Table 1 Overview of the publications included in the review

Angelopoulos et al., 2009 [19]

CHILDREN study

Greece

13 schools

646 pupils

5th grade

(Mean ± SD: 10.3 ± 0.4 years)

–

1 school year

School and home environment (availability of healthy choices)

Policies (Children’s and teachers in-class-material, Enjoyable fitness classes, Schoolyards open after school hours)

Parents engagement (Meetings to support children’s energy-balance related behaviors (EBRBs), Increasing parental support, Overcoming the barriers in accessing physical activity (PA) areas))

Teachers acting as role-models

Theory of Planned Behavior

–

Significant favorable effect on fruits consumption and fats/oils and sweets/beverages consumption.

Significant favorable effect on BMI (P = 0.047) could be explained by the changes in fruit and fats/oils intake.

(+++)

Benjamins et al., 2010 [20]

–

Chicago

2 schools

581 students

1st-8th grade

Jewish schools

2 school years

Formation of a wellness council

Writing of a wellness policyHealth education (via health lessons)

Physical education (by providing funding to increase PA, gender separated swimming lessons)

School environment (removing vending machines, healthy lunches, skim-milk promotion, fruit of the week program)

Family involvement (school events, meetings, newsletters)

Staff wellness (role-models, private dietary consultations, educational sessions)

The Centers for Disease Control (CDC) ecological model-based Coordinated School Health Program

–

Significant favorable effect n the percentage of older students regularly meeting physical activity guidelines. Few changes in attitudes, other behaviors, or environmental factors were seen.

(++)

Bhave et al., 2017 [21] ^a

SYM-KEM Study

India

865 children

3rd and 4th grades (age range: 7.7–9.6 years).

Academically competitive Indian school

2 school years

Increased extra- and intra-curricular physical activity sessions

Daily yoga-based breathing exercises

Making physical activity a ‘scoring’ subject

Nutrition education

Healthier school meals

Removal of fast-food hawkers from the school environs

Health and nutrition education for teachers, pupils and families

Theory Framework not mentioned

5 years

After five years the intervention had significant favorable effect on running, long-jump, sit-up and push-up tests.

Significant favorable effect on sedentary time (watching TV and studying), active play time and fruit consumption.

Significant favorable effect on waist circumference.

No effect on BMI or the prevalence of overweight/ obesity.

(+++)

Brandstetter et al., 2012 [22]

URMEL-ICE

Germany

945 children 2nd grade

(Mean ± SD: 7.6 ± 0.4 years)

–

1 school year

29 teaching modules,

2 short exercise blocks per day

6 family homework lessons

Parental material

Teachers training

Social Cognitive theory

–

No statistically significant effect of the intervention on BMI.

Significant favorable effect on waist circumference and subscapular skinfold thickness before additional adjustment for individual time lag between baseline and follow-up.

The intervention group revealed a higher percentage of children with an improvement and a lower percentage with a worsening of the health-relevant behaviors compared to the control group.

(+++)

Cohen et al., 2014 [23]

The CHANGE study

California, Kentucky, Mississippi and South Carolina, USA

8 schools432 children grades 1-6th

(Mean ± SD: 8.6 ± 1.5 years)

rural low-SES areas

2 school years

Food service component (healthier choices)

Educational curriculum every week

Parent and community outreach components throughout the school district to promote the healthy lifestyle changes encouraged during and after the school day.

Theory Framework not mentioned

–

Significant favorable effect on vegetables consumption and on combined fruits and vegetables consumption

Favorable trend toward more fruit consumption (not significant)

No significant effects on whole grains, legumes, dairy, potatoes/potato products, saturated fat, added sugars, or dietary fiber consumption.

(+)

De Coen et al., 2012 [24]

POP project

Belgium

31 schools, 1102 children

3–6 years

(Mean ± SD: 5.0 ± 1.3 years)

–

2 school years

Family involvement via educational strategies, newsletters, tips, recipes

Development of an active playground

Implementation of health-related physical education

Environmental and policy changes to increase availability of healthy options

Community stakeholders, local policy and media (meetings, brochures) involvement

Socio-ecological model

–

Significant favorable effect on BMI Z-score in the low-socioeconomic status (SES) intervention community.

(+++) only in low-socioeconomic status (SES) groups.

Foster et al., 2007 [25]

–

Philadelphia, USA

10 schools

1349 children

4th - 6th grade

(Mean ± SD: 11.1 ± 1.0 years)

–

2 school years

School Nutrition Policy Initiative: School self-assessment (school rating and action plan for change)

Staff training (10 h)

Nutrition education (50 h)

Nutrition policy (cafeteria offering only healthy options, removal of vending machines)

Social marketing (Slogans, character/ hero, raffle tickets)

Parent outreach (meetings, workshops)

Social marketing and other theories

–

The intervention resulted in a 50% reduction in the incidence of overweight. Significantly fewer children in the intervention schools than in the control schools became overweight after 2 years. The prevalence of overweight was lower in the intervention schools.

No differences were observed in the incidence or prevalence of obesity or in the remission of overweight or obesity at 2 years.

Significant favorable effect on inactive hours per week and on hours spent on TV on weekdays.

(+++)

Jensen et al., 2015 [26]

Copenhagen School Child Intervention Study (CoSCIS)

Copenhagen, Denmark

18 schools

307 children with full data Mean age 6.8 years at baseline

–

3 school years

Two additional physical education (PE) lessons per week

Additional education of PE teachers

Improvement of schoolyard environment (recess)

Parent involvement via newsletters

Establishment of school canteens

Health education in the curriculum

Theory Framework not mentioned

Significant favorable effect on dietary fibre intake

Favorable trend on fat and saturated fatty acids intake.

Significant favorable effect on the intake of saturated fatty acids among children of mothers with higher education.

(+)

Kain et al., 2008 [27]

–

Chile

4 schools

2430 students

1st-8th grade

(Mean ± SD: 10.0 ± 2.3 years)

–

2 school years

Teachers’ training

Parents’ education via meetings

Children’s educational and PE classes

Active recess

Theory Framework not mentioned

–

Significant favorable effect on obesity prevalence and BMI-Z in both boys and girls

(+++)

Kesztyues et al., 2017 [28]^a

The Baden-Wurttemberg Study

“Join the Healthy Boat” program

Germany

1733 children (Mean ± SD: 7.1 ± 0.6 years)

–

1 school year

Teachers’ training

All materials were integrated into the regular curriculum

Materials for children (e.g. activity breaks) and for parents (e.g. family homework and information material)

Translation of the material in order to also reach parents with migration background

Intervention mapping, social cognitive theory & socio-ecological model

–

Significant favorable effect on abdominal obesity

(+++)

Kobel et al., 2017 [29]^a

Migration background Sub-sample

Significant favorable effect on fruits & vegetables intake

Favorable trend on PA and soft drink consumption

(+)

King et al. 2015 [30]^a

–

rural elementary schools in the southern United States

4 rural elementary

School

999 children kindergarten to third grade

(Mean age: 7.3 years)

rural, low-socioeconomic

status elementary schools

1 school year

Nutrition and health Education

SPARK PE curriculum Classroom PA

Strengthening school wellness policies

Health promotion for teachers and families

Promoting family involvement and community partnerships

Culminating goal for each school to achieve ‘bronze’ or higher status of the Healthier US School Challenge

The CDC’s ecological model-based Coordinated School Health Program

Significant favorable effect on nutrition and physical activity behaviors

Significant favorable effect on the percentage of children meeting the nutrition recommendation Significant favorable effect on the percentage of children meeting the physical activity recommendation

(++)

Kipping et al., 2014 [31]

AFLY5

South west England

60 schools2221 students

4th grade

(Age range:

8-9 years)

–

1 school year

Teacher training

Provision of 16 lessons & child-parent interactive homework plans

Materials for lessons and homework, and written materials for school newsletters and parents.

Social Cognitive Theory

–

No effect on the three primary outcomes (PA, sedentary time, diet)

Significant favorable effect on three out of nine of the secondary outcomes, i.e. self-reported time spent in screen viewing at the weekend, self-reported servings of snacks per day, and servings of high energy drinks per day.

(+)

Lawlor et al., 2016 [32]^a

–

–

Significant favorable effect on 3/10 potential mediators, i.e. fruit and vegetable self-efficacy; child-reported maternal limitation of sedentary behavior; and knowledge.

(+)

Anderson et al., 2016 [33]^a

–

1 year post intervention

No effect on mean child-reported screen viewing at the weekend, servings of snacks per day, servings of high-energy drinks per day, servings of high-fat foods per day.

(−)

Llargues et al., 2011 [15]

AVall study

Granollers Spain

16 schools500 students

1st grade

(Age range:

5-6 years)

–

2 school years

Educational sessions to promote healthy eating habits and physical activity

Information session with the parents

Distribution of healthy recipes

Research, Vision, Action and Change (IVAC) methodology

–

Significant favorable effect on BMI and the prevalence of overweight children

Significant favorable effect on the proportion of children that ate a second piece of fruit Significant favorable effect on the consumption of fish.

(+++)

Lloyd et al., 2017 [34]^a

Healthy Lifestyles

Programme (HeLP)

South West of England

32 schools 1324 children

(Age range: 9–10 years)

–

1 school year

Dynamic & interactive activities e.g.

Physical activity workshops

Education sessions delivered by teachers with short homework tasks

Drama sessions

Goal setting to modify behavior with parental support and one-to-one discussions with the project’s coordinators

Extensive stakeholder involvement

Intervention mapping

–

No significant effects on anthropometric or physical activity outcomes

Significant favorable effect on the adjusted means of the Food Intake Questionnaire scores (both weekly and weekday) for energy-dense snacks and negative food markers

(+)

Manios et al., 2002 [35]

–

Crete, Greece

40 schools

5681students

1st grade

(Age range:

6-7 years)

–

6 school years

Multicomponent workbooks for students

Teaching aids included posters, audio-taped fairy tales for classroom use, workbooks, and teaching manuals Non-competitive activities

Meetings with parents

Booklet distribution

Social Cognitive theory

Significant favorable effect on biceps skinfold

Significant favorable effect on total energy intake, consumption of total fat and saturated fat

Significant favorable effect on time devoted to leisure time physical activity

(+++)

Manios et al., 2006 [36]

4 years post intervention

Significant favorable effect on MVPA levels for males and on males meeting the recommendations for physical activity

(+)

Manios et al., 2006 [37]

Significant favorable effect on total cholesterol, LDL-cholesterol, HDL-cholesterol and total cholesterol: HDL-cholestrol ratio

Significant favorable effect on leisure-time physical activities and BMI

No effects on fitness and dietary indices examined.

(+++)

Mårild et al., 2015 [38]^a

IDEFICS study

Belgium, Cyprus, Estonia, Germany, Hungary,

Italy,

Spain,

Sweden

7406 children (age 2–9.9 years) of the 16,228 participating

–

1 school year

Sustainable change in health behaviors and in the community environment in cooperation with political leaders, teachers and stakeholders.

Intervention Mapping

–

No effects on insulin, HOMA-IR, CRP or the MetS score

Significant favorable effect on fasting glucose, a pattern driven by three of the eight countries and more pronounced in children of parents with low education.

Significant unfavorable effect on HbA1c and waist circumference increased more and blood pressure less in the intervention regions.

(+) only in glucose levels but otherwise contradicting results.

Mihrshahi et al., 2017 [39]^a

Good Start Program

Maori and Pacific Islander communities living in Queensland

375 children (6–19 years)

Maori and Pacific Islander communities living in Queensland

1 school year

Class activities focused on one message each term related to healthy eating and physical activity using methods such as cooking sessions and cultural dance.

Theory Framework not mentioned

–

Quantitative uncontrolled pre-post design.

Significant favorable time effect on knowledge of correct servings of fruit and vegetables, knowledge of sugar and caffeine content of common sugar-sweetened drinks, recognition of the consequences of marketing and upsizing, and the importance of controlling portion size, knowledge of physical activity recommendations, as well as the importance of physical activity for preventing heart disease and improving self-esteem

Significant favorable time effect on some attitudes to vegetables and sugar-sweetened drinks and the reported intake of vegetables

(+)

Pablos et al., 2017 [40]

Healthy Habits Program (HHP)

Valencian Community, Spain

2 schools

158 children (10–12 years)

–

1 school year

Free extracurricular activity:

brief 10-min talk about healthy habits

Physical exercise session targeting fun, inclusion and cooperation, and safety (themed games)

All the sessions were led by the same specifically-trained teacher.

A worksheet designed by the research team was given to be

completed at home (29 in total)

Three 45-min talks for parents and teachers about healthy habits for school children.

Theory Framework not mentioned

Significant favorable effect on triglycerides, blood glucose and VO2max, breakfast habits and quality of diet, the prevalence of normal levels for total cholesterol, blood pressure and BMI.

(+++)

Plachta-Danielzik et al., 2007 [41]

KOPS study

Kiel, Germany

32 schools1764 students

(Age: 6 years)

–

1 school year

Teachers training on a structured nutrition education program.

Health messages were given to children, parents, and teachers, conveyed as nutrition fairy tales, interactive games, and by preparing a healthy breakfast. Six nutrition units performed during 2 to 3 weeks within the second term of the first school year. After each unit, running games were offered for 20 min on the schoolyard.Parents were informed during a parental school meeting.

Theory Framework not mentioned

4 years post intervention

No effect on mean BMI

Significant favorable effect on the prevalence of overweight and obesity in children from families with high socioeconomic status and marginally significant in children of normal-weight mothers.

(+++) only in high-SES groups.

Plachta-Danielzik et al., 2011 [42]

8 years post intervention

No effect on mean BMI, lifestyle and blood pressure

Significant favorable effect on the 8-year change in BMI- standard deviation scores (SDS) in high SES groups

(+++) only in high-SES groups.

Rush et al., 2014 [43]^a

Project Energize

New Zealand

193 primary schools

4804 children (Age range: 6-11 years)

42% Māori, the

indigenous people of New Zealand

Encourage healthy behaviors daily

Healthy choices availability and decrease the availability of high energy/ low nutrient foods

Increase the awareness of healthy choices

Consistent nutrition messages in all aspects of school and community interaction e.g., healthy fundraising options

Encourage lunchtime physical activity at least twice a week

Raise awareness of incidental activity opportunities at home and school

Theory Framework not mentioned

Significant favorable effect on the combined prevalence of obesity and overweight and BMI, physical fitness in both boys and girls, both indigenous Maori and non-Maori children, and across SES.

(+++)

Sacchetti et al., 2015 [44]^a

SAMBA project

Bologna, Italy

11 classes

234 school children (Age range: 8-11 years)

–

3 school years

Training modules for teachers

Training modules for instructors of local sport societies

Educational activities in class

Free and structured games inside the school and in the open.

Cookery workshops and sensory courses for parents and teachers.

Moments of movement with parents in free time: homework

Dog walking & Home-school routes on foot/by bike

Creation of didactic materials (recipes, leaflets, DVDs, food pyramids)

Precede-Proceed Model

Significant favorable effect on weight, the percentage of children who consumed an adequate mid-morning snack, the percentage of children who consumed snacks and drinks after the dinner and the percentage of those who consumed five or more portions of fruits and vegetables daily.

(+++)

Sahota et al., 2001 [45]

APPLES

Leeds, UK

10 schools

634 students

(Age range:

7-11 years)

–

1 school year

Teacher training

Modification of school meals

Development of school action plans (Individualized on school level based on their needs)

Parental involvement

Theory Framework not mentioned

–

Significant favorable effect on vegetable consumption

No effect on physical activity or sedentary behavior

(+)

Shofan et al., 2011 [46]

–

Israel

2 schools

108 students

4th–6th grade

(Age range:

9-11 years)

–

2 school years

8 nutritional education lessonsDouble physical education hours (intense aerobic activity designed to increase the aerobic component by 50%)Regular parents meetings, once a month for one hour per session for 10 months a year,

Encouragement of healthy dietary habits.

Theory Framework not mentioned

–

Significant favorable effect on the average BMI percentile

Significant favorable effect on weight for boys No effect on weight or BMI in girls.

(+++)

Spiegel et al., 2006 [47]^a

WAY program

USA

69 classes

1013 students

4th&5th grade

(Age range:

9-11 years)

–

1 school year

Intervention teachers participated in workshops on the intervention and received program materials.Family involvement through activities and discussionsClass modules

Theory of Reasoned Action

–

Significant favorable effect on BMI, the consumption of fruits and vegetables and physical activity levels

(+++)

Springer et al., 2012 [48]

Marathon Kids

Texas, USA

511 students4th–5th grade Mean age: ~ 10 years

Low-SES area

1 school year

Miles trackingNumber of F&V tracking

Kick-off and Final Mile Run in public venues with celebrities-mayors-professional athletes as hosts/ public role-modelsCommunity events/ festivalsT-shirts-medals at the end, logo, stickers, advertising on buses & scheduled time for walking/ running at school

Ecological Model by Sallis et al, 2006

–

Significant favorable effect on the mean time of running in past 7 days the mean fruit and vegetable consumption, athletic identity self-concept, PA outcome expectations, and PA and fruit and vegetable consumption self-efficacy

(++)

Weber et al., 2017 [49]

SMS.

Sei schlau.

Mach mit. Sei fit.

[‘Be smart. Join in. Be fit.’]

Germany

Four 3rd and 4th grade classes (70 children) as intervention &

6 classes (125 children) as control group

Mean age: ~ 9 years

migration background

1 school year

2 additional exercise lessons weekly (“Fitness für Kids”) and 10 nutrition lessons per school year.

In the trial, parental involvement was limited to participation in evening meetings and accompanying their children to extra-curricular activities.

Theory Framework not mentioned

–

Significant favorable effect on fitness and motor skill driven by higher improvements in 5 of the 8 test items, i.e., obstacle race (speed), standing long jump (strength), sit-ups (strength), stand and reach (mobility), and 6 min run (endurance), independently of confounders.

No effects on dietary knowledge and consumption frequencies.

(+)

Xu et al., 2015 [50]^a

CLICK-Obesity Study

Nanjing City, Mainland China

8 urban primary schools

grade 4

1125 students

Mean age: ~ 10 years

1 school year

Classroom curriculum,

School environment support, Family involvement and fun programs/events) together with routine health education

Theory of Triadic Influence (TTI) and the CDC’s ecological model-based Coordinated School Health Program

Marginal (non-significant) favorable effect on mean BMI value. Significant favorable effect on likelihood to decrease their BMI by 0.5 kg/m2 or above, increase the frequency of jogging/ running, decrease the frequency of TV/computer use and of red meat consumption, change commuting mode to/from school from sedentary to active mode, and be aware of the harm of selected obesity risk factors.

(++)