Intervention programs to stimulate physical  activity and nutritional habits in schoolchildren Programas de intervención para estimular la actividad física y los hábitos nutricionales en escolares
	Profesor en la Facultad de Ciencias de la Actividad Física y el Deporte. Universidad de Valencia (España)	Alejandro César Martinez Baena alejandro.martinez@uv.es
	Abstract           A realization reviewing School-run intervention programs promoting physical activity and nutritional habits for subjects in Primary and Secondary Education (5-18 years old). Forty-five studies realized in the last eleven years (2002-2013) were identified through searches in electronic databases using the metasearch engine Scopus. The following areas were consulted: Life Sciences (with more than 3,400 titles), Health Sciences (with more than 5,300 journal titles), Physical Sciences (with more than 5,500 titles), and Social Sciences (with more than 2,800 titles). The following were used as search criterion: ‘Intervention Program’ and ‘health’, of which resulted 15,241 references. Subsequently, we moderated our search to ‘Physical Education’, resulting in a total of 1,909 references. We limited the search again to 1,380 articles applying the search criterion only to research realized in the last eleven years (2002-2013), and finally, we chose the forty-five that are presented in this review. We then obtained findings regarding the most important aspects of the analyzed studies, summed up and shown in an included table. Finally, the results are discussed according to the evolution of the interventions through time, the duration of the intervention, age of the subjects in the study, the importance of social and emotional environments for youth to building effective healthy habits, and the tools used. Ultimately, we analyze the efficiency of different types of interventions on the psychophysical health of the subjects studied.           Keywords: Models. Theoretical. Schools. Adolescent. Child. Health.   Reception: 11/19/2014 - Acceptance: 12/10/2014.
	EFDeportes.com, Revista Digital. Buenos Aires, Año 19, Nº 199, Diciembre de 2014. http://www.efdeportes.com/

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Introduction

    At present, the necessity of practicing Physical Activity (PA) is recognized in order to achieve an optimum state of health [1, 2], as it has been shown that regular physical activity causes benefits physically, psychologically, and socially [3, 4, 5]. Despite these findings, the real levels of habitual practice throughout population prove to be low [6]. Showing a gradual decrease with age [7, 8], above all in two critical moments; adolescence [9, 10] and the university stage [7]. This inactivity, along with inappropriate caloric consumption, starts to generate elevated indexes of infant-juvenile obesity [11, 12, 13].

    This matter was predicted by the European Parlament [14], whose report assesed the regulation and improvement of Physical Education (PE) in European schools as a primary means of health promotion and disease prevention.

    Different measures of action arise in the educational field in order to raise awareness of the importance of a healthy diet and regular practice of physical activity or sport for the reduction of obesity rates [15]. The strategy NAOS is an example of this [16]. School is an important fundamental element for the promotion of physical activity, sport, and the modification of bad nutritional habits [17]. Thus, the application of advocacy programs at the school level is established as the most complete and controlled in order to intervene in the improvement of adolescents’ lifestyles [18].

    Several studies have analyzed the presence and effectiveness of various programs of health intervention at the school and community levels [19, 20, 21, 22]. Van Sluijs, McMinn y Griffin [23] revised 57 studies: 33 addressing children and 24 addressing adolescents. These authors categorized as studies of high methodological quality, only 24 of the total, reaching in some cases increases to 283 minutes per week of physical activity and sport. Salmon, Booth, Phongsavan, Murphy, and Timperio [24], to demonstrate the effectiveness of these interventions with children between the ages of 4 and 12 and adolescents aged between 13 and 19, conducted a search in electronic databases identifying 76 interventions focusing on these age groups. They concluded that the most efficient interventions were conducted in scholastic centers, more so than those done in a familial setting.

    As previously stated and in line of studies like those of Dobbins, De Corby, Robeson, Husson y Tirilis [25], y Doak, Visscher, Renders y Seidell [26], we expect to complete a revision over various scholar intervention programs aimed at the promotion of the PA and/or the modification of nutritional habits in young adolescents. We identified, by means of a theoretical study on fulfilled programs in the current school, the most representative characteristics of the conducted interventions, centralizing ourselves in two factors principally: PA and nutritional habits. We considered the type of program elaborated, duration of the program, the age of the subjects, the agents of the educational community involved, the type of measurements conducted, and the efficiency of the intervention according to the obtained results. We believe that this provides very important information for designing new intervention programs based on scientific evidence found so far.

Method

    The work carried out corresponds with a revision or theoretical study [27]. The method followed for the completion of this revision was from the bibliographic search in scientific databases by means of metasearches, the same as in the Social Sciences Index Citation of the Science Web. Through these we concretely performed two searches:

    The first was completed with the SCOPUS program, a multi-database scientific search program under the informational setting of the University of Granada. This metasearch updates its databases every seven days and uses the following subject areas for its searches: Life Sciences (with more than 3,400 titles), Health Sciences (with more than 5,300 titles of consulted magazines), Physical Sciences (with more than 5,500 titles), and Social Sciences (with more than 2,800 titles).

    We used the following descriptors as search criterion: ‘Intervention program’ and ‘health’, of which resulted 15,241 references. Subsequently, we restricted the search further with ‘Physical Education’, resulting in a total of 1.909 references. Finally, we restricted the search again to 1,380 articles applying to the criterion of completed research during the last eleven years (2002-2013). A period in which the obesity rate among adolescents has increased its figures in a spectacular manner [28, 29]. This coupled with the fact that the heath objectives are an instrument of political heath control [30] and consequently, there is a substantial increase in scientific production in this sense. It awakens our interest in knowing the most consistent points of these intervention measures, centralized in the promotion of more active and healthy lifestyles.

    Secondly, the ISI Web of Knowledge (Web of Science), to consult the following Citation Databases: Science Citation Index Expanded (SCI-EXPANDED), Social Sciences Citation Index (SSCI), and Arts & Humanities Citation Index (A&HCI). After introducing the same search criterion as before, we obtained 6,200 in the first search, 374 references after limiting the search to ‘Physical Education’, and ultimately, we only selected the 274 that were dated from 2002 on.

    The intervention programs analyzed were defined as those who centered their interests in an attempt to curb the emergence of potential risk factors for health, or in the case that they already had appeared, tried to reduce and reinvest in the situation generating healthy living habits in subjects affected with the problem. Therefore, the included criterion in this revision were: (a) Interventions to increase exercise regularly, decrease sedentary behaviors, or modification of nutritional habits in boys and girls; (b) studies wherein they use objective measurement tools, anthropometric-level body composition, behavioral, and/or psychological; (c) studies with samples of school age subjects belonging to primary and secondary education (5-18 years); and, (d) studies that apply intervention programs in the school. Finally forty-five studies were analyzed.

Results

    Based on the studies of Van Sluijs et al. [23] and Doak et al. [26], we used the following table as a model for presenting the results. In this way, we synthesized the information obtained by using an analysis of him following categories:

1. Study: name of authors and year of publication.

2. Program type: Physical Activity incident programs, incident programs of eating behavior modification, or behavior modification programs aimed at a multifactorial intervention with a mixture of both.

3. Participants: sample characteristics.

4. Duration and protocol of the program: a brief description of the intervention process, stages and set duration.

5. Instrument used: parameters measured and the measuring instruments used for evaluation.

6. Main results: behavior and parameters significantly modified or not.

Table 1. Characteristics and Principle Results of de the intervention programs revised in the Educational Scope

Study	Type of program	Participants	Program protocol	Measurements (instruments)	Principle results
Eriksen et al., 2002 [31]	Nutrition	Children aged 6-10 (n = 445)	Duration: 5 Weeks Description: Dietary portions of fruits and vegetables supplied during the break in the class schedule	24-hour recall questionnaire; food-frequency questionnaire	Increase: Fruit Ingested. No significant Increase: Vegetables Ingested; Total ingestion of fruits and vegetables
Lete et al., 2002 [32]	Nutrition	Children of the 3ºESO (n = 130)	Duration: 1 year Description: Introduction to a healthy diet through awareness of parents and teachers.	Assessment Program of the Dietary Intervention Program	Improvement: Individual Diet; Nutritional Knowledge and Dietary programs
Caballero et al., 2003 [33]	PA+ Nutrition	Students of the 3rd-5th grades (n = 1704)	Duration: 3 years Description: 2 classes de 45' per week on healthy habits; nutritional guide for the cafeteria personnel; help and supervision from external nutrition experts; 3 classes de 30' per week of PA during recess; Organization of family events	Anthropometric Data; skin-fold; bioelectrical impedance; accelerometer; self-reported activity questionnaire; knowledge, attitudes and behavior questionnaire; Direct Observation; 24-h dietary Recall	Improvement: Knowledge of health; healthy habits/Reduced: Energetic contribution through fats/Not Reduced: Percent of fat mass; The total energy value of the food/ No significant change: Level of PA
Dwyer et al., 2003 [34]	Nutrition	Students from 88 Schools	Duration: 3 years Description: CATCH Eat Smart Program (material contribution to improving school meals, training school staff)	Surveys of School Cafeteria Menus; Interviews; Nutrition Data System	No significant change: Providing for total sugar input glucose, sucrose, galactose and maltose/Significant Improvement: Lactose Contribution/ Reduced: Total contribution of fats
Kelder et al., 2003 [35]	PA	157 students (elementary school-3rd-5th grade)	Duration: 3 years Description: CATCH PE (3 90’ sessions per week of PA with internal professors and external experts)	System for Observing Fitness Instruction Time; School Staff Questionnaire	Increase PA: At the end of the program/Maintained: High level of PA for 5 years
Neumark-Sztainer et al., 2003 [36]	PA+ Nutrition	Secondary School Students (n = 201)	Duration: 4 months Description: New Moves (4 PA classes per week; social help and food once a week; Student handbook with sections about nutrition and PA)	Physical Activity Stage of Change; Youth and Adolescent food frequency questionnaire; BMI; questionnaires; interviews	Increase: PA level Unchanged: BMI; food habits; Self-efficacy with PA
Osganian et al., 2003 [37]	Nutrition	Students from 88 Primary Schools (n = 1065)	Duration: 3 years Description: CATCH-ON: system for controlling the effectiveness of the CATCH; CATCH Eat Smart Food School Service Program (material contribution to improving school meals, training school staff)	Minnesota Nutrition Data System; Interviews; School Meal Participation Worksheets; Secular Trend Questionnaires; Food Serv. Staff Questionnaires	Reduced: Total assumption of fats; assumption of saturated fats; Non significant: Sodium reduction; Assumption of nutrients
Pangrazi et al., 2003 [38]	PA	4th Grade Students (n = 606)	Duration: 3 months Description: PLAY (classes on the importance of PA, both in school and extra-scholar).	Pedometer Step Counts; BMI	Increase: PA level in girls/No significant differences: PA level in boys/Unchanged: BMI
Steckler et al., 2003 [39]	PA+ Nutrition	3rd-5th Grade Students	Duration: 3 years Description: Training teachers (aims and methods); Training cafeteria personnel; Cafeterias (reduction of caloric-fat); Orientation (selection and preparation of food); Help from outside personnel; Videos, posters and nutritional information; 3 PA classes weekly	Survey; video recordings; Indirect Observations; Food Service Kitchen Contact Form; questionnaires	Increase: Professors Curriculum; general PA; Knowledge of personal nutrition in cafeterias; family participation/Reduced: Fat Contribution/No Significant Increase: Contribution of Fruit, vegetables, skim milk y fat-free cheese
Story et al., 2003 [40]	Nutrition	3rd-4th Grade Students (21 Pathways intervention schools	Training teachers (aims and methods); Training cafeteria personnel; Cafeterias (reduction of caloric-fat); Orientation (selection and preparation of food); Help from outside personnel; Videos, posters and nutritional information; 3 PA classes weekly	Modified School Menu Data Collection; Kitchen Contact Form; Nutrition Data System	Reduced: Total Fat Contribution; Contribution of Saturated Fats No significant change: Total Calories; Total Contribution of nutrients
Dishman et al., 2004 [41]	PA	Secondary School Students (n = 2087)	Duration: 1 year Description: LEAP (PA health orientation directed specifically at girls during the PE classes; Training of the PA personnel; Community and family activities)	3-Day Physical Activity Recall	Increase: efficacy; PA level; PA through the increase of efficacy
Kain et al., 2004 [42]	PA+ Nutrition	1st-8th Grade Students (n = 3577)	Duration: 6 months Description: Improved dining, and funding aimed at nutrition, family involvement; CALC (1 extra PA session per week for 1h30')	Skin folds; height and weight, flexibility test; Leger test; BMI	Bettered: BMI (only boys); skin folds (only boys); physical tests
McKenzie et al., 2004 [43]	PA	24 Secondary Schools (approx. 25,000). Student enjoyment of and attendance at PE. A total of 1578 and 1434 at year 2	Duration: 2 years Description: M-SPAN (5 3h classes directed toward the PA professors; revision of school PA programs, 2 tutoring sessions per month for teachers with external PA experts)	System for Observing Fitness Instruction Time; Observation Schedule; video recordings; questionnaires over PA enjoyment and class attendance; questionnaires to evaluate the quality of the PA classes; Teacher debriefing questionnaire	Increase: moderate PA (boys); quality of the PE classes No Increase: Duration of PA classes; enjoyment of PA
Olivares et al., 2004 [44]	Nutrition	8-13 year old children (n = 1701)	Duration: 1 year Description: book "Food and Nutrition Education for Basic Education" for parents and students; Guidelines for Professors; Guidelines for students (information on nutrition and healthy habits); Intensive Teacher training program	BMI; frequency of consumption survey, food knowledge survey, nutrition knowledge surveys aimed at Parents and Teachers	Bettered: Food Knowledge/Increases: Consumption of Milk, Yogurt, and Fruit/Reduced: Consumption of Bread; percentage of obesity/Not Reduced: Consumption of snacks and drinks
Perry et al., 2004 [45]	Nutrition	Students from 26 Primary Schools (n = 1820)	Duration: 2 years Description: Cafeteria Power Plus Project (increase of fruits and vegetables in cafeterias; nutrition modeling; social support for students)	Nutrition Data System; direct observations	Increase: Fruit Assumption; Vegetable Assumption
Simon et al., 2004 [46]	PA	954 adolescent 11-12 year olds	Duration: 6 months Description: intervention on activity patterns and psychological predictors of PA among adolescents. In order to change knowledge and attitudes, apart from providing social support and improvement of environmental conditions for the promotion of the PA of adolescents inside of and outside school.	Anthropometric measurements (bioelectrical impedance body composition)/Physical activity and sedentary behaviors (Modifiable Activity Questionnaire for Adolescents-MAQ)/Psychosocial measures (questionnaire used in the Stanford Adolescent Heart Health Programme)	ICAPS was associated with a significant improvement in activity patterns and psychological predictors, indicating a promising approach to changing the long-term PA level in adolescents
Dishman et al., 2005 [47]	PA	Secondary School Students (n = 2087)	Duration: 1 year Description: LEAP (PA specifically addressed to girls during physical education classes, increased physical activities to choose from in the classes, reduction of importance of competition, increased importance of small group activities)	Measure of Factors Influencing Enjoyment of Physical Education; Physical Activity Enjoyment Scale; 3-Day Physical Activity Recall	Increase: Enjoyment of PA; PA through the increase in enjoyment of PA
Felton et al., 2005 [48]	PA	9th grade Students (n =2111)	Duration: 1 year Description: LEAP (PA specifically addressed to girls during PE classes, increased physical activities to choose from in the classes, reduction of importance of competition, increased importance of small group activities; medical staff participation in school program, PA-school, education for health family and community involvement)	Interviews; Video Recordings; 3-Day Physical Activity Recall	Increase: moderate PA; vigorous PA
Kafatos et al., 2005 [49]	PA+ Nutrition	1st grade Students (n = 541)	Duration: 6 years Description: Cretan Health and Nutrition Education programme (personal notebooks kept by subjects on habits; 13-17h annual classes on nutrition; 4-6h annual classes on PA theoretics; 2 weekly classes of PA for 45')	BMI	Improved: BMI (only boys) No Significant Difference: Prevalence of Obesity
Pate et al., 2005 [50]	PA	8th-9th Grade Students (n = 1604)	Duration: 1 year Description: LEAP (physical activities specifically targeting girls during PE classes, classes of health education, improvement of the PA staff, increased information about PA, PA promotion, family and community activities)	3-Day Physical Activity Recall; height; weight; BMI	Increase: habitual, vigorous PA Not Improved: BMI
Saksvig et al., 2005 [51]	Nutrition	3rd-5th Grade Students (n = 122)	Duration: 1 year Description: Sandy Lake school-based diabetes prevention program (weekly classes of 45 'on food and health education, family advocacy, radio shows and videos on right food 3 times a week, improving the quality of canteens and school environment)	Height and Weight; bioelectrical impedance, 24-hour Dietary Recall, questionnaires targeting health knowledge and healthy habits; questionnaires to parents	Reduced: Children's’ consumption of fats/No Significant Reduction: Girls’ consumption of fats/Improvement: Knowledge of nutrition-knowledge about healthy habits-Nutrition self-efficacy/Does not vary: BMI-Percentage of body fat mass
Wilson et al., 2005 [52]	PA	11-14 year old Children of Social Minority Groups (n = 48)	Duration: 4 weeks Description: choice of preferred physical activities, 3 extra classes 2 hours per week (30 'work on nutrition, 60' moderate-vigorous PA, 30 'motivational assistance and mentoring, video recordings of self-presentation)	Accelerometer; Motivation for PA questionnaire; Self-Concept for PA Scale; Enjoyment for PA Scale Self-efficacy for Exercise Behavior Scale	Increase: moderate PA; vigorous PA; moderate-vigorous PA; Motivation to PA/No Increase: Self-esteem
Yin et al., 2005 [53]	PA+ Nutrition	3rd-5th Grade Students from 18 Schools (n = 617)	Duration: 3 years Description: 5 times per week; MCG FitKid Project (PA a moderate-high intensity; control over nutrition; training school activity)	DXA; blood analysis; blood pressure; step-test; psychosocial survey	First year (significant beneficial in body fat, bone mineral density and cardiovascular fitness for those with 40% or greater attendance. Relative reduction of body fat
Manios et al., 2006 [54]	PA	Children from 6-15 years (n = 425)	Duration: 6 years Description: Cretan Health and Nutrition Education Programme (personal notebooks on writing habits by the subjects, 13-17h annual nutrition classes, 4-6h annual PA theoretical classes, 2 PA classes weekly of 45')	Activity interview; BMI	Increase: Moderate PA (boys) Reduced: Sedentary (boys) No significant differences: PA Level; sedentary habits in women
Robbins et al., 2006 [55]	PA	Secondary School Students (n = 77)	Duration: 3 months Description: Girls on the Move program (2 emails y phone calls weekly; 30’ sessions with computers, advice of school nurses for the increase of PA)	Height; weight; BMI; Perceived Benefits Questionnaire; Perceived Barriers Questionnaire; Perceived PA Self-efficacy Questionnaire; modified PA Enjoyment Scale; Social Support Scale; Exposure to Models of Exercise Behavior Scale; PA staging questionnaire; Child and Adolescent Activity Log	Improved: Social Support to PA/No significant differences: enjoyment of PA; perception benefits of PA; self-efficacy to PA
Saunders et al., 2006 [56]	PA	Students from 24 Secondary Schools (n = 1604)	Duration: 2 years Description: LEAP (aimed at girls; improving the school environment, increasing intensity and duration of AP classes, modification of sedentary habits)	Lifestyle Education for Activity Program Process Evaluation Framework and Logic Model; Observations; Interviews; LEAP criteria; LEAP P.E. criteria; Accelerometer; 3-Day Physical Activity Recall	Improved: PA level; scholastic atmosphere/No improvement: Education towards health; Health Services
Buddeberg-Fischer et al., 2007 [57]	Nutrition	Adolescents 14-19 years of age (n = 314)	Duration: 18 months Description: Eating Disorders Prevention Project (3 classes of 90’ per month on nutrition, training of groups reflecting on nutrition and personal habits, organization of school picnics, discussions on eating disorders)	Eating Attitudes Test	Improved: Eating Habits; Perception of Body Mass Index; Composition of a well-balanced nutritional plan; Awareness of one’s own eating habits and attention to body signals
Haerens et al., 2007 [58]	PA	281 Students- 7th Grade (13-14 years).	Duration: 3 months Description: Computer program. It consists of three parts: a) An introductory page; b) A diagnostic tool on various aspects related to health, c) individualized personal feedback in order to encourage the maintenance or achievement of active lifestyle healthy.	PA levels-Flemish Physical Activity Questionnaire (FPAQ) y Accelerometers (model 7164, Computer Science Application Inc., Shalimar, FL)	The intervention program reported an increase of 25 minutes of PA at school, but not to increase the PA during leisure time.
Verstraete et al., 2007 [59]	PA	Primary School Students (n = 764)	Duration: 2 years Description: SPARK (small group activities, classes of activities aimed at good health; classes of sporting activities; increased PA leading to a healthy lifestyle in PE classes)	Accelerometer; System for Observing Fitness Instruction Time	Increase through SOFIT: very active PA; PA moderate-vigorous; PA for good heath; Knowledge of Good health/Through Accelerometer No Increase: Moderate PA, vigorous PA, moderate-vigorous PA
Carlson et al., 2008 [60]	PA+ Nutrition	Approx. 180-200 5th Grade Students	Duration: 16 months Description: Multidisciplinary team of teachers, doctors and health professionals as PE specialists. Aimed at increasing the percentage of students who meet the current recommendations for PA and a balanced diet and improve their knowledge and attitudes to this type of lifestyle (8 different plans every 2 months)	Knowledge of health, calorie intake, support and level of parental involvement, PA in leisure time and time off the screen, body mass index, body composition, waist circumference, cholesterol	Demonstrated an effective education to adopting heart-healthy behaviors
Cardon et al., 2009 [61]	PA	412 children (9,7+/-0,7)/ 8 elementary schools	Duration: 2 years Description: SPARK (AP classes to young people through self-management lessons performed by an outside specialist in PE). Subsequent oral survey of the effectiveness of the program to 20 teachers, 50 parents and all children	1-Day Recall; Accelerometer; Fitness-Gram protocol System for Observing Fitness Instruction Time	Children enthusiastic about the program. 80% of teachers and 32% of parents perceived an increase in PA levels of children.
Donnelly et al., 2009 [62]	PA	1527 students (24 primary schools: 14 implementation of PAAC; 10 control groups). subsample of 454 subjects	Duration: 3 years Description: Comparative study centers that applies PAAC regarding not taking any action. PAAC promotes 90 min / wk of moderate to vigorous PA as a supplement to the 60 min / wk by these children in PE classes	Body Mass Index, Metabolic changes in the physical, aerobic capacity, skin folds, circumferences, blood pressure level daily caloric intake and academic performance	Promotion of PA through a curricular approach promotes an improvement in daily PA levels and academic achievement of these primary school children. In addition, from 75 min / wk of PA across the curriculum activities are attenuated increases in BMI
Gorely et al., 2009 [63]	PA+ Nutrition	589 children aged 7 to 11 years belonging to 8 primary schools (4 intervention and 4 control).	Duration: 10 months Description: The program includes: A learning CD-ROM by teachers (8 units of work related to health)/Interactive website for students, teachers and parents (increasing PA and healthy eating)/Two events (increase levels of PA)/Campaign in local media (promotion of health)	PA (Accelerometer Pedometer Digiwalker SW200 and ActiGraph GT1M). Aerobic fitness (Multi-stage Shuttle Running Test and Polar Heart Rate Team System/ Polar Electro (UK) Ltd., Warwick, UK). Anthropometric measures (Leicester stadiometer height-Height Measure, dry ltd., England/Digital portable dry-weight 770, dry ltd, Birmingham, UK/Fold-thickness Harpenden calipers, Baty International, England). Knowledge of lifestyle (questionnaire developed Keystage 2 National Curriculum Requirements and the content of the intervention Programme). Psychological measures Physical Self-Perception Profile (PSPP-C), two sub-scales from the Perceived Locus of Causality scale (PLOC).	Increased levels of moderate to vigorous PA. Decrease in fat mass index and waist circumference. Little or no effect on consumption of fruits and vegetables
Jago et al., 2009 [64]	PA	Two pilot studies were conducted (with 585 and 1,544)	Duration: 7 y 9 weeks Description: Preparation of material and theoretical classes given by the STOPP-T2D Physical Activity Intervention Committee; PE Teacher training; Applying lessons for 7 weeks Expected Duration = 45 min in five of the intervention schools and 90 minutes of the other school, by measurement of peak heart rate obtained results of the PA intensity levels.	Heart Rate (Polar Pacer E600, Polar Electro, Lake Success, NY)	PE can be easily modified for the students that dedicate more than 50% of the time in MVPA
Martínez-Gómez et al., 2009 [65]	PA+ Nutrition	204 adolescents between 13-16 years of age	Duration: 13 months Description: Program divided into two phases: 1 ª - previous pilot study (intensive intervention). A visit a week for two months (1-9 visits). 2nd - Intervention extensive. One visit per month for eleven months. (10-20 visits). The current study includes a nutritional therapy and an educational program about diet, nutrition concepts and PA. Understanding young people from different strategies of motivation and time management in accordance with recommendations of PA practice and time of sleep, dietary advice, family involvement, etc.	Nutritional Habits, Food frequency questionnaire/PA-Accelerometer ActiGraph (GT1M), PAQ-A questionnaire and validation tests and standards included in Eurofit and FITNESSGRAM/Psychological assessment and behavior in eating-PA-5 Self-Concept Questionnaire, anorectic Behaviour Observation Scale (ABOS), Eating Disorder Inventory (EDI-2)/Body composition, pubertal development and blood pressure-Caliper Holtain, bioelectrical impedance (BIA) and X-ray (DXA), OMRON M6.	Program aimed at different areas: eating habits, PA, cognitive and psychological profiles, etc. Few studies used a clinical sample superior to multivariate analysis.   Representative results can be observed between the intensive phase and the extensive stage.   EVASYON study includes the largest and most comprehensive evaluation system.
Yackobovitch-Gavan et al., 2009 [66]	PA+ Nutrition	162 children aged 6 to 11 years old con with a body mass index higher than the 95th percentile	Duration: 3 months Description: Compare effects of exercise, diet or diet + exercise on quality of life in obese children. Through a program of 3 weekly training sessions Duration 90 minutes at 75% of maximum heart rate (45 minutes of aerobic exercise, team sports and running games, 45 'force-resistance exercise by squatting, lifting of different weights, ball games). Classes run by professional coaches absolutely trained. The diet intervention (12 weekly meetings of children and parents with a dietitian and a psychologist). Participants were instructed to maintain a balanced diet hypo-energetic 5025 kJ / d (25% -30% fat, 10% -15% protein, carbohydrates and 55% -65%).	Stadiometer Holtain   Body Composition Scale Analyzer (TBF-300; Tenita Corporation of America, Arlington Heights, III)   Parent-proxy Pediatric Quality of Life Inventory (PedsQL) 4.0	The BMI reduction was significantly greater in the diet + exercise group than those in the only exercise group   Greater reduction in BMI occurred in children whose parents have PedsQL at baseline (n = 105) compared to children whose parents did not
Hatzis et al., 2010 [67]	PA+ Nutrition	1046 children in 1992, 471 (45%) in 1995, 831 (79%) in 1998 and 634 in 2002 (Elementary school)	“Know Your Body”. Included the education of student about dietary issues, physical activity and fitness, alcohol overconsumption, smoking and accident prevention, and generally health promotion, through teaching courses. Parents in the intervention group attended educational sessions covering nutritional, physical activity and health issues.	Dietary assessment (24-hour recall questionnaire)/BMI (calculated by dividing weight (kg) by height squared), left triceps, biceps, subscapular and suprailiac skinfold thickness were measured with a Lange skinfold caliper/Percentage of body fat (based on BMI, sex and age)/The waist-to-hip and waist-to-height ratios were also calculated/Systolic and diastolic blood (mercury manometer)/Physical fitness (EUROFIT Tests Protocol)	Total cholesterol levels (decreased more in the intervention group compared to the control)/Body weight and body mass index (BMI) (increased significantly more in the control group compared to intervention group)/Changes in waist circumference and endurance shuttle run test (did not differ significantly between the two groups). Intervention group showed higher consumption of carbohydrate, monounsaturated fatty acids, folic acid, vitamin C and vitamin B2 intake, whereas the control group had lower total energy and trans fatty acids intake.
Hollard et al., 2010 [68]	PA+ Nutrition	2,494 children (elementary schools). Average age was 8 years (range 6 to 13 years).	Provision of nutritious ingredients and whole foods in breakfasts, lunches, and extended day snacks, which modeled nutrition education in the classrooms; the incorporation of a holistic curricula that taught children, parents, and school staff about good nutrition, healthful lifestyle management, and increased levels of physical activity; and the implementation of other school-based wellness activities such as fruit and vegetable gardens	Body mass index   Weight   Systolic blood pressure   Diastolic blood pressure	Significantly decreased (diastolic blood pressure in girls in the intervention group compared to controls)/Systolic blood pressure (decreased significantly for girls in the intervention group compared to controls during Year 1)/Weight and body mass index (decreased significantly for girls in the intervention group compared to controls).
Graf et al., 2011 [69]	PA+ Nutrition	A total of 97 children (57 intervention, 40 control) aged 9-11 years	Final programme consisted of a six-week homework schedule complemented by an in-class teaching resource, and was designed to support the achievement objectives associated with Level 3 of the New Zealand Health and Physical Education Curriculum. Each child received a homework booklet organized into five physical activity and five nutrition topics: Week 1, walking and fruit/vegetables; Week 2, television and breakfast; Week 3, sports and drinks; Week 4, fun games and food shopping; Week 5, fitness and cooking. Week 6 consisted of the completion of the previous week’s homework in addition to group presentations about key aspects of the programme.	Daily physical activity levels (The NL-2000 pedometer).   A food diary was issued for children to record the type and quantity of all foods and drinks consumed over the four-day period.	Healthy Homework resulted in a significant intervention effect of 2,830 steps-day. This effect was consistent between sexes, schools, and day types (weekdays and weekend days). In addition, significant intervention effects were observed for vegetable consumption and unhealthy food consumption on weekends but not weekdays, with no interactions with sex or school. Effects for all other variables were not statistically significant regardless of day type.
Plachta-Danielzik et al., 2011 [70]	PA+ Nutrition	240 intervention and 952 non-intervention students (6-14 years	Six nutrition units followed by 20-min running games were performed within the first year at school	Body Mass Index (BMI) Standard Deviation Score (SDS)	School-based health promotion- some favourable and sustained effects on 8-year changes in BMI-SDS, which are most pronounced in students of high SES (socio-economic status) families
Manger et al., 2012 [71]	PA+ Nutrition	763 students (First-grade-29 schools)	The VITAL (Values Initiative Teaching About Lifestyle) 8 weekly lessons about healthy eating and appropriate physical activity. Each lesson 30 minutes (15 minutes devoted to teaching and 15 minutes to physical activity).	Teachers’ Evaluation   Parents’ Evaluation   BMI	80% teachers- rated the lessons as good to excellent in promoting good nutrition/77% teachers-rated them good to excellent as promoting physical activity/After the 7th and 8th week (80% of parents reported that their children frequently ate healthy food)/After 8 weeks on the program about 76% were exercising frequently/78% parents indicated that the VITAL program was a good or excellent effort in influencing lifestyle of their children/BMI percentiles declined from 66.1 to 65.0 in control children and from 62.8 to 58.9 in intervention children
Rosário et al., 2012 [72]	PA+ Nutrition	574 children- 464 (239 female, ages ranging from 6 to 12 years old)	Teachers (12 sessions of three hours each with the researchers during six months): 1-Health and prevent disease/2- food and nutrition/3-4-Dietary guidelines/5-water and consumption of sugar-sweetened/6-7, appropriate physical activity levels and healthy eating behaviours/8-teaching strategies/9-strategies to reduce screen exposure time/10-global assessment of the training program/11-12 healthy cooking.	Weight-electronic scale (Seca, Model 703, Germany)/Height- stadiometer with the head in the Frankfort plane/BMI (kg/height m2)-International Obesity Task Force (IOTF)/Dietary intake-24-h dietary recall/Daily routines were used as prompts (waking up, going to bed, time between classes, and before or after school)/Energy and nutritional intake-Portuguese version of the nutritional analysis software Food Processor Plus (ESHA Research Inc., Salem, OR, USA)/Level of physical activity (questionnaire)	In the intervention group the increase in Body Mass Index (BMI) was significantly lower than in the control group. Fewer proportion of children became overweight in the intervened group compared with the control.
Dewar et al., 2013 [73]	PA+ Nutrition	12 secondary schools. 357 adolescent girls (aged 13.2; SD 0.5 years).	NEAT Girls (strategies to promote lifestyle and lifetime physical activity, improve dietary intake and reduce sedentary behaviors). School sport sessions, lunchtime physical activity sessions, nutrition workshops, interactive educational seminars, pedometers for self-monitoring, student handbooks, parent newsletters, and text messages to reinforce and encourage targeted health behaviors.	Body composition (BMI z-scores) (Imp™ SFB7 bioelectrical impedance)/Physical activity- Actigraph accelerometers (MTI models 7164, GT1M, GT3X)/Dietary intake- Australian Child and Adolescent Eating Survey (version 1.2)/Sedentary behavior Adolescent Sedentary Activity Questionnaire	After 24months, there were no intervention effects on BMI There was a group by time interaction for percentage body fat. Intervention effects for physical activity, screen time, and dietary intake were not significant
Johnston et al., 2013 [74]	PA+ Nutrition	71 adolescents (32 males; 45.1%) between the ages of 10 and 14 years	Trim Kids (12-week weight management plan). Nutrition class once a week and a physical activity training class 4 days a week, held during the final school period of the day, lasting 35-40 minutes. Parents were also involved.	Body composition (triceps skinfold thickness).   Total cholesterol, triglycerides, HDL, LDL) (Hitachi, Tokyo, Japan).   Blood pressure- Dinamap Monitor Pro 100 (GE Healthcare, Piscataway, NJ).	Repeated-measures analyses showed that ILI participants showed significantly greater decreases in standardized BMI at 1 and 2 years compared with SH controls.
Perikkou et al., 2013 [75]	Nutrition	218 elementary school students (aged 9 years) in Cyprus.	EDUC. classroom-based educational curriculum about a healthy lifestyle (29 lessons of 15 minutes each) EXPO. These children received no educational curriculum; children exposed to the consumption of a fruit or a healthy snack by their teacher.	Body weight- digital scale (Seca) Standing height- wall mounted stadiometer. Body mass index (BMI) values were calculated and BMI percentiles from the reference growth curves for Cypriot children Dietary intake of the participants was assessed using 2-day food records.	Higher fruit intake was reported by the children in the EXPO and the EDUC groups compared with the control group at the end of the intervention: a statistically significant group effect was found. At 1-year follow-up, results remained significant only for the children in the EXPO group

Discussion

    This review included the interventions focused on both the promotion of health as well as those aimed at preventing obesity. This would confirm that there is now sufficient evidence to support a belief in the effectiveness of such measures and interventions in schools [76]. Nearly all of the interventions included in this review presented some improvement in anthropometric parameters, physical fitness, psychological level, or simply a conductorial/behavioral level, all through the acquisition of new knowledge.

    The studies of Campbell, Waters, O'Meara and Summerbell [77], and Hardeman, Griffin, Johnston, Kinmonth and Wareham [78], specify that more than 50% of the interventions showed effective results in weight reduction, decreased body fat, and increased levels of physical activity from moderate to vigorous.

    In continuation, we will discuss the contrasting facts obtained in different sections of our review. In the first, we highlight the evolution of the interventions over time and the change of their orientation. We will see how, even though most studies focused on a simple intervention (with emphasis on a single variable), the most recent studies are multifactorial. It assumes a clear evolution of the research in this area, confirming the awareness that only one global approach to the problem can determine stable results.

    In the second section, we will discuss the issue of the duration of the intervention and the age of the subjects studied. We will highlight that programs both long and short term can get positive results, although the health issues that influence them are different. We will also discuss the differences in the nature of the programs applied to primary and secondary school children, which reflect the different needs at these stages.

    In the third section, we cover the importance of social and emotional environment for youth to build healthy habits. We will explain that recent studies have shown that 'significant others' are a key variable in their lifestyles. Therefore it is considered essential to them to have some assurance of success in these intervention programs. This is reflected in numerous studies reviewed, although we point out the difficulty of maintaining the control of this variable.

    Next, we make a description of the tools used in the articles reviewed, highlighting the main differences between them and their advantages and disadvantages in school programs.

    Finally, we analyze the efficacy of different interventions on psychological and physical health of the subjects studied. We discuss the effects of univariate interventions aimed at PA or nutrition, to finish talking about the main results obtained and difficulties encountered in multifactorial programs.

Type of program developed: single or multiple interventions

    The studies reviewed show that approximately 60% of the intervention measures elaborated has developed a simple approach of action, i.e. it had affect only on the PA or nutritional habits. In contrast, while performing a temporary division of the revision shown in this work and analyzing the interventions programs’ date ranges, we found an adoption of a global perspective on the problem in the last five years, with multidisciplinary treatment aimed at promoting healthy behaviors as well as the prevention obesity and overweight among young people.

    While it is true that a simple approach to intervention on a single behavior can also be successful [79], several authors argue that a good practice for the prevention of obesity is one that encompasses both the PA and diet. One of the conclusions of the work of Viciana, Salinas and Cocca [80] was precisely this. In their study they were able, after a program of 18 Physical Education sessions, to develop endurance and fundamental quality of the health in secondary school students. However, they did not manage to reduce the undesirable metabolic parameters, such as cholesterol, concluding that a multidisciplinary intervention was needed, combining the PA with a nutrition intervention to achieve these more pretentious effects.

    So, in conclusion, we defend interventions directed at modifying various elements through education (dietary habits, PA, cognitive and psychological profiles), the active participation of boys and girls, and the involvement of various educational agents of the community (teachers and parents), as these are factors of success in the programs reviewed [81].

Time duration of the program and subjects’ characteristics

    The comparison of the mean of the programs’ duration indicates that there are really some effective interventions implemented in short or long periods of time. In Physical Education, the implementation of short programs helps in making a more varied curriculum as well as a great number of content a year, better allowing an adherence to the directions of the educational authorities in the national curriculum [80]. However, taking these interventions as something eventual runs the risk of them falling into oblivion after their application. Therefore, we have two conclusions relating to the duration of the intervention programs. On one hand it is important to know that, contrary to some beliefs, relatively short programs in the context of Physical Education (between 5 weeks and 3 months) are productive in terms of health, though usually focused on improving only a few variables [50, 58]. On the other hand, the application of long-term programs have a greater effect on correct healthy habits and obtain changes in parameters inaccessible with the short programs, such as metabolic indicators measured in blood that reflect personal health [60].

    As for the subjects, the results did not show any specific indication of an ideal age for the intervention. These interventions are narrowly targeted, but hardly characterized by differences in this parameter. In general, all interventions are tailored to the characteristics of subjects according to their ages, as they vary the intent and program strategies. For subjects in the Primary school age (usually 6-12 years), the strategies are based mainly on game and are reinforced by their own intrinsic motivation for the subject. However, subjects in the Secondary school age are externally reinforced to seek the involvement of the young, they often apply themselves to sports content and improved competitiveness and that take into greater account the psychological variables associated with PE, as adolescence is a time of great psychological importance. Collaboration with families is important in any of these stages to increase the program's success [81].

    The gender was not an important differentiating variable (mixed groups are common in education). However, the interests of both sexes are taken into account in the program settings, so in the end these tasks are motivational for everyone and there is full involvement.

    Finally, to state that the mandatory nature of practicing PA during the intervention programs has been a criterion for program effectiveness, as opposed to the ineffectiveness of voluntary PA programs. Only 11 of the 28 programs reviewed by Connelly, Duaso and Butler [82] had positive results coinciding with this, highlighting that a line of the future will be to determine the parameters that make a subject choose the AP as voluntary practice.

Agents in the implicated educational community

    Effects were significantly better in the studies that integrated a high level of parent involvement, for example, parents became aware of the low levels of physical and sporting activity and poor eating habits as well as being sensitized through workshops for the active participation in the lives of their children. In this sense, it is interesting to see how these agents may affect responsibility as role models for these young people in their ages of maximum learning [81]. Therefore, the active participation of parents and other members from the family environment in intervention programs is a key variable for increasing healthy habits among young people [83].

    The influence of these external actors had been previously detected in the amount of PA performed, as well as the continuation of this practice and general motivation that leads to their realization [7]. Therefore, significant others (parents, teachers, family, boyfriends and friends) are a source of enormous influence of success or failure for these programs and must be taken into account as well as involving them to optimize their effects. We begin to take into account family support as a predictor of youth practice [84] and that the effectiveness of certain models of parental guidance are essential in the future acquisition of healthy habits of young people [85].

    In a high percentage of the interventions examined, they attempt an escalation by the increased weekly PA sessions taught by a specialist teacher in the area of Physical Education, the real time of practice driving done by these adolescents, both in school and outside leisure time. In this regard, we note several ideas. The first is that there is an increased activity in the school (e.g., during recess), but little effect on the overall level of daily physical activity and sport. This raises questions about the advisability of these programs in order for a rise in active activities during free time. In this, we emphasize, as noted in the European Parliament [14], increasing the number of hours per week of PE, but omitting a reorientation of these sessions [86]. Therefore, it is appropriate to demand new programs of health intervention closer to the expectations, interests, and demands of society and youth to acquire healthy lifestyles in the future. This is what Johns [87] defined as the reduction of the disparity between what is stipulated as healthy and the reality of today's youth. The second, is the presence in these intervention programs of a training phase for these PE specialists, normally provided by health professionals, prior to the development of these sessions in order to obtain the same maximum benefit. It seeks to increase the percentage of students abiding current PA recommendations. The program pursued by Carlson et al. [60], stresses this regard. The inclusion of this phase in such measures is justified by the need for well-trained specialists who know how to adapt its practices to the new social demands and youth from a critical reflection on their teaching [88].

Type of measurements

    In intervention measures aimed at changing eating behaviors, the goal is to know the types of products consumed, frequency, and energy of the same composition. To do this, the most used tools are the "Youth and adolescents food frequency questionnaire" and "24-hour recall questionnaire”, both used in most large studies [89].

    In measures aimed at increasing physical activity rates and sport, the aim is to know the actual amount of daily practice. To do this, assessments are made using a combination of questionnaires (normally PAQ-A) with acceleromletry (emphasis in most cases the ActiGraph GT1M/ GT3X).

    In other cases, anthropometric measurements such as bioelectrical impedance, skin-folds, and waist circumference were used. Sometimes they are accompanied by psychological assessment variables through a questionnaire (e.g. AF-5 Self -Concept Questionnaire, Physical Self Description Questionnaire, Body Image Anxiety Scale and Contour Drawing Rating Scale). Both variables have proven influence on the amount of physical activity [90].

Effectiveness of the intervention results

    Interventions focused on increasing levels of physical activity and sport, have resulted in increases in the amount of moderate to vigorous practice of about 25 minutes during school hours. Achievements resulting from the modification of motor time commitment in PE sessions where more than 50% of the time is devoted to MVPA. In addition, reductions have been obtained in skin folds due to changes in weight or body mass index as indicated by Damon, Dietrich and Widhalm [91]. This would demonstrate that the reduction of fat may occur in parallel to the maintenance or increase of lean body mass in children. The fact that three studies showed different results by gender indicates the need for further adaptation of these interventions taking into account this factor in the future.

    The results indicated that programs aimed at all children, regardless of the weight or the risk of obesity, are associated with positive outcomes in the body mass index. On the contrary, the selected interventions for the populations at high risk (in this case, overweight and obese children) had poorer results. In explanation, we remember the indications made by Neumark-Sztainer, Story, Hannan and Rex [36], according to which, children that may start from a risk situation or overweight respond more slowly to prevention interventions than children with lower risk.

    In the analysis, the change of the nutritional behavior also appears to be associated with significant positive results. As representative studies, including those by Perry et al. [45] and Olivares et al. [44], which found positive effects on nutritional knowledge, increased consumption of fruit and vegetables, and reduced consumption of bread and fatty foods. By contrast, when considered together, the interventions that have implemented the entire system of nutritional changes seem to get limited effects, as sometimes the percentage of fat mass is not reduced, nor the total energy value of the food. An example would be the frequent consumption of sugary snacks and drinks.

Conclusions

    The variety of studies found, each with a different methodology and a guide to various factors, do not show clearly which aspects of the interventions examined are more likely to produce large-scale success. Despite the uncertainty and variety in the results and methodology, the interventions set out to provide a wealth of information about how to improve programs promoting physical activity and improving nutrition.

    Here are some recommendations for the future, based on the scientific evidences reviewed:

1. Future interventions should take measures such as skin-fold thickness, height, and weight to better assess changes in the body composition.

2. One should bear in mind the difficulty of evaluating these heterogeneous subject groups that are presented in the schools. The ethnicity, gender, and age are key factors for this. For example, different ages require different measures and adaptions. To measure habitual physical activity of children in the first cycle of Primary school a contrast in the measurements with the opinions of the parents is required in order to win in truth, or objectively measure this parameter with instruments such as the activity meter. This measure determines the time of mild, moderate and intense PA versus the Mets used in these activities during a given period. This measure will be much more reliable and valid than a question in a questionnaire such as the 3-Day physical activity recall questionnaire for the study of this particular population.

3. PE should be used more often as a means of promotion, as well as making the program mandatory.

4. All agents of the educational community should be involved (teachers generalist, specialist teachers in PE, parents, etc.)

5. Authors should also assess the potential impact of the intervention in terms of adverse effects, such as the stigmatization of obese children.

6. We recommend the evaluation and publication of all interventions. Even those with small sample size and without effective results in terms of objectives, as it still could be useful in improving and reporting for the development of future interventions.

    In conclusion, we must remember that to reverse the current trend toward high rates of overweight and obesity is not an easy task. Large investments are needed not only economically, but in all sectors of society in matters of time, effort, and dedication. In line with Li, Dibley, Sibbritt and Yan [92], we believe in prevention strategies to address overweight and obesity at younger ages from the school environment to enhance behavioral change in young people. Therefore appreciating, as an aspect of social interest, the contribution that can be done from the school and PE as an area of the curriculum promoting PA and health [93]. The Spanish educational reform itself reflects this change and need in the state curriculum that serves as a reference for PE classes, changing the focus from fitness to a healthy outlook and making numerous references in the document and its health objectives [80]. We should not forget that this is a task for everyone.

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