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The Effects on Children’s Diets of Combining Changes to the School Food Environment with Nutrition Education Compared to Either of These Strategies Alone 

Many schools are making changes to the food environment to improve children’s eating habits. Examples of these changes include healthier food choices in the cafeteria or in vending machines. This summary of a NEL review presents what we know from research about the effects on children’s diets of combining changes to the school food environment with nutrition education, compared to either one of these alone. 

Conclusion

Consistent evidence suggests that combining nutrition education with changes to the school food environment is more effective for improving children’s and adolescents’ dietary intake than making changes to the food environment alone. 

What the Research Says

  • All five studies in this review found that children improved their diets when changes to the food environment at school were combined with nutrition education
  • The types of changes made to the school environment were free breakfast provided at school; promotion of and more fruits and vegetables in the school cafeteria and vending machines; free fruit and vegetable snack; and more choices, promotion, and better cooking and look of fish served in the school cafeteria
  • Four of the five studies looked at “nutrition education combined with changes in the school environment” to “changes to the school environment alone” and found that the combination led to a greater improvement in what children ate, than just only changing the school environment
  • One study looked at “nutrition education combined with changes in the school environment” to “changes in nutrition education alone” and found that the combination improved children’s food choices.  But, the effects were seen only in boys, and not in girls.

Technical Abstract

Background

In an effort to improve children’s dietary intake, many schools are implementing changes to the food environment, such as offering and marketing healthier options at school meals or in vending machines. The objective of this systematic review was to determine the effects of combining changes to the food environment and nutrition education compared to either of these strategies alone on children’s and adolescent’s dietary intake-related behaviors.

Conclusion Statement

Consistent evidence suggests that combining nutrition education with changes to the school food environment is more effective for improving children’s and adolescents’ dietary intake, than making changes to the food environment alone (Grade: Strong).

Methods

Literature searches were conducted using PubMed, EBSCOhost, Education Fulltext, and Global Health to identify studies that compared a combination of changes to the food environment and nutrition education, to either food environment changes or nutrition education alone. 

  • Inclusion Criteria: Published between January 1995 and December 2010; conducted in subjects aged 0–18 years; randomized controlled trials, non-randomized controlled trials, or quasi-experimental studies; subjects from countries with a high or very high human development index; subjects who were healthy or at elevated chronic disease risk; published in English in a peer-reviewed journal
  • Exclusion Criteria: Systematic reviews, meta-analyses, narrative reviews, or prospective cohort, cross-sectional, or case-control designs; studies with no control group; subjects hospitalized, diagnosed with disease, and/or receiving medical treatment.

The results of each included study were summarized in evidence worksheets (including a study quality rating), an evidence paragraph, and evidence table. A group of subject matter experts were involved in a qualitative synthesis of the body of evidence, development of a conclusion statement, and assessment of the strength of the evidence (grade) using pre-established criteria including evaluation of the quality, quantity, consistency, magnitude of effect and generalizability of available evidence. 

Findings

  • Five articles were included in this systematic review. Three studies were randomized controlled trials (RCT) and two were non-randomized controlled trials. Three studies (two RCTs, one non-RCT) received a neutral quality rating, and two received a positive quality rating (one RCT, one non-RCT).
  • Types of changes made to the school food environment included: Free breakfast provided at school, increased availability and promotion of fruits and vegetables in the school cafeteria and vending machines, free fruit and vegetable snack, and increased choice, marketing, and improvement in the preparation and appearance of fish served in the school cafeteria
  • The four studies that compared “nutrition education combined with changes to the school food environment” to “changes to the school food environment alone” found that combining nutrition education with changes to the school food environment improved dietary intake, and provide some evidence that this improvement was greater than when compared to only making changes to the school food environment
  • The study that compared “nutrition education combined with changes to the school food environment” to “nutrition education alone” found some evidence that combining nutrition education with changes to the school food environment improved dietary intake more than only providing nutrition education.

Discussion

The studies included in this review provide evidence suggesting that combining changes to the school food environment with nutrition education is more effective for improving children and adolescent’s dietary intake, than changing the food environment alone. It is important to note that in two studies, the direct comparison between the combination intervention and the food environment intervention did not differ significantly, though the combination intervention led to improvements compared to control while the food environment alone intervention did not. Also, in one study effects were seen only in boys, and not in girls.