Singhetal.BMCPublicHealth (2017) 17:292 DOI10.1186/s12889-017-4201-3 RESEARCH ARTICLE Open Access Impact of school policies on non- – communicable disease risk factors a systematic review Ankur Singh1, Shalini Bassi2, Gaurang P. Nazar2, Kiran Saluja2, MinHae Park3, Sanjay Kinra3 and Monika Arora2* Abstract Background: Globally, non-communicablediseases(NCDs) are identified as one of theleading causes of mortality. NCDshaveseveralmodifiableriskfactorsincludingunhealthydiet,physicalinactivity,tobaccouseandalcoholabuse. Schools provide ideal settings for health promotion, but the effectiveness of school policies in the reduction of risk factors for NCD is not clear. This study reviewed the literature on the impact of school policies on major NCD risk factors. Methods: A systematic review was conducted to identify, collate and synthesize evidence on the effectiveness of school policies on reduction of NCD risk factors. A search strategy was developed to identify the relevant studies on effectiveness of NCD policies in schools for children between the age of 6 to 18 years in Ovid Medline, EMBASE, and Web of Science. Data extraction was conducted using pre-piloted forms. Studies included in the review were assessed for methodological quality using the Effective Public Health Practice Project (EPHPP) quality assessment tool. A narrative synthesis according to the types of outcomes was conducted to present the evidence on the effectiveness of school policies. Results: Overall, 27 out of 2633 identified studies were included in the review. School policies were comparatively more effective in reducing unhealthy diet, tobacco use, physical inactivity and inflammatory biomarkers as opposed to anthropometric measures, overweight/obesity, and alcohol use. In total, for 103 outcomes independently evaluated within these studies, 48 outcomes (46%) had significant desirable changes when exposed to the school policies. Based on the quality assessment, 18 studies were categorized as weak, six as moderate and three as having strong methodological quality. Conclusion: MixedfindingswereobservedconcerningeffectivenessofschoolpoliciesinreducingNCDriskfactors. ThefindingsdemonstratethatschoolscanbeagoodsettingforinitiatingpositivechangesinreducingNCDrisk factors,butmoreresearchisrequiredwithlong-termfollowuptostudythesustainabilityofsuchchanges. Keywords:Non-communicabledisease,Schoolpolicy,Systematicreview,NCDriskfactor Background Disease study, out of all the deaths due to NCDs in Non-communicable diseases (NCDs) cause about 40 2015, approximately 12 million deaths were due to million deaths each year globally [1]. The four most unhealthy diet, 6.5 million were due to tobacco use, important modifiable behavioral risk factors for NCDs 1.8 million were due to alcohol and drug use and include unhealthy diet, physical inactivity, tobacco use 1.6 million deaths were attributed to low physical ac- [2, 3] and harmful use of alcohol [4]. According to the tivity [1]. The major risk factors for NCDs are associ- estimates from the most recent Global Burden of ated with behavioral patterns that are largely established during childhood and adolescence and con- tinue into adulthood [5–7]. The onset of many NCDs *Correspondence:[email protected] like diabetes, obesity, and cardiovascular diseases can 2HealthPromotionDivision,PublicHealthFoundationofIndia(PHFI),Plot No.47,Sector44,Gurgaon,Haryana122002,India Fulllistofauthorinformationisavailableattheendofthearticle ©TheAuthor(s).2017OpenAccessThisarticleisdistributedunderthetermsoftheCreativeCommonsAttribution4.0 InternationalLicense(http://creativecommons.org/licenses/by/4.0/),whichpermitsunrestricteduse,distribution,and reproductioninanymedium,providedyougiveappropriatecredittotheoriginalauthor(s)andthesource,providealinkto theCreativeCommonslicense,andindicateifchangesweremade.TheCreativeCommonsPublicDomainDedicationwaiver (http://creativecommons.org/publicdomain/zero/1.0/)appliestothedatamadeavailableinthisarticle,unlessotherwisestated. Singhetal.BMCPublicHealth (2017) 17:292 Page2of19 be prevented or delayed by addressing these risk fac- establishedtoincludestudiesassessingeffectivenessofei- tors earlier in life [8]. ther existing or new school based policy interventions Children and adolescents should be prioritized as target amongchildrenbetweentheageof6to18yearsaimedat groupsforbehavioralinterventionsduetotheirhighadapt- the reduction of NCD risk factors. Studies that assessed ability and likelihood to be motivated for appropriate the effectiveness of pre-school policy intervention were healthy modifications [9]. In support of this, evidence excluded. The detailed inclusion and exclusion criteria shows that behavioral modifications are more successful if guiding the selection of studies for the review is described implemented at an early stage [10, 11]. Behavioral changes in Table 1. Duplicate references were removed using soft- duringearlyyearsrequireconducivepoliciesandprograms ware(EndnoteX7),andtitlesandabstractswereindepend- [12]. Hence, in addition to prioritizing children for the ently screened by two reviewers (AS and SB). Any adoption of healthy behavioral practices, they should be disagreementswereresolvedbydiscussionandconsultation provided with a supportive environment for behavior withathirdinvestigator(MA).Followingthisstep,fulltext changeinsettingswherechildrenlive,playandstudy[13]. oftheselectedstudieswereretrievedandthenreviewedfor Schools are uniquely positioned as ideal settings to relevance to the inclusion and the exclusion criteria by AS model, promote and reinforce healthy behaviors and SB independently. Disagreements at this stage were among children and adolescents. Children and adoles- resolvedthroughdiscussionbetweenthetworeviewers. cents spend much of the daytime at school and can easily access the schools’ health-related educational Dataextraction programs. Therefore, schools function as health hubs Two reviewers (AS and SB) independently extracted in- by educating and imparting healthy habits among stu- formation from the selected papers using pre-piloted dents [14, 15] as they service a large population of data extraction forms. Any disagreements were resolved children and adolescents [7]. Evidence suggests that either by discussion or by the intervention of another school policies can positively impact Body Mass Index investigator (MA). The following data were extracted: (BMI) [16], physical activity and dietary behaviors study characteristics (primary author, year of publica- [17] among children. tion, study setting, age group, sub-groups analysed, Previous studies have mostly looked at the relationship sample size, data collection methods, inclusion criteria, between school policies and specific risk factors. There randomization information, statistical analysis); inter- existsnoreviewthathassystematicallyidentifiedandcol- vention or policy component, study outcomes (primary lated evidence on the effectiveness of school-based policy outcomes: BMI, waist circumference, overweight, interventions collectively for the four major preventable obesity, physical activity, tobacco use, alcohol use, other NCD risk factors (unhealthy diet, physical inactivity, relevant outcomes; secondary outcomes: knowledge tobacco use and alcohol use). Furthermore, no systematic and attitude), type of effect estimates, main result and review has examined the impact of school policies on the statistical significance of differences. anthropometric & physiological measures in children. Therefore, the aim of this systematic review was to iden- Qualityassessment tify, collate and synthesize the existing literature on the All the papers included in the review were independently impactofschoolpoliciesonmajorriskfactorsofNCDs. assessed for methodological quality using the Effective PublicHealthPracticeProject(EPHPP)qualityassessment Methods tool [19] by AS and then cross-checked by SB. The Searchstrategyandstudyselectioncriteria EPHPP tool contains eight different components but the A review protocol was developed in accordance with scoring on quality assessment is done by six parameters. PRISMA guidelines [18]. The search strategy aimed to These include selection bias, study design, identification identify published articles on the effectiveness of school and treatment of confounders, blinding, data collection level policy interventions to reduce major preventable methods andwithdrawalsand dropouts. The components risk factors for NCDs (unhealthy diet, physical inactivity, wereratedstrong,moderate,orweakaccordingtoastan- tobacco use, alcohol use, excess body weight, high blood dardized guide and corresponding guidelines in the pressure, adverse lipid profile as well as anthropometric dictionary. Those with no weak ratings and at least four and physiological measures) among students. The search strong ratings were considered ‘Strong.’ Those with less was carried out in three electronic databases: Ovid Med- thanfourstrongratingsandoneweakratingwereconsid- line, EMBASE, and Web of Science. The search strategy ered ‘Moderate.’ Finally, those with two or more weak used to identify the studies in Medline is included in ratings were considered ‘Weak.’ The two remaining com- Additionalfile1. ponents within the quality assessment included in the Thedatabasesweresearchedforstudiespublishedfrom assessment were the integrity of the intervention and the January 1990 to January 2014. The inclusion criteria were useofappropriateanalysis[19]. Singhetal.BMCPublicHealth (2017) 17:292 Page3of19 Table1Inclusionandexclusioncriteria InclusionCriteria ExclusionCriteria Population Population Childrenoradolescentsbetweentheage-groupof6–18years. Childrenoradolescentsnotinthespecifiedage-groupandstudies conductedonanimalmodels. Intervention Intervention Policiesthatmodifythefouridentifiedriskfactors(unhealthydiet,physical Policycomponentsthoseareinsufficientlydescribedtoenable inactivity,alcoholandtobaccouse)andassociatedhealthrelatedbehaviors replication.Schoolpoliciesfocusingondifferentlyabledstudents. amongstthestudentseitheraloneoraspartofanyinterventionprogram. Context Context Schoolsasasetting. Community,pre-schoolsandclinicalsettings. Outcome Studydesign PrevalenceofhealthrelatedbehaviorsidentifiedasriskfactorsforNCDs. Editorials,librarythesis,opinionsandletters,paperswithinsufficient methodologicaldetailsreportedtoallowcriticalappraisalofstudy StudyDesign quality,studiesnotinEnglishlanguage.Studiespublishedbefore1990. Anyexperimentalorobservationalstudydesign(randomizedcontrolledtrial controlledbefore-afterstudy,quasi-experimental,interruptedtimeseries, cohortstudyorcross-sectionalstudy). Synthesisofevidence The majority of included studies were from high- Duetotheheterogeneityinpolicycomponentsofthein- income countries, USA (15), Australia (4), UK (2), terventionsincluded,outcomesandeffectmeasures,ameta- Canada (2), Spain (1), Greece (1), combined USA and analysiswasnotconsideredappropriate.Adescriptionofef- Australia (1) with the exception of only one study from fectivenessmeasuresandanarrativereviewwereconsidered India (1). There were 15 interventional studies (eight appropriatetopresentthefindingsofthestudy. randomized controlled trials (RCTs), seven quasi- experimental studies), 11 observational studies (ten Results cross-sectional studies, one case-control) and one Overall, 27 studies were included in the review after the natural experiment. Five out of 27 studies were based in full-text screening of the identified articles through schools from socioeconomically deprived areas. Of the systematic database searching (n = 2633), title and ab- 27 studies, ten assessed the effectiveness of multiple stract screening (n = 90), application of inclusion and policy interventions and 14 studies evaluated multiple exclusioncriteria(n=39)andfull-textreview (Fig. 1). outcomes (physical measures, biomarker levels and Fig.1Flowchartforstudyidentificationandselectionprocess Singhetal.BMCPublicHealth (2017) 17:292 Page4of19 behaviors). The remaining three studies only assessed fitness and school nutrition, school-based nutrition, singleintervention oroutcome.Collectively,the children school and home nutrition and home-based nutrition in within the selected studies ranged from 6 to 17 years BPcontrolshoweddesirableeffects[22,26].Ontheother and were in grades from 1st to 12th. Apart from one hand, one assessing the effectiveness of integration of study [20] which included only boys, remaining studies health promotion in the existing curriculum reported included both boys and girls. Based on the quality non-significantchanges[27](Table3).However,thethree assessment of the selected studies, 18 were categorized studieswerejudgedtobeofweakmethodologicalquality. as having weak methodological quality, six with moderate quality and three with strong methodological Biomarkers quality(Table2;Additionalfile 2). Two out of the27 studies assessed changesin biomarker levels [22, 24]. One study [22] assessed whether Physicalandanthropometricmeasures extended brisk walking lessons as a school level inter- Seven studies assessed the effectiveness of policy inter- vention resulted in changes in serum levels of triglycer- ventions or its association with changes in anthropomet- ides, high-density lipoprotein cholesterol, high-density ric measures [14, 21–26]. Three studies assessed the lipoprotein to total cholesterol ratio and glucose. They effectiveness of school policy in controlling blood pres- reported significantly lower levels of triglycerides, sure [22, 26, 27]. The policy interventions targeted at improvements in high-density lipoprotein cholesterol, anthropometricmeasurements(BMI,waistcircumference, high-density lipoprotein to total cholesterol ratio and heightand weight status) included school nutritionpolicy reductioninglucoselevelstobeassociatedwiththeinter- initiative [14, 21], comprehensive legislation at state level vention.Similarly,desirableserumlevellipidchangeswere tocombatobesity[25],briskwalkinglessons[22],teacher reportedbyManiosetal.[26],intheirstudyontheeffect- trainings, developing activities related to food habits and/ iveness of multicomponent workbooks covering dietary or physical activity [23], fitness guidance, fitness and issues, physical activity and fitness, dental health hygiene, schoolnutrition,school-basednutrition,schoolandhome smoking and accident prevention as school level policies. nutritionandhome-basednutrition[26];multicomponent Additionally, teaching aids including posters, audio-taped workbooks covering dietary issues, physical activity and fairy tales for classroom use, workbooks, and teaching fitness [24] and integration of health promotion in the manuals were provided to class teachers and physical existingcurriculum[27](Table3). education (PE) instructors (Table 3). The studies were Mixed results were reported for the effects of school judgedtohaveweaktomoderatemethodologicalquality. policies on BMI. Non-significant differences or associa- tions with BMI for policy interventions were reported by Unhealthydiet three studies [14, 25, 26]; while two studies reported The majority of selected studies (n = 15) assessed the significantly lower progression of BMI among those effectiveness of policy interventions in changing exposed to policy interventions compared to those who unhealthy dietary behaviors. These policies ranged from did not [23, 24]. The studies that showed policies to be removal of sugar-sweetened beverages (SSBs) and junk effective in reduction of BMI were assessed to have food [28–30]; change in canteen policies (increasing the moderate and strong methodological quality. These availability of lower-fat foods in cafeteria’s à la carte effective policy interventions included teacher training, areas and implementing school-wide, student-based developing activities related to food habits and/or phys- promotions of these lower-fat foods) [31]; school self- ical activity, multicomponent workbooks covering assessment; nutrition education; nutrition policy (meet dietary issues, physical activity, and fitness. Decreased nutritional standards based on Dietary Guidelines for levels of elevated waist circumference as a result of brisk Americans); social marketing; and parent outreach [14]; walking lessons was reported in one of the studies [22]; fruit truck shops [32]; nutrition education and gardening however, this study scored weak in quality assessment. program [33]; brisk walking lessons [22]; integration of Studies where case definitions included overweight health promotion in curriculum [27]; teacher trainings and obesity also showed mixed results. While policy and development of activities related to food habits and/ intervention of school nutrition policy initiative was or physical activity [23]; fitness guidance, fitness and effective in reduction of overweight in one study [14], school nutrition, school-based nutrition, school and an increase in the prevalence of both overweight and home nutrition and home-based nutrition [26]; modified obesity was observed in another [21]. Though, the school lunches, enhanced nutrition education and study showing effectiveness of school nutrition policy increased opportunities for physical activities [34]; initiative had strong methodological quality. comprehensive school health education, physical Two studies that assessed the effectiveness of policies education and physical activity, school nutrition and including brisk walking lessons and fitness guidance, food services, health promotion and wellness, school Singhetal.BMCPublicHealth (2017) 17:292 Page5of19 e e e Quality Weak Weak Weak Moderat Moderat Strong Weak Moderat Weak Outcome/smeasured UtilizationofschoolyardsforPhysicalActivity Changeinstudentsbeverageservings/day Healthpromotionknowledge,behaviorsrelatedtofruitandvegetableintakeandexercise;bloodpressure Currenttobaccouse;dailytobaccouse;studentsperceptionaboutschoolsmoking Currentalcoholuse;alcoholuseinschoolsground Salesoflower-fatàlacartefoods;lowerfatfoodchoices;fruitandvegetableintake;Environmentalandbehavioralperceptions BMI-SD,height,overweight,obese DietaryStatus,NutrientIntake,andWeightStatus Physicalactivitylevel n Policy/PolicyIntervention PhysicalActivity(learninglandscapeprogram)(Renovationofschoolgrounds) EliminationfromSSB(Diet)andotherjunkfoodinschoolsfoodpolicy Integrationofhealthpromotioninexistingcurriculum(Provisionofcognitivebehavioralcomponentsofhealthknowledge,healthpromotionconcepts,nutrition,andexercise). ExistingSchooltobaccopolicies(WashingtonandVictoria)-Comprehensivesmokingbans,policyorientationtowardsabstinenceandharmminimizatioprinciples,possessionoftobaccoproductsamongstudents Schoolalcoholpolicies(IYDS) Schoolself-assessment;nutritioneducation;nutritionpolicy;socialmarketing;andparentoutreach. Schoolnutritionpolicyinitiative Schoolfoodandnutritionpolicy’(ChildrensLifestyleandSchoolPerformanceStudy-CLASS) PhysicalActivityAcrosstheCurriculum(PACC)-90minsmoderateintensityphysicalactivitydeliveredaspartofacademicinstruction ParticipantInclusionCriteria ParticipationinLearningLandscapeProgram;recentschoolyardrenovation,thesizeoftheschool,andthesocialanddemographiccharacteristicsoftheschoolpopulation. Studentsfromgrade9-11 (1)beofAfrican-Americanethnicity,(2)bebetween14and17yearsold,(3)beabletoreadandwriteinEnglish,(4)haveobtainedasignedparental/guardianconsentform,and(5)havesignedaparticipantassentform. Oneclassperschoolwasinvitedtotakepartinthestudy.Selectedclasseswerefromthree-yearlevels:Grade5(age10),Year7(age12)andYear9(age14). Studentsfromgrade5,7or9 Notmentioned Presenceofanàlacarteareaintheschoolcafeteriaoperatedbytheschoolfoodservice;afoodservicedirectorandprincipalwillingtotakepartinthestudyfortwoschoolyears;aninformedconsent Allpublicschoolswereinvitedtoparticipate Notmentioned dies Samplesize(n) n=3688 n=456studentsfrom7schools; n=48(Intervention=31;control=17) n=3466from285schools n=1848 n=10schools;n=1349students n=20schools n=5215(in2003);n=5508(in2011) n=4905children(Intervention=2505andcontrol=2400) u ol al theincludedst StudyDesign Observationalstudy;case-contr Quasi-experimental Quasi-experiment-RepeatedMeasures Cross-sectional Cross-sectional RCT RCT Cross-sectional RCT maryof ountry SA SA SA SA SAandustralia SA SA anada SA m C U U U U UA U U C U su ar 11 08 08 10 13 08 04 13 08 ve Ye 20 20 20 20 20 20 20 20 20 ble2Descripti Study Anthamattenetal. Blumetal. Covellietal. Evans-Whippetal. Evans-Whippetal. Fosteretal. Frenchetal. Fungetal. Gibsonetal. Ta S/No 1 2 3 4 5 6 7 8 9 Singhetal.BMCPublicHealth (2017) 17:292 Page6of19 e e e at at at Strong Strong Weak Moder Weak Moder Moder Weak Theprimaryoutcomevariablewasregularsmoking(smokingon4ormoredaysinthepreviousweek)andthemore‘traditionalmeasureofcurrent’smokingwithinthelast30dayswasusedforsecondaryanalyses Primaryoutcome:DifferenceinBMIprogressionSecondaryoutcomes:changesineatinghabitsandinphysicalactivity Adiposityvariables,BP,lipids,lipoproteins,glucose,insulin,highsensitivityC-reactiveprotein,highmolecularweightadenopectin,aerobicfitness,physicalactivitybehavioranddiet exposureofSSBandstudentconsumptionofSSBduringtheschooldays;schooldistrictpoliciesaboutSSBandexposuretoSSBinschools Studentsmoking HealthKnowledge,Dietary,PhysicalActivity,Fitness,AnthropometricMeasurements,BiochemicalIndices PurchaseandIntakeofFruits OccasionalandCurrentSmoking School-basedsmokingintervention(TheSmokingCessationforYouthProject-SCYP)-Curricular,parent,nursecounsellingcessationsupportandpolicycomponents TeacherTraining,Developactivitiesrelatedtofoodhabitsand/orphysicalactivity PhysicalActivity-BriskWalkingLessons SchooldistrictSSBpolicies School/Districttobaccocontrolpolicies-scaleforprohibition,strength,andcharacteristicsofenforcement.Sevenpolicycomponents:developing,overseeingandcommunicatingthepolicy,purpose,andgoals,prohibition,strengthofenforcement,tobaccousepreventioneducationandassistancetoovercometobaccoaddictions(Perceptionofpolicy) Multicomponentworkbookscoveringdietaryissues,physicalactivityandfitness,dentalhealthhygiene,smokingandaccidentprevention FruitTruckShops Policybanningsmokinginschoolpropertyparticipatedinprovinciallydirectedschool-basedsmokingpreventionprogram o Notmentioned Allthechildrenbornin2000whattendedanyoftheschoolsinGranollerswereeligibletoparticipate Notmentioned Allpublicschoolsthatenrollseventh-gradestudentsandparticipateinUSDAschoolmealprogramswereeligibletoparticipate Notmentioned Allstudentsinthefirstgradeofselectedschools Theschoolwasexcludedifexistingtuckshop,sellinganyfood Notmentioned dies(Continued) n=4636adolescentsfrom30governmenthighschools 509(Control:237,Intervention:272) 182pupilsattendingyear(n=115Inter;77control) n=9151studentsfrom64middleschools n=522,318studentsfrom81secondaryschools n=4171students(Intervention);n=1510students(control) 43primaryschools n=4709grade10students u st theincluded RCT RCT Quasi-experimental Cross-sectional Cross-sectional RCT Randomizedcontrolledtrial Cross-Sectional of a a mmary Australi Spain Australi USA USA Greece UK Canada u 5 1 2 9 6 9 8 8 s 0 1 1 0 0 9 0 0 ve 20 20 20 20 20 19 20 20 ble2Descripti Hamiltonetal. Llarguesetal. Knoxetal. Jhonsonetal. Lovatoetal. Maniosetal. MooreandTapper Murnaghanetal. Ta 10 11 12 13 14 15 16 17 Singhetal.BMCPublicHealth (2017) 17:292 Page7of19 k k k k k k k k k k a a a a a a a a a a e e e e e e e e e e W W W W W W W W W W Behaviorchange:physicalactivity,nutrition,andtobaccouse Frequencyofsmoking Currentsmokingandsmokelesstobaccouse Intakeofbeverages,saltysnacksandsweetsnacks Meandailyintakesofmacro&micronutrientsinschoollunchpackedlunchandtotaldiet BP,DietaryIntake,1.6kmrunandLegershuttlerun,anthropometricmeasurements(subscapularskinfold)BMI,percentagefat BMI Calorieintake,Physicalfitnessassessment,Knowledge,skillsandattitudesrelatedtonutritionandphysicalfitness Thelevelofintensityofphysicalactivity Foodpreferenceassessment,fruitandvegetableintake Comprehensiveschoolhealtheducation,physicaleducationandphysicalactivity,schoolnutritionandfoodservices,healthpromotionandwellness,schoolcounsellingphysicalandbehavioralhealthservices,schoolclimate,physicalenvironment,youth,parent,familyandcommunityinvolvement Tobacco-freeschoolpolicy Tobaccopromotionandavailabilityaroundschools Removalofsnacksoflownutritionalvalue Nutrient-basedstandards Fitness,fitness+schoolnutrition,school-basednutrition,school+homenutrition,home-basednutrition Comprehensivelegislationtocombatobesity Modifiedschoollunches,Enhancednutritioneducationandincreasedopportunitiesforphysicalactivities DistrictmandatedPhysicalActivityPolicy(20min) Nutritioneducation,gardeningprogram Notmentioned Allregularpublicschoolscontaininggrades9,10,11,or12wereincludedinthesamplingframe Maleadolescents(aged13-15yrs.)notmeetingtheagecriteriawereexcluded Notmentioned Notmentioned Notmentioned Notmentioned Notmentioned Notmentioned EligibilityforparticipationinthestudywasforstudentstobeenrolledinschoolGrades5or6. dies(Continued) n=80,428studentsin328schoolsacrossthestateofMaine.n=123intervention;205non-interventionschools n=983;14schools n=172studentsfrom2schools –n=385[20034];–n=632[20089] 1147studentsfrom30schools n=2202 n=170 Fourelementaryschools(gradek-5;68classroomteachers;1284students n=127children(11-12years) u st theincluded Cross-Sectional Cross-Sectional Cross-Sectional Quasi-Experimental NaturalExperiment Cross-Sectional RCT Quasi-Experimental Quasi-Experimental Quasi-Experimental of a a y ali ali mmar USA USA India USA UK USA Austr USA USA Austr u 0 3 2 9 3 5 9 7 3 2 s 1 1 1 0 1 9 0 9 1 1 ve 20 20 20 20 20 19 20 19 20 20 ble2Descripti OBrienetal. Paeketal. Pateletal. Schwartzetal. Spenceetal. Vandongenetal. Raczynskietal. Harrisetal. Holtetal. Jaenkeetal. Ta 18 19 20 21 22 23 24 25 26 27 Singhetal.BMCPublicHealth (2017) 17:292 Page8of19 g, StrengthofAssociation 2;Followup:Control(Baseline:20.76kg/m22)Intervention(Baseline21.07kg/m;23.06kg/m2)p-value0.71Followup23.06kg/m –AdjustedOddsforIncidence:-0.67(0.470.96) –AdjustedOddsforIncidence:-1.00(0.661.52) Overweight(Prevalenceratio,adjustedchange:1.03(0.94,1.12) Obesity(Prevalenceratio,adjustedchange:1.26(1.08,1.48)) Prevalenceofelevatedwaistcircumference:Control:-9.8%Intervention:-6.9 PrevalenceofelevatedBP:Control:-3.3%Intervention:-0% 22(16.7kg/mtoControl(Baseline:16.5kg/m222)Followup:18.3kg/m(17.9kg/mto17.5kg/m22))Intervention(Baseline:17.1kg/m18.7kg/m222(16.7kg/mto17.5kg/m)Followup:17.9kg/m22(17.4kg/mto18.4kg/m) 22Followup:32.8kg/m)Control(Baseline:24.4kg/m2Followup:Intervention(Baseline:16.2kg/m2)p=0.00116.3kg/m 2;1yearfollowup:MeanBMI:(Baseline:28.8kg/m22;2yearfollowup:25.7kg/m;3year23.2kg/m2)pvaluenon-significant.followup:26.9kg/m Means:2(95%CIBMI(InterventionBaseline:18.0kg/m222,18.3kg/m)Followup:18.5kg/m17.8kg/m22(18.0kg/m,18.5kg/m)ControlBaseline:222(16.9kg/m,18.3kg/m)Followup:17.6kg/m222(17.4kg/m,18.9kg/m)18.2kg/m Systolicbloodpressure(InterventionBaseline:104.8mm/Hg(104.0mm/H105.9mm/Hg)Followup:102.2mm/Hg(101.4mm/Hg,104.9mm/Hg)ControlBaseline:105.9mm/Hg(104.1mm/Hg,107.7mm/Hg)Followup:103.1mm/Hg(101.3mm/Hg,106.5mm/Hg) e orablechang pact(+)FavdsignificantNochange Iman(=) = + = = + + + + + = = = Specificoutcome BMI Overweight(BMIforagefromthe85thto94.9thpercentile) Obesity(BMIforage_95thpercentile) Overweight Obesity Waistcircumference SystolicBloodpressure BMI BMI BMI BMI Systolicbloodpressure asurementsandbiomarkers Outcomes BMI,Overweight,Obesity OverweightandObesity(BMImeasurements) Waistcircumference,SystolicBloodPressure BMIprogressionaftertwoyears BMIProgression BMI BMI,Systolicbloodpressure,Percentagebodyfat,Tricepsskinfold,Subscapularskinfold onphysical,anthropometricme Policy nts Schoolself-assessment;nutritioneducation;nutritionpolicy;socialmarketing;andparentoutreach. Schoolbasednutritionpolicy Briskwalkinglessons Teachertrainings,Activitiesaroundfoodhabitsandphysicalactivity –Multi-componentworkbooksNationalpolicyforhealtheducation Comprehensivelegislation Guidancearoundfitnessandnutrition(Fitness,Fitness+SchoolNutrition,Schoolnutrition,Schoolandhomenutrition,homenutrition,Allgroupstogether) enessofpolicies Design pometricmeasureme RCT Cross-sectional Quasi-experimental RCT RCT RCT CrossSectional v o Table3Effecti Study PhysicalandAnthr Fosteretal.,2008[14] Fungetal.,2013[21] Knoxetal.,2012[22] Llarguesetal.,2011[23] Maniosetal.,1999[24] Raczynskietal.,2009[25] Vandongenetal.,1995[26] Singhetal.BMCPublicHealth (2017) 17:292 Page9of19 Percentagebodyfat(InterventionBaseline:22.4%(21.9%,23.0%)Followup:23.1%(22.5%,23.7%)ControlBaseline:21.2%(19.6%,22.8%)Followup:21.9%(20.3%,23.6%) Tricepsskinfold(InterventionBaseline:14.5mm(14.0mm,14.9mm)Followup:15.1mm(14.5mm,15.6mm)ControlBaseline:13.0mm(11.9mm,14.1mm)Followup:14.2mm(12.6mm,15.7mm)) Subscapularskinfold(InterventionBaseline:10.3mm(9.8mm,10.8mm)Followup:11.1mm(10.5mm,11.6mm)ControlBaseline:10.2mm(8.7mm,10.8mm)Followup:10.7mm(9.1mm,12.2mm)) SBP:Intervention(Baseline119.7mm/HgFollowup116.2mm/Hg)Control(Baseline119.2mm/HgFollowup119.1mm/Hg;p=0.56) DBP:Intervention(Baseline66.2mm/HgFollowup67.2mm/Hg)Control(Baseline66.8mm/HgFollowup68.0mm/Hg;p=0.97) ElevatedTriglycerides(Control:-2.5%;Intervention:-1.2%) Elevatedhighdensitylipoproteincholesterol(Control:-3.7%vs.Intervention:-1.2%2.7%) Highdensitylipoproteincholesteroltototal−cholesterolratio(mean+SD:2%±4%[confidenceinterval−=3.5,p=.001)(CI)o.o5=1%to2%>],t80 −Glucose(.1±.4mmol/Lp=.002) Intervention(Baseline187.4mg/dlFollowup173.7mg/dl)Control(Baseline177.3mg/dlFollowup190.6mg/dl;p=0.001) = + = = + + + + + ol (Continued) Percentagebodyfat Tricepsskinfold Subscapularskinfold Bloodpressure Triglycerides Highdensitylipoproteincholester Highdensitylipoprotein:totalcholesterol Glucose TotalSerumCholesterol s er asurementsandbiomark Maintenanceofbloodpressure Bloodlevelsoftriglycerides,highdensitylipoproteincholesterol,highdensitylipoprotein:totalcholesterol,glucose Serumlevellipidchanges e m c n – etri otio oks nphysical,anthropom Integrationofhealthpromintocurriculum Briskwalkinglessons Multi-componentworkboNationalpolicyforhealtheducation o - olicies mentaleasures mental p eriM eri enessof Quasi-expRepeated Quasi-exp RCT v cti 7] e 2 Table3Eff Covelli,2008[ Biomarkers Knoxetal.,2012[22] Maniosetal.,1999[24] Singhetal.BMCPublicHealth (2017) 17:292 Page10of19 counselling, physical and behavioral health services, comprehensive school health education, school counsel- school climate, physical environment, youth, parent, fam- ling, physical and behavioral health services, school cli- ily and community involvement [35]. Six out of seven mate, physical environment, youth, parent, family and studiesassessingpolicyeffectivenessinreductionofsugar communityinvolvement[35](Table5). intake reported desirable changes and reduction in sugar Current smoking was the preferred outcome of evalu- orSSBsconsumption[21,26,28,29,35,36].Theseeffect- ation for tobacco use among four out of seven studies ive policies included elimination of SSB and other junk [20,37,38,40]andsmokelesstobaccousewasmeasured foodinschools’foodpolicy,havinga schoolfoodandnu- as an outcome in only one of the seven studies [20]. trition policy in place, school district SSB policies, school Several other outcomes such as frequency of tobacco nutritionandfoodservices,nutrition-basedstandardsand use, perception about school smoking and occasional fitness guidance, fitness and school nutrition, school- smoking were also assessed in some of the included based nutrition, school and home nutrition and home- studies. Two studies reported non-significant differences basednutrition.Amongthesepolicyinterventions,studies between those exposed and not exposed to policy with moderate methodological quality evaluated school [35, 37] while five studies reported a significant reduc- food and nutrition policy and school district SSB policies, tion in tobacco use among those exposed [20, 38–41]. while the remaining studies were judged to have weak Among the effective interventions, only school based methodologicalquality. harm minimization smoking intervention was observed School policies were also observed to be effective in to be tested within a study with strong methodological increasing fruit and vegetable intakes in four out of five quality. Theremainingfourstudiesscoredweakinquality studies [23, 27, 31–33]. Desirable effects of increased assessment.Onlyonestudytestedtheassociationbetween fruitandvegetableintakeswerenotedwiththepolicyin- school-level policies and alcohol use and reported that terventions of integration of health promotion in the when the students believed the policy enforcement was curriculum,changeincanteenpolicies,nutritioneducation not strict, the chances of students consuming alcohol on and gardening program, teacher training and development schoolgroundswerehigher[42](Table5).Thisstudywas of activities related to food habits and/or physical activity judgedtohavemoderatemethodologicalquality. and fruit truck shops. Out of these effective interventions, teacher training and development of activities related to Physicalinactivity food habits and/or physical activity and fruit truck Among the 27 studies, ten assessed associations between shops were observed to be reported from studies with school policies and changes in physical activity [22–24, moderate and strong methodological quality. Regard- 26, 27, 34, 35, 43–45]. The school policies included ing fat reduction and salty snacks, school dietary learning landscape program (renovation of school policies were reported to reduce their prevalence grounds) [43]; 90 min moderate intensity physical activ- [26, 30, 36] (Table 4). All the three studies were ity delivered as part of academic instruction [44]; lessons judged to have weak methodological quality. on brisk walking [22]; district mandated physical activity policy (20 min per day) [45]; integration of health pro- Tobaccoandalcoholuse motion in existing curriculum (provision of cognitive Seven out of 27 studies assessed the effects of school behavioral components of health knowledge, health pro- tobacco control policies on the prevalence of tobacco use motion concepts, nutrition and exercise) [27]; teacher [20, 35, 37–41]. These school level tobacco control trainings, developing activities related to food habits policies included comprehensive smoking bans, policy and/or physical activity [23]; fitness trainings [26]; in- orientation towards abstinence and harm minimization creased opportunities for physical activities (installing principles, penalty on possession of tobacco products physical fitness stations in each classroom; initiating a among students [37]; school-based smoking intervention: non-competitive incentive system based on students’ curriculum, parent, nurse counselling cessation support personal goals; training of PE teachers and lesson plans and policy components such as scale for prohibition, for PE teachers) [34]; comprehensive school health edu- strength and characteristics of enforcement [38]. One cation, including physical education and physical activ- studyassessedsevenpolicycomponents:developing,over- ity, school nutrition and food services, health promotion seeingand communicating the policy, purpose, and goals, and wellness, school counselling, physical and behavioral prohibition,thestrengthofenforcement,tobaccousepre- health services, school climate, physical environment, vention education and assistance to overcome tobacco youth, parent, family and community involvement [35]; addictions (perceptions regarding policy) [39]. Others multicomponent workbooks covering dietary issues, assessed a policy banning smoking in school property physical activity and fitness, dental health hygiene, [40],tobacco-freeschoolpolicy[41],reducedtobaccopro- smoking and accident prevention [24]. All studies motion and availability around schools [20] and finally reported significant and positive changes in physical