-Based Nutrition Education; CG, control group; FV, fruit and vegetable; HCBNEd, Health
Content-Based Nutrition Education; HBM, Health Belief Model; HPM, Health Promotion Model; IG, intervention group; NE, nutrition education; PA, physical activity; RCT, randomized controlled
trial; SCT, Social Cognitive Theory.

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Nutrition ReviewsV Vol. 76(8):553–580
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 Table 4 Nutrition education interventions at the preschool level
References Study sample Objective of nutrition Study design Length and fre- Behavioral theory/ Achievement of Risk of bias Major findings
education quency of construct objectives
intervention
De Bock et al. 377 children aged To assess the effects of Cluster 15 sessions, 2 h Pandura’s social Partially Moderate Significant change from baseline in FV

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(2012)56 3–6 y a preschool-based randomized each, over a 6- learning theory achieved intake (P < 0.05 and P < 0.01): mean
nutritional interven- mo period and Zajonc’s ex- increase from baseline of 0.17 point
tion on both behav- posure effect on the 6-point ordinal scale
ioral outcomes, such (P < 0.05) for fruit consumption fre-
as children’s FV and quency and 0.22 point (P < 0.01) for
water consumption, vegetable consumption frequency.

Nutrition ReviewsV Vol. 76(8):553–580

and anthropometric Intervention had no significant effect
measures on daily water intake, consumption
of high-energy drinks, BMI, waist-to-
height ratio, or total body fat
Gao et al. 1819 preschool chil- To examine the effect RCT Monthly lecture Cognitive Behavioral Achieved Moderate At end of intervention, significant differ-
(2016)57 dren aged 4–6 y of NE on children’s and activities Change Theory ence between IG and CG in frequency
breakfast patterns for 8 mo (2 of eating breakfast (P ¼ 0.02)
semesters in a At end of study, children in IG chose
kindergarten) more nutrient-dense foods for breakfast
compared with children in CG, who
chose more energy-dense foods accord-
ing to the nutrition label on the food
(P < 0.001)
Quantity of food consumed at breakfast
increased significantly in IG but de-
creased in CG (P < 0.001)
Hoffman et al. 297 children in kin- To examine the effects Randomized, Daily or most of SCT and SLT Partially Moderate In year 1, children in IG consumed 22
(2011)58 dergarten and 1st of a multicomponent, multiyear the days dur- achieved more grams (1.5 tbsp) of fruit and 7
grade theory-based, 2.5-y intervention ing the school more grams (1.5 tsp) of vegetable per
intervention on child- year lunch (P < 0.0001 and P < 0.005, re-
ren’s FV consumption, spectively) compared with children in
FV preferences, FV CG
knowledge, and BMI In year 2, IG consumed 15 more grams (1
tbsp) of fruit and 3 more grams (0.5
tsp) of vegetables per lunch
(P < 0.0005 and P < 0.05, respectively)
compared with children in CG
In year 3 and follow-up, IG did not con-
sume more fruit than CG (P < 0.05)
In year 3, IG consumed 3 more grams of
vegetables than CG (P < 0.05)
Children in IG scored about 0.5 to 0.66 of
a point higher for knowledge than chil-
dren in CG at each point of data collec-
tion. Experimental minus control
knowledge score at year 1: 0.49; at year

569
(continued)

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 Table 4 Continued
References Study sample Objective of nutrition Study design Length and fre- Behavioral theory/ Achievement of Risk of bias Major findings

570
education quency of construct objectives
intervention
2: 0.51; at year 3: 0.67; and at follow-
up: 0.49 (P < 0.05)
Hu et al. 1819 children aged To evaluate the impact RCT Once monthly No theory Partially Low Post intervention, significant differences
(2010)59 4–6 y of NE in kindergart- for 8 mo achieved between IG and CG for unhealthy
ens and to promote snacks (31.7% vs 41.8%), monotonous
healthy dietary habits diet (16.8% vs 18.7%), adult assistance
in children during meals (9.5% vs 12.5%), playing
during dinner (17.5% vs 25.2%), and
watching television during dinner
(19.3% vs 17.8%) (P < 0.05)
Healthy lifestyle behavior, such as eating
breakfast (91.0% at baseline to 92.3%
after the intervention) and taking part
in outdoor activities (62.5% at baseline
to 63.0% after the intervention), im-
proved markedly in IG (P < 0.05). Mean
scores for nutritional knowledge among
IG parents rose significantly from pre
test (10.5 points) to post test (11.9
points) (P < 0.0001)
Lerner-Geva 204 children aged To assess the effective- Cluster RCT with One lesson per No theory Partially Moderate Significant association between level of
et al. 4–6 y ness of an interven- 3 groups: full week for achieved nutritional knowledge and age
(2015)60 tion program to intervention 10 wk (P < 0.01). In the initial analysis ad-
improve kindergarten (NE plus PA), justed for baseline measures, signifi-
children’s eating and intervention cant reduction in daily energy intake
leisure habits in Israel (only NE), and was seen in entire IG with entire in-
CG tervention (NE and PA), from 5239 kJ
at baseline to 4709 kJ at follow-up
(P ¼ 0.03). Group with intervention
(only NE) significantly increased nu-
tritional knowledge (P ¼ 0.03). No
changes in BMI, time spent watching
television or playing computer
games, exercise, and sleep observed
after the intervention
Pe~nalvo et al. 2062 children aged To evaluate the efficacy Cluster RCT During 1 aca- SCT and trans-theo- Partially Low After 1 school year, the intervention in-
(2013)61 3–5 y of the Program SI! in demic year: retical models in achieved creased children’s knowledge, atti-
improving indicators 20 h of instruc- health promotion tudes, and habits scores, both overall

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of the acquisition of tion per pro- (3.45; 95%CI, 1.84–5.05) and compo-
healthy behaviors in gram compo- nent specific (diet: 0.93; 95%CI, 0.12–
children aged 3–5 y nent (diet, PA, 1.75; PA: 1.93; 95%CI, 1.17–2.69; hu-
and human man body: 0.65; 95%CI: 0.07–1.24)
body) and 10 h score. However, no effect on the school
of instruction environment or on overall scores for

Nutrition ReviewsV Vol. 76(8):553–580

for managing parents or teachers was found
emotions
(continued)
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 diseases. This approach was used to allow for the di-

the assessment conducted 3 mo after

sumption of vegetable snacks by ap-

Abbreviations: BMI, body mass index; CG, control group; CMH, Color Me Healthy; FV, fruit and vegetable; IG, intervention group; NE, nutrition education; PA, physical activity; RCT, randomized
verse range of reported statistics, outcomes, and mea-

cantly increased their consumption

between baseline assessment and

Children who received CMH signifi-
surement units.63

20.8% (P < 0.001) and their con-

of fruit snacks by approximately

proximately 33.1% (P < 0.01)

completion of CMH program

Major findings

RESULTS

A total of 41 studies describing nutrition education

interventions focused on children and published be-
tween 2009 and 2016 were assessed for their effective-
ness on the basis of reported evidence that the
interventions met their stated primary research objec-

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tives. A majority of the studies (73%; n ¼ 30) were con-
Risk of bias

ducted outside the United States, while slightly more

Moderate

than one-fourth of the studies (27%; n ¼ 11) were con-

ducted within the United States. Most of the studies
(63%; n ¼ 26) targeted elementary school children
Length and fre- Behavioral theory/ Achievement of

(Table 2), while 8 (20%) targeted secondary school chil-

objectives

dren (Table 3) and 7 (17%) targeted preschool children

Achieved

(Table 4).
A total of 19 studies (46%) met their primary re-
search objectives, as evidenced by their reported results,
while another 19 studies (46%) partially met their stated
objectives and 3 studies (7%) did not meet their stated
construct

objectives. Seventeen of the 41 studies were informed

Weekly sessions No theory

by theory but were not theory driven. There was no

controlled trial; SCT, Social Cognitive Theory; SLT, Social Learning Theory; tbsp, tablespoon; tsp, teaspoon.

convincing difference between the studies that used the-

ory as compared with those that did not use theory.
of 15–30 min
intervention
quency of

Successful nutrition education interventions in

for 6 wk

elementary schools

Successful interventions targeting elementary school

study with IG
Study design

children engaged parents by means of face-to-face ses-

263 preschool chil- To determine whether Intervention

sions, identified specific behaviors to be modified, and

nutrition and PA pro- and CG

assured fidelity by training teachers or recruiting

trained experts to deliver the intervention. In addition,
they allowed adequate dosage, with an intervention du-
children, increases FV
Objective of nutrition

CMH, an interactive

ration of at least 6 months, and used age-appropriate

gram for preschool

activities.
education

consumption

Parental engagement. Although engaging parents in the

interventions was a common factor in both successful
and unsuccessful interventions, half of the successful
interventions engaged parents on a face-to-face basis in-
dren aged 4–5 y

stead of simply sending information to

Study sample

parents.28,33,37,42–44 For example, Muros et al37 con-

ducted 6 nutrition classes for parents in addition to the
activities provided for children in the 3 groups that re-
Table 4 Continued

ceived nutrition education (nutrition education, nutri-

tion education plus physical activity, and nutrition
Witt & Dunn

education plus physical activity plus provision of 2 L of

References

(2012)62

extra virgin olive oil per week so that parents could sub-
stitute olive oil for the usual oil consumed). After the
intervention, the children’s cholesterol intake was

Nutrition ReviewsV Vol. 76(8):553–580 R

571
significantly decreased in all 3 groups (P ¼ 0.000, example, in the study by Cunningham-Sabo and
P ¼ 0.001, and P ¼ 0.000, respectively), bringing the Lohse,25 food educators received for 30 hours of train-
cholesterol values closer to the stated recommendations ing to teach cooking and tasting lessons for the inter-
of less than 300 mg/d. In contrast, studies that engaged vention. This study significantly increased the
parents remotely by providing websites, assigning preferences of fruits and vegetables (P ¼ 0.012 and
homework, or sending written materials such as news- P ¼ 0.001, respectively) and improved attitudes toward
letters did not report achieving their objectives.24,27,32,35 cooking (P¼0.02). Conversely, interventions that lacked
For example, the study by Morgan et al35 provided 3 se- proper training for the implementers compromised fi-
ries of newsletters that focused on the health benefits of delity and were unsuccessful.8,24,35,34,39,41 For instance,
eating fruits and vegetables and included strategies for although the study by Battjes-Fries et al24 provided an
increasing fruit and vegetable intake at home. This in- introductory workshop as well as manuals and materials

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tervention did not succeed in increasing either vegeta- for the teachers, a standardized protocol for implemen-
ble or fruit consumption (P ¼ 0.22 and P ¼ 0.23, tation to ensure fidelity was lacking. Teachers were
respectively). Similarly, 8 (57%) of the studies that tar- given options to implement the intervention over
geted elementary school students but did not engage 2 weeks, 1 week, or even a semester. As a result of the
parents at all were not successful in achieving their lack of a standardized implementation plan, only one-
objectives.3,29,34,36,39,41,45,46 For example, Moss et al36 third of the intervention was implemented, leaving the
conducted an intervention that aimed to increase other two-thirds of the intervention uncompleted and,
knowledge and consumption of fruit and vegetables therefore, unsuccessful.
among 3rd-grade students. They reported improved
knowledge of fiber (P < 0.001) and vitamins and miner- Adequate duration of intervention (at least 6 months). In
als (P < 0.05), but they did not find a significant change addition to fidelity, an adequate nutrition education
in consumption of fruit and vegetables. dosage or intervention period of 6 months or more was
predictive of success for most of the successful interven-
Specific and measurable behavioral outcomes. Similarly, tions (67%; n ¼ 8).28,33,37,38,40,42–44 For example, the in-
identification of a specific desired behavioral outcome tervention carried out by Parmer et al38 focused on
was critical in achieving stated objec- increasing fruit and vegetable knowledge, preferences,
tives.25,28,31,33,37,38,40,43,44,47 For example, Kristjansdottir and consumption among 2nd-grade children for a du-
et al33 aimed to increase fruit and vegetable intake in ration of 7 months. The results showed significant im-
the intervention group by at least 20%. Participants in provement in nutrition knowledge (P < 0.01) and taste
this study increased their intake of fruits and vegetables ratings (P < 0.001) in the intervention group compared
by 54%. Other common behavioral outcomes identified with the control group. In contrast, the 8 studies (57%)
were to improve fruit and vegetable preferences25,28,38; that spent less than 6 months on the intervention did
to increase knowledge about nutrition38,42,44 and physi- not meet or only partially met their stated objec-
cal activity31,42,44; and to improve health-related param- tives.3,27,29,30,34–36,46 For example, a 1-time (135 min) in-
eters such as physiological and/or anthropometric tervention study by Mittman et al34 among 7- to 14-
measurements.42,43 In contrast, interventions designed year-old children and their parents did not achieve its
with broad goals that were not specific to a behavior stated objective of increasing fruit and vegetable intake
were not successful in achieving their objec- in any of the assessment periods. Instead, fruit and veg-
tives.24,27,29,30,35,39,41,45,46 For instance, the intervention etable intake showed a significant decline between base-
by Steyn et al45 aimed to promote physical activity and line and the 2 follow-up assessments.
healthy eating habits among the participants. Although
dietary diversity increased, physical activity and fruit Age-appropriate activities. Finally, successful interven-
and vegetable consumption did not. The intervention tions targeting elementary school children used
was not specific to the desired behavioral outcomes of age-appropriate activities.25,26,28,31,37,38,40,42,44,47 Age-
increased physical activity and improved eating habits. appropriate activities at the elementary school level in-
cluded cooking and/or tasting sessions25,28,47; a
Fidelity of interventions. The importance of implement- learning-through-playing approach based on age or
ing the interventions as intended by using a standard- grade40,44,47; gardening sessions28,38; training classes in
ized protocol to ensure fidelity was critical among physical activity37,42; the use of posters, masks, and
successful interventions targeting elementary school songs31,44; and the use of vocabulary and mathematics
children. Successful interventions either trained existing questions based on nutrition-related issues.26,31 In par-
teachers or engaged nutrition experts in the implemen- ticular, the intervention carried out by Keihner et al31
tation of the intervention.26,28,33,37,38,40,42–44,47 For designed different activities based on grade level.

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For example, 4th-grade students were asked to search cafeterias replaced soft drinks and high-calorie foods
for a nutrition-related word and write a composition with healthful Indian foods. At the 6-month follow-up
about its qualities and health benefits, while the 5th- assessment, a significant reduction was found in the
grade students completed a word scramble and pre- proportion of children who consumed soft drinks (from
pared a group oral report about food qualities and 26.3% to 11.2%; P < 0.001) and energy-dense unhealthy
health benefits. This study significantly increased stu- foods (from 16.1% to 7.2%; P ¼ 0.03). Likewise,
dents’ knowledge of fruits and vegetables (P < 0.05) and Maatoug et al50 encouraged the snack stores in schools
self-efficacy toward eating fruits and vegetables to replace sugary snacks with healthful snacks and en-
(P < 0.001), while interventions that implemented a sin- couraged students to include fruit, vegetables, or dairy
gle intervention within a wide age range without dis- products in their meals by offering incentives. After the
criminating according to age were not successful in intervention, students in the intervention group signifi-

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achieving their objectives.3,8,24,27,29,30,34,39,46 For exam- cantly increased their intake of fruit and vegetables
ple, Herbert et al29 evaluated the effectiveness of their (P ¼ 0.04).
intervention in changing behavior and physical activity
habits among children aged 7 to 11 years. This interven- Age-appropriate activities. Similar to the interventions
tion, which included a 15-minute lecture on different conducted among elementary school children, interven-
nutrition topics, a 10-minute physical activity warm-up, tions that used age-appropriate activities among sec-
and a 35-minutes aerobic exercise and fitness game, ondary school children were more likely to achieve
provided the same activities for all age groups. their objectives. Age-appropriate activities in secondary
Although the intervention group showed a significant school included role play, peer-led discussions, student
reduction in the consumption of french fries and chips, health fairs, sports games, the use of cosmetic content–
there was no significant increase in either the consump- based nutrition education, and the use of technology,
tion of vegetables or physical activity in comparison such as surfing the internet or using a multimedia
with the control group. CD.49,50,54,55 For example, the intervention developed
by Dehdari et al49 focused on frequency and nutrient
Successful nutrition education interventions in intake during breakfast, using the theory of Pender’s
secondary schools Health Promotion Model. Students were divided into
small groups to surf the internet, design posters, or cre-
The successful nutrition education interventions that ate role play about aspects of breakfast consumption.
targeted secondary school children added policy and Other activities included strategies to overcome the per-
environmental changes to the intervention, used age- ceived barriers to eating a healthy breakfast. The results
appropriate activities that included technology, identi- of the intervention showed significant increases in per-
fied specific behaviors, aligned activities with their ceived benefit, perceived self-efficacy, positive activity-
stated objectives, offered the intervention frequently related affect, interpersonal influences, situational
(such as weekly or biweekly), engaged parents on a influences, commitment to a plan of action, and weekly
face-to-face basis, and trained implementers to ensure frequency of breakfast consumption in the intervention
fidelity. group compared with the control group (P < 0.05). In
addition, the use of age-appropriate topics relevant to
Environmental and policy changes. Change of environ- secondary school children was effective in changing be-
ment was a factor in 3 of the 8 successful interventions havior. For instance, Somsri et al54 compared the effec-
in this category.48,50,53 It was effective in increasing tiveness of a cosmetic content–based nutrition
healthy food choices, changing attitudes, or reducing education with that of a health content–based nutrition
weight as measured by body mass index (BMI). For ex- education in promoting fruit and vegetable consump-
ample, an intervention by Campos Pastor et al48 pro- tion. After the intervention, knowledge scores, attitude
vided a daily balanced breakfast composed of a dairy scores, and the amount and variety of fruits and vegeta-
product, fruits, cereals, nuts, and a sandwich with pro- bles consumed in the cosmetic content–based nutrition
tein content; a prescribed well-balanced diet; and les- education group significantly increased compared with
sons on dietary and lifestyle recommendations for baseline (P < 0.001).
students, family members, and teachers. After the inter-
vention, the authors observed decreases in the preva- Aligning objectives with activities. Alignment of interven-
lence of overweight and obesity (P < 0.001) and the tion activities with the stated objectives and the desired
prevalence of metabolic syndrome (P < 0.001). outcome was critical for the success of interventions
Similarly, a study by Singhal et al53 that introduced en- among secondary school children.48,49,53–55 For example,
vironmental and policy-level change in the school the intervention developed by Viggiano et al55 assessed

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573
the effectiveness of the game Kaledo in improving nu- Specific and measurable behavioral outcomes. Targeting
trition knowledge and in promoting long-term healthy specific behaviors to modify was one of the characteris-
dietary behavior in adolescents. The intervention fo- tics commonly observed among the successful interven-
cused on the use of Kaledo, a board game that repre- tions.56–58,62 For example, Hoffman et al58 planned a
sents a journey through daily meals of the 2.5-year intervention that included knowledge, prefer-
Mediterranean diet. After 6 months of the intervention, ence, and consumption of fruits and vegetables. More
the results showed a significant improvement in the specifically, their results showed a significant increase
children’s nutrition knowledge, physical activity, food in fruit and vegetable intake, ie, 1.5 tablespoons of fruit
habits, and BMI z score in the intervention group com- (P < 0.0001) and 1.5 teaspoons of vegetables during
pared with the control group (P < 0.001). lunch (P ¼ 0.005) for the duration of the project.

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Adequate duration of intervention (at least 6 months). Aligning objectives with activities. Successful interven-
Adequate dosage and frequency of exposure were im- tions strongly aligned their objectives with the activities
portant factors among successful secondary school implemented.57,58,60,61 For instance, Gao et al57 exam-
interventions. Six of the 8 successful interventions pro- ined the effect of nutritional education on children’s
vided weekly or biweekly sessions that lasted between breakfast patterns. The intervention included teaching
30 and 60 minutes.48,49,52–55 For instance, Campos parents the benefits of breakfast for children and the
Pastor et al48 designed a 45-minute program that was methods of breakfast preparation. The lessons were ac-
implemented biweekly for 1 academic year. Significant companied by visual aids such as pictures and food
decreases in the percentage of students who were over- models of breakfast items and an illustrated book for
weight (P < 0.001) and who improved their glucose and children. Parents received brochures with example of
triglyceride levels (P < 0.001) were observed in the in-
breakfast meals. This intervention resulted in a signifi-
tervention group.
cant increase in both the frequency of breakfast intake
(P ¼ 0.02) and the selection of more nutrient-dense
Parental engagement. Similar to findings in effective ele-
breakfast meals (P < 0.001) in the intervention group
mentary school interventions, 4 of the 8 successful
compared with the control group. In contrast, 2 inter-
interventions involved face-to-face interaction with
ventions that partially met their objectives did not align
parents.48–50,53 For instance, the study by Singhal et al53
their stated objectives with the activities.56,59 For exam-
engaged parents by providing a day-long health camp
ple, De Bock et al56 conducted an intervention aimed to
led by a trained nutritionist. At the 6-month follow-up
improve fruit, vegetable, and water consumption and to
assessment, significantly more students from the inter-
decrease anthropometric measurements such as BMI,
vention group brought lunch from home that included
fruit (P < 0.001) as compared with the control group. waist circumference, waist-to-height ratio, and total
body fat. The intervention activities were focused on
Fidelity of interventions. As noted with the elementary fruits and vegetables as snacks and the importance of
school interventions, accurate implementation of inter- drinking water. Although the intervention significantly
ventions is critical to ensure fidelity. Among the sec- increased the intake of fruits and vegetables (P < 0.05
ondary school interventions, all 8 interventions were and P < 0.01, respectively), there was no significant
implemented by trained nutritionists, researchers, or change in daily water consumption, BMI, waist-to-
teachers and reported using a standardized format.48–55 height ratio, or total body fat.

Successful nutrition education interventions in Parental engagement. As observed among successful

preschools interventions in elementary and secondary schools, 5 of
7 studies that targeted preschoolers in this review in-
Successful nutrition interventions in preschoolers tar- cluded parental engagement on face-to-face basis, with
geted specific behaviors, aligned activities with the hands-on activities in addition to lectures.56,57,59–61 For
stated objectives and expected behaviors, engaged example, De Bock et al56 created hands-on activities in
parents on a face-to-face basis, and provided hands-on which parents and children interacted in activities such
activities. Similar to successful interventions in the as preparing fruit and vegetable snacks. These strategies
other age groups, effective preschool interventions in- significantly increased the intake of fruits (P < 0.05)
cluded age-appropriate activities, ensured fidelity by and vegetables (P < 0.01).
providing training to teachers, and offered short but
frequent sessions to accommodate the short concentra- Fidelity of interventions. To ensure fidelity, all successful
tion span of preschoolers. nutrition education interventions provided training to

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teachers58,60–62 or health professionals56,57,59 to imple- between the stated objectives, the intervention, and the
ment the interventions. For instance, Lerner-Geva desired outcome, which is needed to affect weight or
et al60 provided training for teachers. By the end of the BMI (downstream outcome). The findings of the cur-
intervention, children showed significantly increased rent systematic review are based on critical analysis of
nutritional knowledge (P ¼ 0.03). these factors. The use of behavior theories in the studies
reviewed was not associated with success of interven-
Age-appropriate activities. Although age-appropriate tions, perhaps because other factors mentioned above
interventions were important in all age groups, they were more critical or because the majority of the studies
were critical in the preschooler age group.56–60,62 Age- that used theory were informed by theory but were not
appropriate activities in preschool included learning theory driven. However, a review by Murimi et al22 that
through a story book57,59; using role models through
looked at factors associated with successful interven-

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play acting, posters, or videos56,58; exploring with the
tions among adults found that interventions were more
senses62; and playing games or coloring sheets with
likely to succeed if they were theory driven. Theory-
peers.60 For instance, the intervention conducted by
driven studies use the specific theory constructs in the
Witt and Dunn62 consisted of hands-on, 30-minute
methodology, intervention, and assessment, while
weekly lessons. It included the use of music, exploration
of the senses, colors, and imaginary trips to promote theory-informed studies might identify the theory that
the consumption of fruits and vegetables. The interven- informs their studies but may not use all its constructs
tion was delivered in short but frequent sessions to throughout the study.4
accommodate the short concentration span of pre-
schoolers. As a result, there was a significant increase
between baseline and the 3-month follow-up in the con- Multicomponent and multilevel interventions
sumption of fruit snacks (by approximately 20.8%;
P < 0.001) and vegetables snacks (by approximately Effective nutrition education is a complex undertaking
33.1%; P < 0.01). In contrast, a study by Pe~nalvo et al61 that calls for a systematic and comprehensive assess-
designed to promote healthy behaviors in preschool ment of the determinants of—as well as the barriers
children included activities to teach correct manage- to—the desired outcome to inform the intervention.64
ment of emotions to develop protective behaviors This review found that nutrition education interven-
against abuse of tobacco, alcohol, and drugs. At the end tions with a comprehensive, multicomponent, and mul-
of the intervention, no significant improvement in this tilevel approach were more likely to achieve their stated
component was observed. In the current systematic re- objectives in all age groups. For example, a majority of
view, the discussion of tobacco, alcohol, and drugs was the preschool interventions that were successful utilized
not considered age-appropriate for preschool children. both teachers and nutrition experts to implement the
interventions in school settings and engaged the parents
DISCUSSION to extend the intervention to the home.56–62 In addition
to incorporating multiple components, they included
The purpose of this systematic review was to identify several levels of intervention, such as knowledge, tasting
factors characterizing studies published between 2009
sessions, and skills building.56,60,61,62 These findings
and 2016 that were successful in achieving their stated
confirm the finding of a systematic review by Colquitt
objectives in nutrition interventions among children. In
et al,65 who concluded that multicomponent interven-
order to capture age-based strategies, studies were
tions in preschool children were associated with a re-
grouped and reviewed according to their targeted age
duction in overweight or obesity. Similarly, the current
groups: preschool, elementary, and secondary school
children. Seven overarching factors emerged as critical review found that nutritional interventions in elemen-
to successful nutrition education among children: (1) a tary schools were more likely to meet their objectives
multicomponent (involving teachers and parents), mul- when they were multifaceted, had a high frequency of
tilevel (including the schools and the home) approach; exposure, were delivered by nutritionists or trained
(2) adequate duration of intervention and frequency of teachers, and engaged parents. This confirms the find-
exposure; (3) parental engagement; (4) age-appropriate, ings of a review by Van Cauwenberghe et al,66 namely
hands-on experiences; (5) fidelity as ensured by training that multicomponent interventions that include im-
of the implementers and standardization of the protocol proved availability of fruit and vegetables, a nutrition
among all groups; (6) environmental change to impact education curriculum delivered by teachers, and at least
knowledge (upstream outcome) and then behavior some parental involvement can improve intake of fruits
(midstream outcome); and (7) proper alignment and vegetables.

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Duration and frequency of exposure diet, physical activity, and behavior) were delivered to
the parents of elementary school children, children’s
Health-related behavior change is a complex process body weight improved by significantly decreasing an
that includes new behaviors to learn and undesired average of 0.1 in BMI z score at the longest follow-up
behaviors to reduce. This process often requires time to period (9–12 months) (P ¼ 0.04). Similarly, Meiklejohn
learn new skills, identify resources, practice the new be- et al72 found significant changes in anthropometric
havior, and identify support to sustain the new behav- measures among adolescents when parents were en-
ior.67 In addition to including multiple levels and gaged. More importantly, active parental engagement
multiple components, this current review found that compensated for short intervention durations, as dem-
reviewed interventions were more likely to meet their onstrated by a review conducted by Neimeier et al,19
stated objectives when they were implemented for more who found that children and adolescents’ actual BMI

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than 6 months and offered frequent exposures, such as reductions were greater in interventions that engaged
weekly or biweekly. This finding was in agreement with parents, even when controlling for the duration of
the results of a systematic review performed by Murimi interventions. In addition, the duration of interventions
et al22 on nutrition education for adults, which found and parent participation both contributed indepen-
that interventions implemented for more than 5 months dently to intervention success rates.19
were more likely to meet their stated goals. Similarly, a
systematic review by Ling et al68 found that increasing Age-appropriate and experiential learning
the length of an intervention or including a long-term
follow-up of at least 12 months might help to identify a The pool of interventions in the current review repre-
delayed intervention effect. sented a wide age range, from preschool to high school
age. The wide difference in age implies a wide differ-
Parental engagement ence in cognition, abstract thinking, and skills, among
others.15–18 It was therefore critical for this review to as-
Although most school children spend most of their day sess the design of the interventions on the basis of age
time at school, significant health and dietary behaviors appropriateness. The results of this assessment showed
are acquired long before school age and are enforced that interventions applying age-appropriate and/or ex-
daily either by parental modeling, feeding style, or avail- periential activities were more likely to be successful.
ability of the desired food choices during breakfast or For example, Hoffman et al58 and Witt and Dunn62
dinner.69 It is therefore critical for interventions target- designed studies to increase the consumption of fruits
ing children to incorporate both the school and the and vegetables among preschoolers by implementing
home environment to be effective in promoting a sus- age-appropriate activities such as the use of role models
tainable healthy lifestyle.70 This systematic review found (cartoons, teachers, coaches) and activity-based lessons
parental engagement in all 3 age groups to be critical that included tasting, imagining, and color associations
for successful interventions aimed at modifying dietary with fruits and vegetables. Hoffman et al58 significantly
behavior or weight loss. The majority (n ¼ 21) of the increased the consumption of fruits and vegetables, and
studies did not engage parents, and other studies en- Witt and Dunn62 significantly increased the consump-
gaged parents by passive methods (n ¼ 6) such as pro- tion of fruit and vegetable snacks. The findings of this
viding them with written information or directing them systematic review concur with those of Dudley et al,73
to a website.24,27,31,32,35,62 Successful studies were more who concluded that experiential learning strategies
likely to engage parents actively, ie on a face-to-face ba- were associated with the largest effects across studies
sis, by offering them nutrition classes33,37,49,59,60 or that reported outcomes of reduced food consumption
health fairs42,50,53,61; requiring them to accompany their or energy intake, increased fruit and vegetable con-
children during cooking, tasting, or nutrition education sumption or preference, and increased nutritional
sessions43,48,56,57; or allowing them to be part of the pro- knowledge. Similarly, all elementary school interven-
gram’s staff.28,44 This was especially critical in the inter- tions that met their stated objective applied interactive
ventions that targeted preschool students.56,57,59–61 education and hands-on experiences in teaching physi-
These findings are congruent with the results of a meta- cal activity and healthy eating behav-
analysis performed by Ling et al,68 who concluded that iors.25,26,28,31,33,37,38,40,42–44,47 Among secondary school
interventions providing skills training and behavioral children, age-appropriate activities that led to successful
change strategies aimed at parents were associated with interventions included the use of topics important to
improvement of children’s BMI in preschool. Similarly, adolescents. For example, the cosmetic content–based
a systematic review by Loveman et al71 demonstrated nutrition intervention by Somsri et al54 (a nutrition ed-
that, when interventions with multiple components (ie, ucation intervention that explained the benefits of fruit

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and vegetable consumption for the skin, body shape, the school or community environment were successful
body weight, and other aspects of body image) was in decreasing the BMI of participants. Examples of envi-
more effective in increasing fruit and vegetable con- ronmental strategies included modification of food
sumption than the health-based intervention. served in schools and creation of safe walking routes to
schools. Another environmental strategy, the Delicious
Fidelity of interventions and Nutritious Garden intervention, included cooking
and taste testing reported a significant increase in the
Fidelity in intervention ensures that all intervention ac- number of fruits and vegetables ever eaten, in vegetable
tivities are executed as planned in the methods. In this preferences, and in fruit and vegetable asking behavior
review, studies that had high fidelity were more likely to at home.
succeed in achieving their stated objectives, ie, approxi-

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mately 82% (n ¼ 31) of the interventions that met or Activities based on stated objectives and targeted
partially met their objectives trained existing teachers or expected outcomes
engaged nutrition and physical activity experts in the
implementation of the interventions. These findings are The importance of setting realistic objectives and plan-
in agreement with a review by Ross et al74 and Ling et ning activities aligned with the objectives and the de-
al,68 who found that providing preschool teachers with sired behavior was critical in studies that were
a health promotion opportunity to enhance their health successful in achieving their objectives. Nutrition edu-
knowledge increased healthy behaviors, reduced stress, cation interventions that succeeded had clear alignment
and increased the fidelity and quality of the between the stated objectives, the desired outcome, and
intervention. the implemented activities. For example, in the study by
Gao et al,57 the objective of the program was to promote
Environmental changes for upstream and midstream consumption of a healthy breakfast for children. To
outcomes achieve their objectives, the authors addressed both the
children, who had a role in consuming the breakfast,
The results of this review found that environmental and the parents, who had a role in preparing the break-
changes were critical in achieving stated objectives fast. The intervention included educating children
among interventions that targeted secondary school stu- about the benefits of eating breakfast and educating
dents. For example, 3 of the 7 successful interven- parents about the methods of breakfast preparation.
tions48,50,53 were effective in increasing positive This intervention resulted in a significant increase in
attitudes toward increasing fruit and vegetable con- the number of times children ate breakfast and the se-
sumption and reducing either weight as measured by lection of more nutrient-dense breakfast choices in the
BMI or unhealthy food choices such as carbonated intervention group. Another example is provided by
drinks, burgers, pizzas, and french fries. Environmental Singhal et al,53 whose study among adolescents focused
changes included providing a standardized breakfast for on the benefits of physical activity and healthy foods
students during the duration of the intervention and such as fruits, vegetables, and dairy and the harmful
prescribing a well-balanced diet. These resulted in a sig- effects of junk foods. The study promoted healthy life-
nificant decrease in the prevalence of overweight and styles among the adolescents by engaging them in activ-
obesity (P < 0.001) and metabolic syndrome ities such as planning their own lunch, planning healthy
(P<0.001).48 Similarly, a study by Singhal et al53 that diets daily by themselves, and listing healthy alternatives
implemented an environmental and policy-level inter- to high-calorie foods. The intervention significantly
vention by replacing sugar-added beverages with lowered the consumption of carbonated drinks and
healthful Indian foods was successful in reducing the energy-dense foods and significantly increased fruit in-
consumption of sugar-added beverages and increasing take during lunch. Other systematic reviews found simi-
the consumption of healthful alternatives. Other sys- lar findings. For example, a review by Murimi et al22
tematic reviews have found environmental and/or pol- found that studies whose objectives, activities, and de-
icy interventions to be effective in changing behavior. sired outcomes were aligned were more likely to be suc-
For example, a systematic review by Silveira et al75 cessful. Similarly, a systematic review by Silveira et al75
showed that school environmental change to ensure an concluded that interventions using structured activities
uninterrupted supply of fruits and vegetables in schools aligned with specific objectives to provide knowledge
allowed children and adolescents to have access to these about the benefits of maintaining a healthy diet were
foods, thereby increasing the feasibility of incorporating more likely to be successful.
fruits and vegetables in their diet. Similarly, a systematic This review has 2 limitations. First, only articles
review by Mercado et al76 found studies that addressed published in English were considered. Therefore, it is

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possible that some recent and important findings pub- behavior in all age groups of school children.
lished in languages other than English were left out. Researchers planning to implement interventions
Second, this review was limited by a lack of adequate in- among preschool children are encouraged to design
formation in the methods and results of some articles. short but frequent sessions to accommodate the short
This hindered the ability to properly evaluate the con- attention span of preschoolers, to include hands-on ac-
tributions and effectiveness of specific components of tivities, and to work with parents, preferably on a face-
nutrition education interventions, including the use of to-face basis. A combination of adequate dose (duration
theory and the dosage of interventions (frequency and of at least 6 months) and trained implementers is criti-
duration). Despite these limitations, the strength of the cal for elementary school children, while the use of
current review lies in its analysis of several factors that technology and age-appropriate topics is important for
contributed to the success of various types of interven- secondary school children. Although the use of theory

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tions. This is different from previous reviews that fo-
did not determine the success of the interventions ana-
cused primarily on the analysis of a single type of
lyzed in this review, it is important to note that most of
intervention and the related outcome.
the interventions were only informed by a theory but
were not designed and driven by theory. As indicated
CONCLUSION
by a previous systematic review on nutrition education
This review indicates that nutrition education interven- in adults, theory-driven interventions are more likely to
tions are more likely to be successful in achieving their be successful.22
objectives when experiential activities such as gaming,
gardening, and cooking demonstrations are incorpo- Acknowledgments
rated and when specific dietary behaviors are targeted
for modification. In addition, interventions that en- Author contributions. M.W.M. conceptualized the sys-
gaged parents through face-to-face interaction and de- tematic review. M.W.M., A.F.M-C., B.N., S.S., and R.A.
livered extensive training for external experts and conducted the literature search, screened the selected
teachers to enhance fidelity were more likely to achieve articles, and assessed the quality and extracted the infor-
their objectives. While all the successful interventions mation of the included articles. B.N. and S.S. wrote the
reported an increase in participants’ knowledge, inter- introduction. M.R.A. wrote the methods section.
ventions were more likely to be successful in changing M.W.M., A.F.M-C., and V.N. analyzed the articles.
behavior when the duration of the intervention was M.W.M. and A.F.M-C. wrote the results section.
more than 6 months. M.W.M. and V.N. wrote the discussion and conclusion
Studies that delivered interventions within a period and provided critical revision of the manuscript.
of less than 6 months, used intervals of more than A.F.M-C. edited the manuscript. M.W.M. approved the
2 weeks between lessons, or delivered a single-dose edu- final version of the manuscript.
cational intervention were less likely to be successful in
achieving their objectives. Similarly, interventions that Funding/support. No external funds supported this
delivered passive education programs for parents, such work.
as providing a web link or written material, did not
benefit from that component of parental involvement. Declaration of interest. The authors have no relevant
In addition, interventions were less likely to meet their
interests to declare.
stated objectives if they broadly promoted healthy eat-
ing in general without targeting a specific behavior or
Supporting Information
did not ensure fidelity but just provided tool kits with-
out specific guidance on the usage of the material in-
The following Supporting Information is available
stead of training the teachers directly. While most
through the online version of this article at the publish-
interventions were successful in improving knowledge,
er’s website.
attitudes, and behavioral measures, downstream varia-
Appendix S1 PRISMA checklist
bles such as BMI, waist circumference, and percent
body fat, when used as outcome measures, did not
show any meaningful improvement without the use of REFERENCES
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