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What is the effect of nutrition education with parental involvement compared to no parental involvement on children’s dietary intake-related behaviors?

Conclusion

Limited and inconsistent evidence is available to assess the effects of involving parents in nutrition education on children’s (ages nine and older) dietary intake-related behaviors. Some evidence suggests that involving parents in a nutrition education intervention improves outcomes, while other evidence finds no added benefit of including parents. In children less than nine years of age, there is no evidence to assess the effects of nutrition education with parental involvement on dietary intake-related behaviors.

Grade

III - Limited

 

Evidence Summary Overview

Overall, the ability to draw strong conclusions as to the effect of parental involvement in nutrition education of children’s dietary intake is limited by the small number of relevant studies and large degree of variation in intervention design and study characteristics. Specifically, research is needed to determine the effects of parental involvement among younger children, especially those younger than age nine years. Furthermore, because several studies found greater improvements in dietary intake among girls compared to boys, there is some suggestion that girls may be more affected by parental involvement than boys. Finally, the method and dose of parental involvement may impact the degree to which children’s dietary intake changes following nutrition education. However, the limited number of studies and inconsistency in study designs used limits the conclusions that can be drawn.

Description of the Evidence

The literature search for studies that tested the effects of nutrition education delivered to children and adolescents with parental involvement compared to no parental involvement identified 3,538 articles, 432 of which were selected for review (Fig. 4-B.1). Of these 432 articles, four were selected for inclusion in the systematic review. In addition, six articles were identified via hand search. Therefore, this systematic review includes a total of 10 articles. A detailed description of literature search results, including the databases searched and the number of articles identified using each database, articles identified using hand search, a list of citations for all included articles, and a table that lists excluded studies with rationale for exclusion can be found in Appendix E.

Click Figure 4-B.1. to see flow chart of literature search results for studies examining The Effects of Nutrition Education Delivered to Children and Adolescents with Parental Involvement Compared to No Parental Involvement.

All 10 studies included in this review were randomized controlled trial (RCTs) [Beech et al, 2003 (positive quality); De Bourdeaudhuij et al, 2002 (positive quality); Haerens et al, 2006 (positive quality); Haerens et al, 2007a (neutral quality); Hopper et al, 1996 (neutral quality); Kitzman-Ulrich et al, 2009 (neutral quality); Luepker et al, 1996 (positive quality); Nader et al, 1996 (positive quality); Vandongen et al, 1995 (positive quality); Wind et al, 2008 (positive quality)]. Seven studies received a positive quality rating, and three received of neutral quality rating. Five studies took place in the United States, three studies took place in Belgium, one study was done in Australia, and one study was done in Europe (Norway, Spain, The Netherlands). Sample sizes varied from 42 to 4,019 study participants (two studies had <100 subjects, four studies had 100 to 500 subjects, one study had 500 to 1,000 subjects, and three studies had >2,000 subjects). The ages of subjects ranged from nine years to 18 years (three studies in nine-year-olds, one study in 10- to 12-year-olds, one study in 11-year-olds, one study in 12-year-olds, three studies in 13-year-olds, and one study in 15- to18-year-olds), with no studies identified in children less than nine years. One study (Beech et al, 1996) included 100% African American females. The other nine studies included both boys and girls.

A variety of intervention designs were used to test the influence of parent involvement in nutrition education on children’s dietary behaviors. One study compared a child-only intervention to a parent-only intervention (Beech et al, 1996). One study tested various combinations of fitness education, school nutrition education, and home nutrition education (Vandongen et al, 1995). Six studies compared a child-only intervention to a parent-child intervention (De Bourdeaudhuij et al, 2002; Haerens et al, 2006; Haerens et al, 2007a; Hopper et al, 1996; Kitzman-Ulrich et al, 2009; Luepker et al, 1996). Two studies conducted a post-hoc analysis to assess outcomes in relation to the level of parental participation that occurred (Nader et al, 1996; Wind et al, 2008).

On the whole, these studies varied widely in design and methodology, and it is possible that a number of factors that varied between the studies could have influenced the impact the role parental involvement had in the dietary intake of children. Some of these factors identified from these studies are discussed in further detail below.

Subject Characteristics

Age

The ages of subjects in the studies reviewed ranged from nine years to 18 years, with no studies identified in children less than nine years. In addition, nine out of the 10 studies reviewed, included children from nine to 13 years of age, and only one study included older adolescents (15 to 18 years of age). It is possible that younger children, due to developmental factors, may respond differently to parental involvement than pre-adolescents or adolescents. However, because studies were not available in younger children, it is not possible to assess the impact of age on the effects of including parents in a nutrition education intervention. In addition, research was not available to fully investigate whether differences also exist between pre-adolescents and older adolescents. Further, none of the studies reviewed conducted secondary analyses to investigate whether age influenced outcomes. Therefore, more research is needed to assess the effects of parental involvement in nutrition education on dietary intake in children across the developmental spectrum, particularly among those less than nine years of age, as well as in older adolescents.

Gender

Several of the studies reviewed report differential effects on dietary intake for girls and boys. Two studies (Haerens et al, 2006; Haerens et al, 2007a) found that while neither girls nor boys in the intervention groups improved intakes of fruit, soft drinks, or water, girls significantly decreased fat intake, while boys did not. In one study (Vandongen et al, 1995), girls in the two groups that included a home component reduced fat intake and increased fiber intake, while boys in one of the groups that included a home component reduced sugar intake. Therefore, three out of the ten studies reviewed demonstrated differential effects in outcomes between girls and boys, and in all three cases, girls demonstrated greater improvements in dietary intake compared to boys. However, these studies were not designed to specifically address the effects of gender and parental involvement, and additional research is needed to explore the role of gender in more depth.

Country

The studies reviewed were conducted in several different countries, including the United States (5), Belgium (3), three countries of Europe (1), and Australia (1). All of the studies that found that nutrition education with parental involvement was more effective for changing children’s dietary intake were conducted outside of the United States, while all of the studies conducted in the United States found that including parental involvement in nutrition education did not improve outcomes. Therefore, it appears that there may be some aspects of cultures outside of the United States that contribute to improved dietary intake when parents are involved in nutrition education. However, it is not possible to draw further conclusions from this body of literature, and more research is needed to better understand the effects of cultural differences.

Method of Parental Involvement

A variety of different strategies were used to involve parents. Some studies used more direct methods, such as face-to-face nutrition education sessions or meetings (Beech et al, 1996; Kitzman-Ulrich et al, 2009), others used indirect methods, such as newsletters or other educational materials sent home (De Bourdeaudhuij, 2002; Hopper et al, 1996; Vandongen et al, 1995; Wind et al, 2008). Several used a combination of direct and indirect methods (Haerens et al, 2006; Haerens et al, 2007a; Luepker et al, 1996; Nader et al, 1996). Of the two studies using direct methods to involve parents in the intervention, one (Beech et al, 1996) reported a positive, but non-significant trend for fewer sweetened beverages consumed by the parent-targeted group compared to the child-alone targeted group, while the other reported no effects (Kitzman-Ulrich et al, 2009). Among the four studies that used both direct and indirect methods to engage parents in intervention activities, three of the studies (Haerens et al, 2006; Haerens et al, 2007a; Luepker et al, 1996) reported some improvement in dietary intake with parental involvement. Of the three studies that used indirect methods to engage parents, two reported some improved outcomes with a parental component (Vandongen et al, 1995; Wind et al, 2008) and two reported no effects of parental involvement on children’s dietary intake (De Bourdeaudhuij et al, 2002; Hopper et al, 1996). Methods of parental involvement were not thoroughly examined in this body of literature. More research is needed to determine whether using direct methods, or a combination of direct and indirect methods of involving parents in a nutrition education intervention, may be more effective for improving children’s outcomes.

Dose of Parental Involvement

In addition to the methods of parental involvement used, the dose, or amount of time parents were involved, may also impact study outcomes. Two of the studies reviewed, directly examined the dose of parental involvement in relation to outcomes (Nader et al, 1996; Wind et al, 2008). Both studies conducted secondary analyses of data collected as part of a nutrition education intervention that included parental involvement. The studies determined parents’ level of involvement, and conducted dose response analyses to determine whether increasing the “dose” of parental involvement was associated with improved outcomes among children in the study. Nader et al, 1996 found no significant effects on dietary behaviors related to dose of adult participation. However, Wind et al, 2008 found that children with the highest dose of parental involvement showed the highest increases in vegetable intake compared with children whose parents had lower levels of participation. Because the available evidence reviewed is conflicting, there is a need for additional research to investigate whether dose, or level of parental participation as part of a nutrition education intervention, leads to greater improvements in children’s dietary intake, and if so, what dosage is optimal.

Click on Table 4-B.1. to view the Summary of Outcomes and Type of Parental Involvement Tested from Studies Examining the Effects of Nutrition Education Delivered With and Without Parental Involvement. 

Evidence Summary Paragraphs

Beech et al, 2003 (positive quality) conducted an RCT in the United States to assess the effects of a culturally tailored, family-based intervention to prevent excess weight gain in African American girls. The girls were randomly assigned to one of three intervention groups: (1) a child-targeted intervention, (2) a parent-targeted intervention, and (3) a control group. Both interventions were 12 weeks long, and consisted of 90 minutes per week education sessions. The final sample included 60 girls (mean age=nine years). There was a non-significant trend for the parent-targeted group to consume fewer sweetened beverages than the child-targeted group (-0.64 servings per day; P=0.09). The parent-targeted intervention group significantly reduced intake of sweetened beverages compared to the control group (P<0.001).

De Bourdeaudhuij et al, 2002 (positive quality) conducted a RCT in Belgium to investigate the effects of a tailored nutrition education program. Children were randomly assigned to one of three intervention groups: (1) family-based (child + parent), (2) parent (parent alone), and (3) child (child alone). The intervention consisted of tailored nutrition education letters mailed home. The final sample included 134 subjects (15 to 18 years). There were no significant differences between the intervention groups in fat intake following the intervention. Subjects with baseline fat intake above recommended levels significantly decreased (P<0.001) fat intake post-intervention; however, there were no differences between the groups.

Haerens et al, 2006 (positive quality) and Haerens et al, 2007a (neutral quality) reported results from a group RCT in Belgium to evaluate the effects of a middle school physical activity and healthy eating intervention. Young adults were randomly assigned to one of three conditions: (1) intervention with parental involvement, (2) intervention alone, and (3) control. The intervention consisted of a two-year school-based program combining environmental changes with computer-tailored feedback to promote healthy food and physical activity. The parental component involved school meetings, newsletters, and a computer CD sent home. Haerens et al, 2007a reported results at the one-year time point from a final sample of 2,840 subjects (13 years; 37% female). Girls in the intervention group with parental support decreased fat and percent energy from fat significantly more than the intervention group without parental support (P<0.05) and control (P<0.001). For boys, there were no significant (NS) differences in fat intake between any of the groups. Also, in both girls and boys, there were NS differences between any of the groups for fruit, soft drink, or water intake. Haerens et al, 2006 reported results at the two-year time point from a final sample of 2,287 subjects (13 years; 38% female). In both girls and boys, there were NS differences between the intervention groups in any dietary behaviors following the intervention. The girls in both intervention groups significantly decreased fat intake and percent energy from fat compared to control (P<0.05). For boys, there were NS differences between the intervention groups and the control group in any dietary behaviors following the intervention.

Hopper et al, 1996 (neutral quality) conducted an RCT in the United States to examine the efficacy of school-based exercise and nutrition programs. In this study, subjects from 5th and 6th grade classrooms were randomly assigned to three different treatments conditions: (1) school-home intervention, (2) school-only intervention, and (3) control. The school intervention consisted of an enhanced classroom-based nutrition education program, while the school-home intervention combined the school-based nutrition education with a parent/home education component. The control group received the usual school nutrition education. The final sample included 132 subjects (12 years). There were no significant differences between the school-home and school-only groups in fat intake following the intervention. Both the school-home and school-only groups decreased fat intake compared to control (P<0.05).

Kitzman-Ulrich et al, 2009 (neutral quality) conducted an RCT in the United States to determine the effects of nutrition education delivered via multi-family therapy and/or psycho-education. Teenage girls were randomly assigned to one of three groups: (1) multi-family therapy + psycho-education, (2) psycho-education-only, or (3) control. The psycho-education intervention consisted of a 16-week educational curriculum with behavioral-skill-building and psychosocial components. The multi-family therapy intervention consisted of a 45-minute group session. The final sample included 42 girls (13 years). The psychoeducation-only group demonstrated a greater decrease in energy intake compared to both the multi-family therapy plus psychoeducation and control groups (P<0.01).    

Luepker et al, 1996 (positive quality) conducted a randomized controlled multi-state study (CATCH) to assess the outcomes of health behavior interventions, focusing on the school environment, classroom curricula, and home programs, for the primary prevention of cardiovascular disease. Children were randomly assigned to one of three groups: (1) school-family, (2) school-only, or (3) control. The CATCH intervention consisted of modifications to the school food environment, physical education interventions, and nutrition education curriculum. The parent component included educational materials that complemented classroom education materials. The control group received usual health curricula, physical education, and food service programs. The final sample included 4,019 subjects (nine years; 32% female). No significant differences in any of the measured dietary behaviors were found between the intervention groups following the intervention. The intervention groups significantly decreased total fat, saturated fat, MUFA, PUFA, and cholesterol compared to the control group (P<0.01). There was a trend for decreased sodium and increased protein and carbohydrate intake in the intervention groups compared to the control group (P<0.09).

Nader et al, 1996 (positive quality) conducted a secondary analysis of data from a randomized controlled multi-state study (CATCH) to assess the effect of the level of adult participation on outcomes (see Luepker et al. for study details). This secondary analysis included a dose analysis of the family component to assess the effects of level of adult participation on outcomes. Adult participation was determined by the number of activity packets that adult household members completed with the child. The final sample included 336 children (9 yrs). There were no significant differences in measured dietary behaviors by dose of adult participation.

Vandongen et al, 1995 (positive quality) conducted an RCT in Australia to test the effects of nutrition and fitness programs. Youths were randomized to one of six groups: (1) fitness-only, (2) fitness-school nutrition, (3) school nutrition-only, (4) school nutrition-home nutrition, (5) home nutrition-only, or (6) control. The fitness intervention included classroom-based physical education, the school nutrition intervention included classroom-based nutrition education, the home nutrition intervention included educational materials sent home for use by the parent-child, and the control group received no intervention. The final sample included 423 subjects (10 to 12 years). Comparisons were only made relative to control, and not between intervention groups. In girls, fat intake decreased significantly (P<0.05) in the two home nutrition groups and fiber intake increased (P<0.05) in the school-home nutrition and fitness groups. Boys in the fitness, fitness-school nutrition, and school-home nutrition group reduced sugar intake (P<0.05).

Wind et al, 2008 (positive quality) conducted an RCT in Europe (Norway, Spain, The Netherlands) to test the effects of a school-based intervention on children’s fruit and vegetable intake. The intervention consisted of school nutrition education, parental involvement via newsletters, a computer-tailored tool, and changes to the school food service environment. Analyses were conducted to determine the effects of parental involvement (whether or not parents participated in intervention components at home) on fruit and vegetable intake. The final sample included 868 subjects (11 years; 55% female). Children with the highest parental involvement showed higher increases in frequency of vegetable intake, compared with children who had medium or low parental involvement (P<0.05). No significant associations were found between parental involvement and changes in frequency of fruit intake.



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Author, Year,
Study Design,
Class,
Rating
Subject Characteristics Methods Outcomes Limitations
Beech BM, Klesges RC et al, 2003 

Study Design: Randomized Controlled Trial

Class: A 

Rating: Positive

N=60 (100% female)

Mean age: 9 years

Race: African American

Location: United States.

 

Child-targeted intervention (girls only) vs. Parent-targeted intervention (parents only) vs. comparison group.

Both interventions consisted of 90 minutes per week educational sessions for 12 weeks.

Dietary intake was assessed using dietary recall.
 

 

 

NS trend for the parent-targeted group to consume fewer sweetened beverages than the child-targeted group (-0.64 servings per day; P=0.09).

Parent-targeted intervention group significantly ↓ intake of sweetened beverages compared to the control group (P<0.001).

 

Fewer meetings for the comparison group vs. the active arms (3 vs. 12).

 
De Bourdeaudhuij I, Brug J et al, 2002 

Study Design: Randomized Controlled Trial

Class: A 

Rating: Positive

N=134 (males and females)

Mean age: 15-18 years

Race: White

Location: Belgium.

 

Family-based (child + parent) vs. Parent (parent alone) vs. Child (child alone)

Intervention consisted of tailored nutrition education letters mailed home six weeks after completion of a FFQ at baseline. Post-test questionnaires collected after four weeks.

Dietary intake assessed using a FFQ.

 

NS differences between the intervention groups in fat intake following the intervention.

Subjects with baseline fat intake above recommended levels significantly ↓ fat intake post-intervention; however, there were no differences between the groups.

 

Selection bias due to self-selected recruitment, oversampling of mothers with lower fat intake may not be representative of the general populations, long-term effects not examined, the amount of family participation was not measured or controlled directly. 

 
Haerens L, De Bourdeaudhuij I et al, 2007 

Study Design: Randomized Controlled Trial

Class: A 

Rating: Neutral

N= 2,840 (37% female)

Mean age: 13 years

Race: White

Location: Belgium.

 

Intervention with parental involvement vs. Intervention alone vs. Control

Intervention consisted of a 1-year school-based program combining environmental Δs with computer-tailored feedback to promote healthy food and physical activity. The parental involvement component consisted of in-person meetings, provision of a computer CD on reducing fat intake, and educational materials and newsletters sent home.

Dietary intake assessed using an FFQ.

 

Girls: Intervention group with parental support ↓ fat/% energy from fat significantly more than the intervention group without parental support (P<0.05) and control (P<0.001).

Boys: NS differences between any of the groups.

Girls and Boys: NS differences between any of the groups for fruit, soft drink, or water intake.

 

The self-reported character of the measurements. Self-reported measures used to assess dietary intakes of adolescents tend to result in reporting errors and limited data are available to understand the reporting bias in this age group.

 
Haerens L, Deforche B et al, 2006 

Study Design: Randomized Controlled Trial

Class: A 

Rating: Positive

N= 2,287 (38% female)

Mean age: 13 years

Race:  White

Location: Belgium.

 

Intervention with parental involvement vs. Intervention alone vs. Control.

Intervention consisted of a two-year school-based program combining environmental Δs with computer-tailored feedback to promote healthy food and physical activity. The parental involvement component consisted of in-person meetings, provision of a computer CD on reducing fat intake, and educational materials and newsletters sent home.

Dietary intake assessed using an FFQ.

 

Girls and Boys: NS differences between the intervention groups in any dietary behaviors following the intervention.

Girls in both intervention groups significantly ↓ fat and % energy from fat compared to control (p<0.05). For boys, there were NS differences between the intervention groups and the control group in any dietary behaviors following the intervention.

 

Lack of process evaluation data on levels of parental involvement makes it hard to draw conclusions.

High percentage of dropouts (25%).

Self-reported character of measurements of dietary intake and physical activity.

 
Hopper CA, Gruber MB et al, 1996 

Study Design: Cluster Randomized Trial

Class: A 

Rating: Neutral

N= 132 (males and females)

Mean age: 12 years

Race: N/A

Location: United States.

 

School-home intervention vs. School-only intervention vs. Control.

School intervention consisted of classroom-based nutrition education, while the school-home intervention combined the school-based nutrition education with a parent/home education component. Parent/home education component included educational materials sent home. Control group received the usual school nutrition education.

Dietary intake assessed using 24-hour dietary recall.

 

NS differences between the school-home and school-only groups in fat intake following the intervention.

Both the school-home and school-only groups ↓ fat intake compared to control (P<0.05).

 

Measurement tools may not have been sensitive enough to detect differences.

Intervention was done at the classroom level, and it was not possible to control for classroom-to-classroom differences in intervention delivery.

 
Kitzman-Ulrich H, Hampson R et al, 2009 

Study Design: Randomized Controlled Trial

Class: A 

Rating: Neutral

N= 42 (100% female)

Mean age: 13 years

Race: 55% White

Location: United States.

  

 

Multi-family therapy + psychoeducation vs. Psychoeducation-only vs. Control

Psychoeducation intervention consisted of a 16-week educational curriculum with behavioral-skill building and psychosocial components.

Multi-family therapy intervention consisted of a 45-minute group session.

Dietary intake assessed using 24-hr dietary recall.
 

 

Psychoeducation-only group demonstrated a greater ↓ in energy intake compared to the multifamily therapy plus psychoeducation and control groups (P<0.01).  

 

Low attendance (<50%) may have ↓ the impact of the intervention.

Intervention was relatively short, and long-term effects are not known. 

Accuracy of the 24-hour dietary recall methods may not have captured Δs in this small sample.

 
Luepker RV, Perry CL et al, 1996 

Study Design: Randomized Controlled Trial

Class: A 

Rating: Positive

N= 4,019 (32% female)

Mean age: 9 years

Race: 69% White

Location: United States.

 

School-family vs. School-only vs. Control.

CATCH intervention consisted of modifications to the school food environment, physical education interventions, and nutrition education curriculum. Home curriculum included packets sent home and a family activity night. Control group received usual health curricula, physical education, and food service programs.

Dietary intake assessed using 24-hour dietary recall.

 

NS differences between the intervention groups in any dietary behaviors following the intervention.

The intervention groups significantly ↓ total fat, saturated fat, MUFA, PUFA, and cholesterol compared to control (P<0.01). There was a trend for ↓ sodium and ↑ protein and CHO intake in the intervention groups compared to control (P<0.09).

 

Participation and attrition rates were relatively ↑.

Amount of intervention that was feasible in public elementary schools was limited due to costs, staff time, and competing classroom instructional requirements.

 
Nader PR, Sellers DE et al, 1996 

Study Design: Randomized Controlled Trial

Class: A 

Rating: Positive

N= 336 (males and females)

Mean age: 9 years

Race: N/A

Location: United States.

 

Secondary analysis of data from the CATCH intervention to conduct a dose analysis of the family component to assess the effects of level of adult participation on outcomes.

CATCH intervention consisted of modifications to the school food environment, physical education interventions, and nutrition education curriculum. The home curriculum included packets sent home and a family activity night. Parental participation assessed as number of completed activity packets.

Dietary intake assessed using 24-hour dietary recall.

 

NS differences in measured dietary behaviors by dose of adult participation.

 

Validity of self-reported measures.

Limited ability to analyze family characterisitcs that may explain the variance in adult participation, as well as adult-child interaction.

 
Vandongen R, Jenner DA et al, 1995 

Study Design: Randomized Controlled Trial

Class: A 

Rating: Positive

N= 423 (males and females)

Mean age: 10-12 years

Race: N/A

Location: Australia.

 

Fitness-only vs. Fitness-School Nutrition vs. School Nutrition-only vs. School Nutrition-Home Nutrition vs. Home Nutrition-only vs. Control.

School Nutrition: classroom-based nutrition education.
 

Home Nutrition: Educational materials sent home for use by the parent-child.

Control: No intervention.

Dietary intake was assessed using food records.

 

Comparisons were only made relative to control, and not between intervention groups.

Girls: Fat intake ↓ significantly in the two home nutrition groups and fiber intake ↑ in the school-home nutrition and fitness groups.

Boys in the fitness, fitness-school nutrition, and school-home nutrition group ↓ sugar intake.

 

Authors did not identify limitations.

 
Wind M, Bjelland M et al, 2008 

Study Design: Cluster Randomized Trial

Class: A 

Rating: Positive

N= 868 (55% female)

Mean age: 11 years

Race: N/A

Location: Europe.

 

Intervention consisted of school nutrition education, parental involvement via newsletters, a computer-tailored tool, and Δs to the school food service environment. Analyses were conducted to determine the effects of parental involvement (whether or not parents participated in intervention components at home) on fruit and vegetable intake.

Dietary intake was assessed using a validated questionnaire.

 

Children with the highest parental involvement showed the highest ↑ in frequency of vegetable intake compared with children or had medium or low parental involvement (P<0.05).

NS associations were found between parental involvement and Δs in frequency of fruit intake.

 

Self-report dietary intake measures.

Lack of ability to state causality.

Validity/reliability of the assessment of the intervention characteristics were not tested.

 

Research Design and Implementation
For a summary of the Research Design and Implementation results, click here.
Worksheets
Beech BM, Klesges RC, Kumanyika SK, Murray DM, Klesges L, McClanahan B, Slawson D, Nunnally C, Rochon J, McLain-Allen B, Pree-Cary J. Child- and parent-targeted interventions: The Memphis GEMS pilot study. Ethn Dis. 2003 Winter; 13 (1 Suppl 1): S40-S53.

De Bourdeaudhuij I, Brug J, Vandelanotte C, Van Oost P. Differences in impact between a family vs. an individual-based tailored intervention to reduce fat intake. Health Educ Res 2002;17 (4): 435-449.

Haerens L, De Bourdeaudhuij I, Maes L, Vereecken C, Brug J, Deforche B. The effects of a middle-school healthy eating intervention on adolescents' fat and fruit intake and soft drinks consumption. Public Health Nutr. 2007 May; 10 (5): 443-449. PMID: 17411463.

Haerens L, Deforche B, Maes L, Cardon G, Stevens V, De Bourdeaudhuij I. Evaluation of a 2-year physical activity and healthy eating intervention in middle school children. Health Educ Res. 2006; 21(6): 911-921.

Hopper CA, Gruber MB, Munoz KD, MacConnie, S. School based cardiovascular exercise and nutrition programs with parent participation. Journal of Health Education. 1996; 27: S32-39.

Kitzman-Ulrich H, Hampson R, Wilson DK, Presnell K, Brown A, O'Boyle M. An adolescent weight-loss program integrating family variables reduces energy intake. J Am Diet Assoc. 2009 Mar; 109(3): 491-496.

Luepker RV, Perry CL, McKinlay SM, Nader PR, Parcel GS, Stone EJ, Webber LS, Elder JP, Feldman HA, Johnson CC, et al. Outcomes of a field trial to improve children's dietary patterns and physical activity. The Child and Adolescent Trial for Cardiovascular Health. CATCH collaborative group. JAMA. 1996 Mar 13; 275(10): 768-776.  

Nader PR, Sellers DE, Johnson CC, Perry CL, Stone EJ, Cook KC, Bebchuk J, Luepker RV. The effect of adult participation in a school-based family intervention to improve children's diet and physical activity: The Child and Adolescent Trial for Cardiovascular Health. Prev Med. 1996; Jul-Aug: 25(4): 455-464. 

Vandongen R, Jenner DA, Thompson C, Taggart AC, Spickett EE, Burke V, Beilin LJ, Milligan RA, and Dunbar DL. A controlled evaluation of a fitness and nutrition intervention program on cardiovascular health in 10- to 12-year-old children. Prev Med. 1995; 24: 9-22.

Wind M, Bjelland M, Pérez-Rodrigo C, et al. Appreciation and implementation of a school-based intervention are associated with changes in fruit and vegetable intake in 10- to 13-year-old schoolchildren: The Pro Children study. Health Educ Res. 2008; 23(6): 997-1,007.