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School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6 to 18

  1. Maureen Dobbins*,
  2. Heather Husson,
  3. Kara DeCorby,
  4. Rebecca L LaRocca

Editorial Group: Cochrane Metabolic and Endocrine Disorders Group

Published Online: 28 FEB 2013

Assessed as up-to-date: 21 OCT 2011

DOI: 10.1002/14651858.CD007651.pub2


How to Cite

Dobbins M, Husson H, DeCorby K, LaRocca RL. School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6 to 18. Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No.: CD007651. DOI: 10.1002/14651858.CD007651.pub2.

Author Information

  1. McMaster University, School of Nursing, Hamilton, Ontario, Canada

*Maureen Dobbins, School of Nursing, McMaster University, 1200 Main Street West, Rm 3N25G, Hamilton, Ontario, L8N 3Z5, Canada. dobbinsm@mcmaster.ca.

Publication History

  1. Publication Status: New search for studies and content updated (no change to conclusions)
  2. Published Online: 28 FEB 2013

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Characteristics of included studies [ordered by study ID]
Angelopoulos 2009

MethodsDesign: cluster randomized controlled trial
Theoretical framework: Theory of Planned Behavior
Number of intervention groups: 1
Number of control groups: 1
Follow-up: immediately post-intervention


ParticipantsN (intervention): 321
N (control): 325

Age (mean): 10.3 years
Sex: male and female
Ethnicity: Greek


InterventionsCountry: Greece
Setting: school, urban and rural
Provider: classroom teachers
Duration: 12 months
Intervention: 12-month program (January 2005 to January 2006) integrated in the existing school curriculum in combination with physical education (PE) and science and environmental classes, providing the least possible disturbance. Program material included a student's workbook and teacher's manual, which offered activities for use in class in an appendix. The manual covered: self-esteem, body image, nutrition, physical activity, fitness and environmental issues, and materials were used 1 to 2 h per week. Motivational methods and strategies were used to increase knowledge (i.e. discussion, active learning, cues), increase skills and self efficacy (i.e. modeling, guided practice, enactment), achieve better self-monitoring (i.e. problem solving, goal setting), improve attitudes and beliefs (i.e. self re-evaluation, environmental re-evaluation, arguments, modeling, direct experience), and modify social influence (i.e. modeling, mobilizing social support). School teachers trained by the research team delivered the intervention and there was a home component for which parental involvement was required to provide reinforcement
Control: not specified


OutcomesMean systolic blood pressure (mmHg)

Mean diastolic blood pressure (mmHg)

BMI (kg/m2)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskComment: random digits used to develop allocation sequence

Allocation concealment (selection bias)Low riskComment: criterion not applicable because all participants were allocated at 1 point in time following recruitment, so at time of recruitment allocation was not known

Blinding (performance bias and detection bias)
All outcomes
Unclear riskComment: no information given, likely not done

Incomplete outcome data (attrition bias)
All outcomes
High riskComment: cannot determine how many students started the study only know how many finished

Selective reporting (reporting bias)Low riskComment: all outcomes identified a priori were reported on

Confounders controlled?Low riskComment: all relevant confounders were controlled for

Data collection methods valid and reliable?Low riskComment: data collection methods valid and reliable

Araujo-Soares 2009

MethodsDesign: cluster randomized controlled trial
Theoretical framework: Social Cognitive Theory
Number of intervention groups: 1
Number of control groups: 1
Follow-up: 9 months post-intervention


ParticipantsN (intervention): 105

N (control): 90

Age (mean): 12.1 years

Sex: male and female

Ethnicity: unstated


InterventionsCountry: Portugal
Setting: school, unstated if urban or rural
Provider: research worker, psychologist, physical education teacher
Duration: 12 weeks
Intervention: 2 classroom-based physical activity sessions of 90 min each, along with homework, delivered by a trained psychologist, assisted by a sports education teacher. The psychologist received workshop training from the research team. A member of the research team served as supervisor to help prepare the sessions. In the week proceeding both physical activity sessions, adolescents were asked to keep a self-monitoring diary as homework, to keep track of daily physical activities in detail. After the intervention they were encouraged to maintain the diary for 2 more weeks. During sessions, worksheets and a 3-min film were used. At the end of the sessions, each student received a pamphlet reinforcing main topics of the session
Control: not specified


OutcomesDuration of physical activity


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: randomization process not reported

Allocation concealment (selection bias)Low riskComment: criterion not applicable because all participants were allocated at 1 point in time following recruitment, so at time of recruitment allocation was not known

Blinding (performance bias and detection bias)
All outcomes
Unclear riskComment: no information given, likely not done

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: unsure if intention to treat conducted at 9-month follow-up

Selective reporting (reporting bias)Low riskComment: all outcomes identified a priori were reported on

Confounders controlled?High riskComment: not all relevant confounders accounted for

Data collection methods valid and reliable?Low riskComment: data collection tools reported to be valid and reliable

Barbeau 2007

MethodsDesign: randomized controlled trial
Theoretical framework: unstated
Number of intervention groups: 1
Number of control groups: 1
Follow-up: immediately following intervention


ParticipantsN (intervention): 118
N (control): 83

Age (mean): 9.5 years
Sex: female
Ethnicity: African-American


InterventionsCountry: US

Setting: school, unstated whether urban or rural
Provider: classroom teachers and teaching assistants
Duration: 10 months
Intervention: 10-month after-school physical activity (PA) program on body composition and cardiovascular fitness in young black girls, offered every school day during the school year with transportation (i.e. school bus service) provided to encourage participation. 30 min of homework time while subjects received a free, healthy snack, and 80 min of PA. Snacks were individually packaged, and every day offered something salty (e.g. crackers and cheese), something sweet (e.g. low-fat cookies), or a fruit or vegetable. Subjects chose 1 snack with the option of another if they wished. The PA included 25 min of skill development, 35 min of moderate to vigorous physical activity (MVPA), with 20 min of toning and stretching. Subjects wore Polar Accurex Plus HR monitors (Port Washington, NY) every day and were instructed to maintain their heart rate above 150 beats/min during the MVPA. MVPA activities included games such as basketball, tag, softball, relay races, etc., modified for activity of all subjects through the 35-min period. Subjects received small weekly prizes for behavior and attitude, and for having no more than 1 unexcused absence. A student of the month in each school received a slightly larger prize with the prizes intended to reward good behavior, participation, and effort. Parents were called when students had 2 consecutive unexcused absences, with reasons discussed and parents encouraged to send their daughter back to the program. Teachers mostly worked the intervention in their own school and in some cases were assigned to work in a different school. Teachers received formal training with background information on childhood obesity, PA, and cardiovascular risk factors, study goals, and the study protocol and types of activities appropriate for each segment of the intervention. Role playing was a large component of the training; teachers were asked to prepare a lesson plan for 1 day and did a shortened simulation of it, so feedback could be provided. A Manual of Procedures for each school included all information needed to implement the intervention, including several potential activities. Teachers hired after the training received one-on-one training on the theoretical aspects and observed several sessions before their own implementation
Control: not specified


OutcomesDuration of physical activity

BMI (kg/m2)
VO2ax (mL/kg/minute)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: randomization process not reported

Allocation concealment (selection bias)Low riskComment: allocation occurred after testing, therefore concealed. It was not known or determined at time of entry to study which group the next participant would go

Blinding (performance bias and detection bias)
All outcomes
Unclear riskComment: no information given, likely not done

Incomplete outcome data (attrition bias)
All outcomes
High riskComment: incomplete outcome data not addressed

Selective reporting (reporting bias)Low riskComment: all outcomes identified a priori were reported on

Confounders controlled?High riskComment: important variables like socioeconomic status not assessed or controlled for

Data collection methods valid and reliable?High riskComment: reliability and validity of most outcomes not stated

Bayne-Smith 2004

MethodsDesign: randomized controlled trial
Theoretical framework: unstated
Number of intervention groups: 1
Number of control groups: 1
Follow-up: immediately post-intervention


ParticipantsN (intervention): 310
N (control): 132

Age (mean): 16.1 years
Sex: female
Ethnicity: mixed


InterventionsCountry: US
Setting: urban
Provider: unstated
Duration: 12 weeks
Intervention: the PATH curriculum was taught as a personal wellness course that integrated vigorous exercise, health and nutrition education, and behavior modification. PATH student manuals were developed to provide students with information about the anatomy and physiology of the heart, cardiovascular risk factors, the heart disease process, proper exercise and nutrition, stress management, cigarette smoking avoidance and cessation techniques, and strategies for modifying high-risk health behaviors. PATH teacher manuals were provided to physical education (PE) teachers containing instructions for teaching the program curriculum and assessing outcomes. PE teachers using the PATH curriculum received in-service training from the investigation team before and during the intervention. The PATH program consisted of 30-min classes conducted 5 days per week for 12 weeks. Individual classes began with a 5- to 10-min lecture and discussion featuring a topic on cardiovascular health and fitness and suggestions for modifying health behaviors. In addition, students frequently were given homework assignments designed to enhance or clarify lecture material through use of the PATH manuals. The lecture and discussion were followed by 20 to 25 min of vigorous physical activity in the form of either resistance exercise to improve muscular strength and endurance or aerobic exercise to improve cardiovascular fitness. Students alternated resistance and aerobic training each day. Resistance exercise consisted of a vigorous program of circuit weight training at a variety of isotonic and isokinetic exercise stations. Students performed 90- to 120-second bouts of weight lifting at 50% to 70% of the 1-repetition maximum (the maximum resistance that can be lifted 1 time). Aerobic training included a variety of vigorous exercises, such as stationary bicycling, stair stepping, rope jumping, fast walking, jogging, step aerobics, and aerobic dance. Students were instructed to exercise continuously at 70% to 85% of their age-predicted maximum heart rate. Students were taught how to self-monitor heart rates during or immediately upon cessation of exercise by palpation of the radial or carotid pulse
Control: the frequency and duration of traditional PE classes were identical to those of PATH classes. Since PE classes did not have lecture and discussion, they had approximately 5 min more physical activity per class than PATH classes


OutcomesDuration of physical activity
Mean systolic blood pressure (mmHg)
Mean diastolic blood pressure (mmHg)
Mean blood cholesterol level (mg/dL)
BMI (kg/m2)
VO2max (mL/kg/minute)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: randomization process not reported

Allocation concealment (selection bias)Low riskComment: criterion not applicable because all participants were allocated at 1 point in time following recruitment, so at time of recruitment allocation was not known

Blinding (performance bias and detection bias)
All outcomes
Unclear riskComment: no information given, likely not done

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskComment: incomplete outcome data not addressed

Selective reporting (reporting bias)Low riskComment: all outcomes identified a priori were reported on

Confounders controlled?High riskComment: while there were no significant differences in most confounders, there were a few small differences which were not accounted for

Data collection methods valid and reliable?High riskComment: reliability and validity of most outcomes not stated

Burke 1998

MethodsDesign: cluster randomized controlled trial
Theoretical framework: unstated
Number of intervention groups: 5
Number of control groups: 1
Follow-up: 6 months post-intervention


ParticipantsN (total): 720

Age (mean): 11 years
Sex: male and female
Ethnicity: unstated


InterventionsCountry: Australia
Setting: school, home, unstated if urban or rural
Provider: teachers, research staff, parents
Duration: 9 months
Intervention 1: standard physical activity (PA) and nutrition program (WASPAN) in 6 schools, which consisted of classroom lessons to establish a rationale, plus 20-min fitness sessions daily by means of small group activities that allowed for individual fitness levels and provided a range of options by means of progression through graded activities. Four fitness sessions per week were considered a realistic expectation. The nutrition program aimed to improve children's diets by prompting families to review their diets; reducing consumption of fat, sugar, and salt; increasing fiber intake; and creating links between home and school for health promotion. The nutrition program is built around 4 comic books in which 2 space creatures must discover the dietary habits of humans. It includes a Teachers' Handbook, Home-based Mission Booklet, Class Activities Booklet, Incentives, and a Recipe Booklet that presents recipes written for children by children. Home-based Missions and Class Activities are combined in activities such as planning a week's grocery shopping on the basis of advertised prices and in learning strategies to resist peer pressure. The Incentives Booklet includes a progress chart, stickers, and a completion certificate to encourage participation from children and parents. Duration of nutrition class activities aimed for 1 hour per week.
Intervention 2: standard WASPAN program plus a PA-enrichment program for higher-risk children in 7 schools, which consisted of incorporating the teacher-parent-student triad and allowed for PA needs and preferences to be met outside the setting of the whole class. Children kept regular, but not continuous, 7-day PA diaries, which were used by teachers to identify preferred activities and ways these might be increased in duration or frequency. Teachers and students worked together to establish goals and decide on how these might be attained. Parents were asked to monitor completion of the diaries and to encourage increased levels of PA
Control: no program in 5 schools


OutcomesTelevision viewing (minutes spent watching television)
Mean systolic blood pressure (mmHg)
Mean diastolic blood pressure (mmHg)
BMI (kg/m2)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: randomization process not reported

Allocation concealment (selection bias)Low riskComment: criterion not applicable because all participants were allocated at 1 point in time following recruitment, so at time of recruitment allocation was not known

Blinding (performance bias and detection bias)
All outcomes
Unclear riskComment: no information given, likely not done

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: outcome data complete

Selective reporting (reporting bias)Low riskComment: all outcomes identified a priori were reported on

Confounders controlled?Low riskComment: all relevant confounders were accounted for

Data collection methods valid and reliable?High riskComment: reliability and validity of most outcomes not stated

Bush 1989

MethodsDesign: cluster randomized controlled trial
Theoretical framework: PRECEDE, Social Learning Theory
Number of intervention groups: 2
Number of control groups: 1
Follow-up: immediately post-intervention


ParticipantsN: 431

Age (mean): 10.5 years
Sex: male and female
Ethnicity: African-American


InterventionsCountry: US
Setting: school, home, community, physician office, mix of urban and rural
Provider: teachers, research staff, volunteers, advisory board
Duration: 4 years
Intervention 1: 'Know Your Body' curriculum. Focus on nutrition, fitness, and the prevention of cigarette smoking. Curriculum to motivate students to attain and maintain life styles that will that will reduce the students' risk of developing heart disease and cancer. Includes a personalized health screening with each student receiving results on a 'health passport'. Parents are involved through several mechanisms, they are mailed 2 copies of their children's screening results, 1 copy to keep and 1 for the child's physician, copies of a quarterly 'Know Your Body' newsletter, and the program is introduced by staff at parent-teacher association meetings
Intervention 2: received the same intervention as Intervention 1, but only their parents received the results of their cholesterol tests and the students were not provided with the results to enter on their 'health passports' with other screening results
Control: did not receive the 'Know Your Body' curriculum and were not provided with any of their screening results. Only parents of control subjects received the screening results


OutcomesMean systolic blood pressure (mmHg)
Mean diastolic blood pressure (mmHg)
Mean blood cholesterol level (mg/dL)
BMI (kg/m2)
Pulse rate (beats/minute)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: no description of the randomization process given

Allocation concealment (selection bias)Low riskComment: criterion not applicable because all participants were allocated at 1 point in time following recruitment, so at time of recruitment allocation was not known

Blinding (performance bias and detection bias)
All outcomes
Unclear riskComment: no information given, likely not done

Incomplete outcome data (attrition bias)
All outcomes
High riskQuote: "Only 431 (41.4% of participants were rescreened 2 years after forming the cohort. Students who had moved from a control to an intervention school or vice versa were dropped from the analysis" (Bush 1989, p472)

Selective reporting (reporting bias)Low riskComment: all outcomes identified a priori were reported on

Confounders controlled?Low riskQuote: Multiple regression analysis was used to adjust the observed difference in scores between the control and intervention groups for these confounders" (Bush 1989, p472)

Data collection methods valid and reliable?Unclear riskComment: insufficient data to determine reliability and validity

Colin-Ramirez 2010

MethodsDesign: cluster randomized controlled trial

Theoretical framework: not stated

Number of intervention groups: 1

Number of control groups: 1

Follow-up: immediately post-intervention


ParticipantsN (intervention): 245

N (control): 253

Age (mean): 9.4 years

Sex: male and female

Ethnicity: Mexican


InterventionsCountry: Mexico

Setting: grade school, urban

Provider: mixed – a) health teams including a physician, dentist, psychologist, nurse, social worker, b) classroom teachers, physical education (PE) teachers

Duration: 2 academic years

Intervention: RESCATE program, included physical activity and nutritional components. Physical activity was addressed at 3 levels: individual, school, and family. At the 'individual level', classroom lessons and exercise breaks were implemented. The educational component in the classroom involved weekly 30-min lessons that emphasized the importance of physical activity, delivered by trained health teams (a physician, a dentist, a psychologist, a nurse and a social worker). Exercise breaks in the classroom lasting 2–10 min were designed to increase energy output and promote physical activity in the classroom. The TAKE 10 program of classroom physical activity was adapted for this purpose and included in the procedure manual for the classroom teachers who led the exercises. 'School-level' intervention included PE classes. The aim of this component of the program was to increase the length of time that children participated in moderate to strenuous exercise during PE classes. For 30 min twice a week, there was a substitution of regular exercise during PE classes for new ones that required moderate to vigorous energy output. PE teachers received a manual with the appropriate exercise options. 'Family level' involved family members in support and reinforcement of classroom lessons. Each child received a book of activities to take home with exercises that corresponded to the lessons at school and was implemented with collaboration with his parents. In addition, the parents received recommendations for achieving a more active lifestyle. Recommendations included decreasing time spent on sedentary activities such as watching television, using a computer or playing video games
Control: no physical activity/nutrition program


OutcomesPhysical activity rates (% of sample physically active)

Television viewing (minutes spent watching television)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: no description of the randomization process given

Allocation concealment (selection bias)Low riskComment: criterion not applicable because all schools were allocated at 1 point in time following recruitment, so at time of recruitment allocation was not known

Blinding (performance bias and detection bias)
All outcomes
High riskComment: data collected through self report from participants

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: 80% participation rate, no details/reasons given for attrition

Selective reporting (reporting bias)Unclear riskComment: no information given, likely not done

Confounders controlled?High riskComment: confounders not addressed

Data collection methods valid and reliable?Unclear riskComment: authors state reliability and validity of questionnaire has been reported previously and validated for a Spanish population, but no details provided other than a citation

Dishman 2004

MethodsDesign: cluster randomized controlled trial
Theoretical framework: Social Cognitive Theory
Number of intervention groups: 1
Number of control groups: 1
Followup: immediately post-intervention


ParticipantsN: 2111

Age (mean): 13.6 years
Sex: female
Ethnicity: White and African American


InterventionsCountry: US
Setting: school, community, mixed urban and rural
Provider: classroom teachers
Duration: 1 year
Intervention: Lifestyle Education for Activity Program (LEAP), a comprehensive school-based intervention that emphasized changes in instruction and the school environment. Designed to increase physical activity in high-school girls by creating a school environment that supported the unique physical activity needs and interests of adolescent girls. Aimed to increase girls' self-efficacy for physical activity, via physical education (PE), school environment, health education, school health services, faculty or staff health promotion, and parent and community involvement. The intervention staff assisted teachers to develop curricula designed to help adolescent girls enhance physical activity self-efficacy through successful experiences with physical activity both inside and outside of school and develop physical and behavioral skills necessary to adopt a physically active lifestyle during the teenage years and to maintain it through adulthood. Teachers at each school developed behavioral skill instructional units that emphasized the acquisition and practice of self-regulatory behaviors (e.g. goal setting, time management, identifying and overcoming barriers, and self-reinforcement); the units were implemented in health education, biology, family and consumer science, or PE, depending on how each school provided health education. The PE component developed motor skills in a variety of physical activities that were popular with high-school girls including aerobics, weight training, dance, and self-defence using approaches that favored small groups and cooperative and successful learning experiences. In addition to facilitating noncompetitive mastery of skills, the instruction also used modeling of success, encouragement, and moderately intense exercise directed toward enhancing self-efficacy
Control: standard PE as part of school curriculum


OutcomesPhysical activity rates (% of sample physically active)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: randomization process not reported

Allocation concealment (selection bias)Low riskComment: criterion not applicable because all participants were allocated at 1 point in time following recruitment, so at time of recruitment allocation was not known

Blinding (performance bias and detection bias)
All outcomes
Unclear riskComment: no information given, likely not done

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: missing data for physical activity at follow-up were imputed

Selective reporting (reporting bias)Low riskComment: all outcomes identified a priori were reported on

Confounders controlled?Low riskComment: relevant confounders were controlled including age, ethnicity, body mass index

Data collection methods valid and reliable?Low riskComment: data collection tools reported to be valid and reliable

Donnelly 2009

MethodsDesign: cluster randomized controlled trial
Theoretical framework: unstated
Number of intervention groups: 1
Number of control groups: 1
Follow-up: immediately post-intervention


ParticipantsN (intervention): 792

N (control): 698

Age (mean): 8.2 years

Sex: male and female
Ethnicity: White


InterventionsCountry: US
Setting: school, urban
Provider: classroom teachers
Duration: 3 years
Intervention: Physical Activity Across the Curriculum (PAAC), provided training for classroom teachers (6 hour in-service session) to deliver existing academic lessons taught thorough physical activity, using examples from TAKE 10!, a program of the International Life Sciences Institute Research Foundation/Center for Health Promotion. 90 min/week of moderate to vigorous physically active academic lessons were delivered intermittently throughout the school day
Control: regular classroom instruction without physically active lessons


OutcomesDuration of physical activity

BMI (kg/m2)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: no description of the randomization process given

Allocation concealment (selection bias)Low riskComment: criterion not applicable because all participants were allocated at 1 point in time following recruitment, so at time of recruitment allocation was not known

Blinding (performance bias and detection bias)
All outcomes
Low riskComment: blinding was done where possible - research assistants were blinded to condition for measurement of the primary and secondary outcomes and for data entry

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: there was 2.5% missing data, not likely to affect results

Selective reporting (reporting bias)Low riskComment: all outcomes identified a priori were reported on

Confounders controlled?Low riskComment: all relevant confounders taken into account

Data collection methods valid and reliable?Low riskComment: data collection tools reported to be valid and reliable

Dorgo 2009

MethodsDesign: cluster randomized controlled trial
Theoretical framework: unstated
Number of intervention groups: 2
Number of control groups: 1
Follow-up: immediately post-intervention


ParticipantsN (intervention): 93

N (control): 129

Age (mean): 15.9 years
Sex: male and female
Ethnicity: unstated


InterventionsCountry: US
Setting: school, unstated if urban or rural
Provider: research worker, PE teachers
Duration: 18 weeks
Intervention 1: physical education (PE) program that used manual resistance training (MRT) in every session. 80-min class sessions 3 times per week, plus a 10- to 15-min warm-up segment with light cardiovascular activities and dynamic stretching followed by the MRT-specific segment of approximately 20 to 30 min conducted and supervised by trained research assistants
Intervention 2: MRT PE program plus a cardiovascular endurance training segment in every session. 80-min class sessions, 3 times per week, plus a 20- to 30-min MRT segment conducted and supervised by trained research assistants, with an additional 20- to 30-min period devoted to cardiovascular endurance training. Cardiovascular activities included walking, jogging, step aerobics, and aerobic kickboxing
Control: a regular PE program that followed the usual school curriculum. 80-min class sessions 3 times per week. PE classes focused on skill development for various individual physical activities (i.e. bowling, badminton, tennis, table tennis, golf, various track and field events) and team physical activities (i.e. soccer, basketball, softball/baseball, volleyball, floor hockey), as well as participation in leisure activities (i.e., hiking) and sport tournaments


OutcomesBMI (kg/m2)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: randomization process not reported

Allocation concealment (selection bias)Low riskComment: criterion not applicable because all participants were allocated at 1 point in time following recruitment, so at time of recruitment allocation was not known

Blinding (performance bias and detection bias)
All outcomes
Unclear riskComment: no information given, likely not done

Incomplete outcome data (attrition bias)
All outcomes
High riskQuote: "24 subjects failed to attend the post-test data collection and were not included in the data analyses" (Dorgo, 2009, p2291).

Selective reporting (reporting bias)Low riskComment: all outcomes identified a priori were reported on

Confounders controlled?High riskComment: not all relevant confounders taken into account

Data collection methods valid and reliable?Low riskComment: data collection tools reported to be valid and reliable

Ewart 1998

MethodsDesign: randomized controlled trial
Theoretical framework: unstated
Number of intervention groups: 1
Number of control groups: 1
Follow-up: immediately post-intervention


ParticipantsN (intervention): 44
N (control): 44

Age: grade 9 (mean age not provided)
Sex: females
Ethnicity: White, African American


InterventionsCountry: US
Setting: school, home, urban
Provider: research staff
Duration: 18 weeks
Intervention: 50-min 'Project Heart' aerobic exercise classes including didactic instruction
Control: 50-min standard physical education classes


OutcomesDuration of physical activity
Mean systolic blood pressure (mmHg)
Mean diastolic blood pressure (mmHg)
BMI (kg/m2)
Pulse rate (beats/minute)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: randomization process not reported

Allocation concealment (selection bias)Low riskComment: criterion not applicable because all participants were allocated at 1 point in time following recruitment, so at time of recruitment allocation was not known

Blinding (performance bias and detection bias)
All outcomes
Low riskComment: technicians taking measurements were reported not aware of girls' experimental status

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: outcome data complete

Selective reporting (reporting bias)Low riskComment: all outcomes identified a priori were reported on

Confounders controlled?Unclear riskComment: authors state no differences in behavioral and familial factors were observed, but do not indicate which factors these were

Data collection methods valid and reliable?Unclear riskComment: reliability and validity of data collection tools was not mentioned

Gentile 2009

MethodsDesign: cluster randomized controlled trial
Theoretical framework: Social Ecological Model
Number of intervention groups: 1
Number of control groups: 1
Follow-up: 6 months post-intervention


ParticipantsN: 1029

Age (mean): 9.6 years
Sex: male and female
Ethnicity: White


InterventionsCountry: US
Setting: community, home, school, unstated if urban or rural
Provider: research worker, lay person, volunteer, teachers
Duration: 8 months
Intervention: 'Switch' program, promoted healthy active lifestyles by encouraging students to 'Switch what you Do, Chew, and View', including: be active for 60 min or more per day, limit total screen time to 2 hours or fewer per day, and to eat 5 fruits/vegetables or more per day. Community component: promotion of awareness of healthy lifestyles and the prevention of childhood obesity included: paid advertising (e.g. billboards) and unpaid media emphasizing the key messages. School component: teachers were provided with materials and ways to integrate key concepts into their existing curricula. Family component: provided parents (and children) with materials and resources to facilitate the adoption of the healthy target behaviors. Monthly packets containing behavioral tools were provided to assist parents and children in modifying their behaviors
Control: no intentional exposure to the Switch program. May have been exposed to the community component of the intervention. Did not receive any school materials. Did not receive materials/resources, other than surveys


OutcomesTelevision viewing (minutes spent watching television)

BMI (kg/m2)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: randomization process not reported

Allocation concealment (selection bias)Low riskComment: criterion not applicable because all participants were allocated at 1 point in time following recruitment, so at time of recruitment allocation was not known

Blinding (performance bias and detection bias)
All outcomes
Unclear riskComment: no information given, likely not done

Incomplete outcome data (attrition bias)
All outcomes
High riskComment: incomplete outcome data was not adequately addressed

Selective reporting (reporting bias)Low riskComment: all outcomes identified a priori were reported on

Confounders controlled?Low riskComment: all relevant confounders taken into account

Data collection methods valid and reliable?Low riskComment: data collection tools reported to be valid and reliable although methods could have been stronger for body mass index

Haerens 2006

MethodsDesign: cluster randomized controlled trial
Theoretical framework: Transtheoretical Model
Number of intervention groups: 2
Number of control groups: 1
Follow-up: immediately post-intervention


ParticipantsN: 2434

Age (mean): 13.1 years
Sex: male and female
Ethnicity: White


InterventionsCountry: Belgium
Setting: school, urban
Provider: teachers
Duration: 2 years
Intervention 1: physical activity (PA) and nutrition intervention. The PA intervention focused on increasing levels of moderate to vigorous physical activity (MVPA) to at least 60 min per day. Schools received an intervention box with sports materials such as ropes, balls, and beach ball sets and were encouraged to create more noncompetitive opportunities to be physically active during breaks, at noon or during after-school hours, and to vary content of PAs offered. Children received a physical fitness test at the beginning of the second intervention year where all children had to cycle for 10 min on a computerized cycle ergometer, then were given information on their fitness levels and possible ways to improve it. The computer-tailored portion of the intervention was completed once each school year during 1 class hour. Children completed PA questions on a computer screen, which was immediately followed by tailored feedback on the screen (e.g. normative feedback regarding activity levels, PA recommendations). The nutrition intervention focused on 3 behavioral changes: (i) increasing fruit consumption 2+ pieces/day, (ii) reducing soft drink consumption and increasing water consumption, and, (iii) reducing fat intake. Schools were asked to sell fruit at very low prices or for free at least once a week, to offer fruit for dessert at lunch, and to offer free water via drinking fountains
Intervention 2: PA and nutrition intervention (same as Intervention 1 group) plus parental involvement. Schools invited parents for an interactive meeting on healthy food, PA and the relationship with overweight and health. Three times per year, information on healthy food and PA was published in school papers and newsletters for parents, and parents received a free CD with the adult computer-tailored intervention for fat intake and PA (same as the children's computer tailored intervention) for use at home, and asked to discuss results with their child and to give their child support to create a healthier lifestyle
Control: no PA and nutrition intervention


OutcomesDuration of PA
Television viewing (minutes spent watching television)
BMI (kg/m2)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: randomization process not reported

Allocation concealment (selection bias)Low riskComment: criterion not applicable because all participants were allocated at 1 point in time following recruitment, so at time of recruitment allocation was not known

Blinding (performance bias and detection bias)
All outcomes
Unclear riskComment: no information given, likely not done

Incomplete outcome data (attrition bias)
All outcomes
High riskComment: incomplete outcome data was not adequately addressed

Selective reporting (reporting bias)Low riskComment: all outcomes identified a priori were reported on

Confounders controlled?Low riskComment: all relevant confounders taken into account

Data collection methods valid and reliable?Low riskComment: data collection tools reported to be valid and reliable

Haerens 2009

MethodsDesign: cluster randomized controlled trial
Theoretical framework: Transtheoretical Model
Number of intervention groups: 1
Number of control groups: 1
Follow-up: 3 months post-intervention


ParticipantsN (intervention 1): 433
N (control): 448

Age (mean): 14.6 years
Sex: male and female
Ethnicity: : White


InterventionsCountry: Belgium
Setting: school, urban
Provider: N/A (computer-based intervention)
Duration: 3 months
Intervention: computer tailored physical activity (PA) program consisting of 3 parts: (a) an introduction page, (b) a diagnostic tool, and (c) advice. The questionnaire used in the diagnostic tool could be filled out on the computer screen and consisted of a demographic questionnaire, a PA questionnaire, and a questionnaire on psychosocial determinants. After questionnaires were completed, feedback was selected out of a database with messages for each possible combination of answers (e.g. normative feedback that related students' PA levels to the PA guidelines).
Control: 1.5pg advice including information on the benefits of PA, public health recommendations, differences between moderate and vigorous intensity activities, and tips on how to become more active. The information was a selection of the most essential information in the tailored advice, but not tailored to each individual.


OutcomesDuration of PA


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: no description of the randomization process given

Allocation concealment (selection bias)Low riskComment: criterion not applicable because all participants were allocated at 1 point in time following recruitment, so at time of recruitment allocation was not known

Blinding (performance bias and detection bias)
All outcomes
Unclear riskComment: no information given, likely not done

Incomplete outcome data (attrition bias)
All outcomes
High riskComment: incomplete outcome data was not adequately addressed

Selective reporting (reporting bias)Low riskComment: all outcomes identified a priori were reported on

Confounders controlled?Low riskComment: all relevant confounders taken into account

Data collection methods valid and reliable?Low riskComment: data collection tools reported to be valid and reliable

Jones 2008

MethodsDesign: cluster randomized controlled trial
Theoretical framework: Transtheoretical Model, Social Cognitive Theory
Number of intervention groups: 1
Number of control groups: 1
Follow-up: immediately post-intervention


ParticipantsN (intervention): 291
N (control): 315

Age (mean): 11.6 years
Sex: female
Ethnicity: White


InterventionsCountry: US
Setting: school, unstated if urban or rural
Provider: peer, physical education (PE) teachers and other teachers
Duration: 1.5 school years
Intervention: the IMPACT intervention included 3 major components: 1) a health curriculum for grades 6 and 7 (classroom lessons and behavioral journalism); 2) a PE program; and 3) a school food service component that emphasized calcium-rich food choices). Peer-based behavioral journalism involved the use of media (e.g. school-based newsletter with role model stories). The intervention used a 6th grade health curriculum, including 16 sessions that were implemented during PE classes, 3 times per week. The lessons in this curriculum promoted increased consumption of calcium-rich foods and increased weight-bearing physical activities. The curriculum also contained behaviorally based and active lessons adapted to the PE environment. Science-based lessons were administered during 7th grade science classes. The PE component of the program (i.e. "IMPACTivities") was implemented in the 6th and 7th grades during PE and athletics classes. The classes contained an initial 10-min warm-up (i.e. high-impact activities - rope-jumping, circuit training, and box-step activities)
Control: the control group participated in the usual health program


OutcomesDuration of physical activity

Television viewing (minutes spent watching television)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: a computer-generated random numbers table was used for the randomization process

Allocation concealment (selection bias)Low riskComment: criterion not applicable because all participants were allocated at 1 point in time following recruitment, so at time of recruitment allocation was not known

Blinding (performance bias and detection bias)
All outcomes
High riskComment: no information given, likely not done

Incomplete outcome data (attrition bias)
All outcomes
High riskComment: incomplete outcome data was not adequately addressed

Selective reporting (reporting bias)Low riskComment: all outcomes identified a priori were reported on

Confounders controlled?Low riskComment: all relevant confounders taken into account

Data collection methods valid and reliable?Low riskComment: data collection tools reported to be valid and reliable

Kipping 2008

MethodsDesign: cluster randomized controlled trial
Theoretical framework: unstated
Number of intervention groups: 1
Number of control groups: 1
Follow-up: immediately post-intervention


ParticipantsN (intervention): 304

N (control): 300

Age (mean): 9.4 years
Sex: male and female
Ethnicity: unstated


InterventionsCountry: UK

Setting: school, unstated whether urban or rural
Provider: classroom teachers
Duration: 5 months
Intervention: the intervention included 16 lessons on healthy eating, increasing physical activity, and reducing television viewing (adapted and abbreviated form of the 'Eat Well Keep Moving' program). The 10 teachers providing the intervention were trained by 2 other teachers familiar with the program and provided with further training/study materials (i.e. lesson plans for 9 physical activity lessons, 6 nutrition lessons and 1 lesson about screen viewing). In the physical activity lessons, the children played games based on the food groups using photographs of food that reinforced the theory taught in the nutrition lessons
Control: the control school were provided with the teacher training and materials following study completion


OutcomesTelevision viewing (minutes spent watching television)

Body mass index (kg/m2)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "random allocation to intervention or control school was concealed and done by one of the authors" (Kipping 2008, p469)

Comment: not stated exactly how the randomization sequence was generated by this author

Allocation concealment (selection bias)Low riskQuote: "random allocation to intervention or control school was concealed and done by one of the authors (DAL). The investigator who did the random allocation had no prior knowledge of characteristics of any of the schools" (Kipping 2008, p471)

Blinding (performance bias and detection bias)
All outcomes
Low riskQuote: "school health assistants, who were blinded to the allocation of schools, took height and weight measurements" (Kipping 2008, p470)

Comment: there was some initiative taken to blind although incomplete blinding could still introduce bias

Incomplete outcome data (attrition bias)
All outcomes
High riskQuote: "all analyses were undertaken using an intention to treat protocol, regardless of the number of lessons taught in intervention schools. However, we only included in the analyses those children with complete data at baseline and outcome" (Kipping 2008, p470)

Comment: therefore, intention to treat not done

Selective reporting (reporting bias)Low riskComment: all outcomes identified a priori were reported on

Confounders controlled?Low riskComment: all relevant confounders were controlled for

Data collection methods valid and reliable?High riskComment: the physical activity instrument was not shown to be valid or reliable although other measurements were

Kriemler 2010

MethodsDesign: cluster randomized controlled trial
Theoretical framework: Socio-ecological Conceptual Model
Number of intervention groups: 1
Number of control groups: 1
Follow-up: immediately post-intervention


ParticipantsN (intervention): 297
N (control): 205

Age (mean): 6.9 years

Sex: male and female
Ethnicity: : White


InterventionsCountry: Switzerland
Setting: school, urban and rural
Provider: physical education (PE) and classroom teachers
Duration: 1 school year (9 months)
Intervention: all children participated in 3 mandatory, 45-min PE lessons per week; the intervention group participated in 2 additional 45-min PE lessons per week. The mandatory PE lessons were given by the usual classroom teachers according to the specified curriculum; the additional lessons were taught mostly outdoors by PE teachers. Three to five 2 to 5-min activity breaks (motor skill tasks - jumping or balancing on 1 leg, power games, coordinative tasks) were provided each day during academic lessons. The children also received daily physical activity homework (10 min' worth), prepared by the PE teachers, including: aerobic, strength, or motor skill tasks (e.g. brushing their teeth while standing on 1 leg, hopping up and down the stairs, rope jumping, or comparable activities)
Control: the control group continued to participate in the usual, mandatory PE lessons (45-min, 3 times per week); they were not informed that an intervention group existed in the other schools (teachers in the control group were aware but did not know the content of the intervention)


OutcomesDuration of physical activity

Mean systolic blood pressure (mmHg)

Mean diastolic blood pressure (mmHg)

BMI (kg/m2)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskComment: randomized using a random numbers table

Allocation concealment (selection bias)Low riskComment: criterion not applicable because all participants were allocated at 1 point in time following recruitment, so at time of recruitment allocation was not known

Blinding (performance bias and detection bias)
All outcomes
High riskQuote: "due to the immense personnel used to perform all assessments, only a part of the researchers were blinded to group allocation. Blinded measurements included height and weight assessment, bioelectrical impedance, dual energy x-ray absorptiometry, and some of the fitness tests" (Kriemler 2010, p2)

Comment: did not fully implement blinding

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: intention-to-treat principle employed

Selective reporting (reporting bias)Low riskComment: all outcomes identified a priori were reported on

Confounders controlled?Low riskComment: relevant confounders taken into account

Data collection methods valid and reliable?Low riskComment: data collection tools reported to be valid and reliable

Li 2010

MethodsDesign: cluster randomized controlled trial

Theoretical framework: not stated

Number of intervention groups: 1

Number of control groups: 1

Follow-up: 1 year post-intervention


ParticipantsN (intervention): 2092

N (control): 2028

Age (mean): mean 9.4

Sex: mixed

Ethnicity: Chinese


InterventionsCountry: China

Setting: school

Provider: classroom teachers

Duration: 1 academic year

Intervention: The Happy 10 program (based on the principle of TAKE10! - http://www.take10.net) included 2 daily 10-min physical activity sessions during the break between classes. Teaching materials provided included: activity cards (each activity card introduced 1 exercise and explained how to perform it); video demonstrations (showing students from the pilot study performing the activities; teachers could either demonstrate the activity or show it on a video); and tracking posters and stickers (used to illustrate the progress of each class). Teachers (i.e. classroom tutors, health educators, or both) attended a half-day training session (conducted by the staff of the National Institute for Nutrition and Food Safety, China CDC) to learn how to integrate the program into the school curriculum, and how to perform the activities. The training also included information about childhood obesity, risk factors, health consequences, and prevention. Activities (taken from TAKE 10! Program) included: "invisible jump rope"; "copy cat"; "all about you"; "stories on the move!"; and "stories in space". Students, teachers, and parents were encouraged to develop new activity models along with program staff (and included: "story in zoo"; "story in farm"; "who is wearing yellow today"; "time like a colt"; "happy and health"; and "little frog"). All activities were of moderate to vigorous intensities. Each 10-min session included: 1) the teacher or student selected an activity card(s) - 1 to 3 activities were performed at each session; 2) several children were chosen to model the exercise(s) in the front of the classroom with the other students following along; 3) a cool-down period following the activities; and 4) the students were taught a health message
Control: no intervention took place


OutcomesBody mass index (kg/m2)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: no description of the randomization process given

Allocation concealment (selection bias)Low riskComment: criterion not applicable because all participants were allocated at 1 point in time following recruitment, so at time of recruitment allocation was not known

Blinding (performance bias and detection bias)
All outcomes
Low riskComment: outcome assessors blinded

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: approximately 10% of intervention and control groups did not provide follow-up data (either moved away or absent on day outcomes were measured)

Selective reporting (reporting bias)Unclear riskComment: no Information given, likely not done

Confounders controlled?High riskComment: did not take any confounders into account

Data collection methods valid and reliable?Unclear riskComment: while blinded outcome assessors measured height and weight in an objective way, reliability across outcome assessors was not reported. Validity not addressed in article

Lubans 2009

MethodsDesign: cluster randomized controlled trial
Theoretical framework: Social Cognitive Theory
Number of intervention groups: 1
Number of control groups: 1
Follow-up: immediately post-intervention


ParticipantsN (intervention): 53
N (control): 53

Age (mean): 14.1 years
Sex: male and female
Ethnicity: unstated


InterventionsCountry: Australia
Setting: school, home, unstated whether urban or rural
Provider: teachers
Duration: unstated
Intervention: the intervention group (Program X intervention, based on the LEAF pilot study) included the same school sport program (as the control), however, with the following additions/alterations: 1) enhanced school sport program, delivered once a week for 10 weeks, focusing on lifetime physical activities that can be continued into adulthood (e.g. aerobics, weight training); 2) information sessions and interactive summary lecture focusing on physical activity and healthy eating; 3) pedometers for physical activity monitoring over the 6-month intervention; 4) physical activity and nutrition handbooks and monthly information newsletters for parents (designed to educate parents on strategies to support the health behaviors taught to their children in Program X); and 5) social support for physical activity and dietary behavior change using e-mail. Teachers introduced 1 of 10 physical activity and nutrition messages (selected because they represent the behaviors commonly associated with lower levels of disease risk and maintaining a healthy weight) at the beginning of each school sport session and delivered an activity reinforcing the message. These messages included: 1) Keep track of your physical activity (using goals/diary); 2) every step counts; 3) reduce your time spent watching television, using the computer, and playing electronic games immediately after school; 4) be active with friends and family; 5) identify excuses for not being active; 6) keep track of fruit and vegetable intake (using goals/diary); 7) aim for 2 pieces of fruit and 5 servings of vegetables each day; 8) drink more water and swap sugary drinks for diet drinks; 9) reduce your portion sizes and eat at the dinner table; and 10) reduce your junk food snacks. A member of the research team delivered an interactive lecture summarizing the 10 messages following the 10-week school sport component of the study.
Control: the control group attended a 10-week school sport program and were given instructions (exercise program booklet) on how to complete the school sport sessions. They were not given any of the 'Program X messages' or additional materials or strategies to support behavior change or nutrition behaviors


OutcomesDuration of physical activity

Television viewing (minutes spent watching television)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: although an envelope was used to attain concealment, having an envelope with the assignment does not tell us how authors generated the randomization sequence

Allocation concealment (selection bias)Low riskQuote: "a randomization envelope was prepared by a member of the research team and schools were assigned to one of two treatment conditions" (Lubans 2009, p177)

Comment: concealment was attained

Blinding (performance bias and detection bias)
All outcomes
Low riskComment: blinding implemented

Incomplete outcome data (attrition bias)
All outcomes
High riskComment: incomplete outcome data not adequately addressed

Selective reporting (reporting bias)Low riskComment: all outcomes identified a priori were reported on

Confounders controlled?High riskComment: all relevant confounders were not controlled for

Data collection methods valid and reliable?Low riskComment: tools were shown to be valid and reliable for both pedometers and the method to measure television viewing

Luepker 1996

MethodsDesign: cluster randomized controlled trial
Theoretical framework: Health Belief Model
Number of intervention groups: 2
Number of control groups: 1
Follow-up: immediately post-intervention


ParticipantsN (intervention): 3297

N (control): 722

Age (mean): 8.8 years
Sex: male and female
Ethnicity: : White, African-American, Hispanic


InterventionsCountry: US
Setting: school, home, urban
Provider: teachers, research staff, cafeteria staff
Duration: 3 years
Intervention (overview): The CATCH intervention included school-based (school food service, physical education, classroom curricula) and family-based (home curricula, family fun nights) components. The school food service changes and physical education enhancement were ongoing throughout the 3 school years whereas the classroom and home curricula were implemented (by classroom teachers) over a fixed time period during each school year and addressed eating habits (grades 3 through 5), physical activity (grades 4 and 5), and cigarette smoking (grade 5 only). Eat Smart, the food service intervention, provided children with healthy meals that maintained recommended levels of essential nutrients and child participation in the school meal programs. Food service personnel attended a 1-day training session at the beginning of each school year. They were provided with more information, assistance in planning, and other support during monthly follow-up visits to the schools and booster sessions. The physical education specialists and teachers attended 1 to 1.5 days of training every school year. The classroom curricula included: the Adventures of Hearty Heart and Friends (grade 3 to 15, 30- to 40-min classes during 5 weeks); Go for Healths (grade 4 to 24, 30- to 40-mi classes during 12 weeks); and Go for Health-5 (grade 5 to 16, 30- to 40-min classes during 8 weeks) and F.A.C.T.S. for Five (grade 5 - 4-session tobacco use prevention curriculum). The classroom teachers attended 1 to 1.5 days of training every year to learn how to implement the curricula. For the home curriculum, 19 activity packets (over the course of 3 school years) that complemented the classroom curricula were sent home with the students and required adult participation to complete. During grades 3 and 4, students invited their family members to a "family fun night" (dance performances, food booths, recipe distribution, games). The intervention schools were further randomized into 2 equal subgroups
Intervention 1: One group received a school-based program consisting of school food service modifications, physical education interventions, and the CATCH curricula
Intervention 2: One group received the same school-based program plus a family-based program
Control: the control group received the usual health curricula, physical education, and food service programs, but none of the CATCH interventions


OutcomesDuration of physical activity
Mean systolic blood pressure (mmHg)
Mean diastolic blood pressure (mmHg)
Mean blood cholesterol level (mg/dL)
BMI (kg/m2)
Pulse rate (beats/minute)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: randomization process not reported

Allocation concealment (selection bias)Low riskComment: criterion not applicable because all participants were allocated at 1 point in time following recruitment, so at time of recruitment allocation was not known

Blinding (performance bias and detection bias)
All outcomes
Unclear riskComment: no information given, likely not done

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: outcome data complete

Selective reporting (reporting bias)Low riskComment: all outcomes identified a priori were reported on

Confounders controlled?Low riskComment: all relevant confounders were accounted for

Data collection methods valid and reliable?Low riskComment: data collection tools were valid and reliable

Martinez 2008

MethodsDesign: cluster randomized controlled trial
Theoretical framework: unstated
Number of intervention groups: 1
Number of control groups: 1
Follow-up: immediately post-intervention


ParticipantsN (intervention): 465
N (control): 579

Age (mean): 9.4 years

Sex: male and female
Ethnicity: : White


InterventionsCountry: Spain
Setting: school, urban and rural
Provider: sports instructors, classroom teachers
Duration: 9 months
Intervention: the intervention group received: 1) the standard, compulsory physical education curriculum (3 hours per week of low-to-moderate intensity activity); 2) recreational, noncompetitive, after school physical activity program (3 x 90-min sessions per week, for 24 weeks)
Control: the control group received the standard, compulsory physical education curriculum: 3 hours per week of physical activity at low-to-moderate intensity


OutcomesMean systolic blood pressure (mmHg)

Mean diastolic blood pressure (mmHg)

Mean blood cholesterol level (mg/dL)

BMI (kg/m2)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskComment: randomization took place using computer generated random numbers

Allocation concealment (selection bias)Low riskComment: criterion not applicable because all participants were allocated at 1 point in time following recruitment, so at time of recruitment allocation was not known

Blinding (performance bias and detection bias)
All outcomes
High riskQuote: "two certified, trained nurses, who were unblinded to school allocation made the anthropometric and blood pressure measurements. The laboratory analysts who determined blood lipids were blinded to school allocation" (Martinez 2008, p14)

Comment: only partial blinding implemented

Incomplete outcome data (attrition bias)
All outcomes
Low riskQuote: "analyses were performed according to the intention-to-treat, with children analyzed in their original randomized allocation, regardless of the number of scheduled physical activity sessions attended" (Martinez 2008, p15)

Selective reporting (reporting bias)Low riskComment: all outcomes identified a priori were reported on

Confounders controlled?High riskComment: not all relevant confounders accounted for

Data collection methods valid and reliable?Low riskComment: data collection methods were shown to be valid and reliable

McManus 2008

MethodsDesign: cluster randomized controlled trial
Theoretical framework: Health Belief Model, Social Cognitive Theory, Diffusion of Innovation
Number of intervention groups: 2
Number of control groups: 1
Follow-up: 6 months post-intervention


ParticipantsN (intervention 1): 64

N (intervention 2): 61
N (control): 68

Age (mean): 10.4 years
Sex: male and female
Ethnicity: Chinese


InterventionsCountry: China
Setting: school, urban
Provider: unstated
Duration: 2 years
Intervention 1: educational program group completed a 2-week education program using targeted materials, providing learner guidance and feedback, and promoting retention of the desired behavior. Content included heart rate monitor skills and education about heart health, goal-setting, and role play. Heart rate monitor skills and goal setting included: information about activity targets (light, moderate, vigorous); daily activity accumulation to achieve 30 to 60 min of moderate-to-vigorous intensity activity (MVPA); and how to use a heart rate monitor for feedback about progression to this goal. This content was taught via an active games approach and a take home booklet. Following the educational program, children in the 2 intervention groups completed 2 weeks with heart rate feedback and 2 weeks without heart rate feedback (counterbalanced)
Intervention 2: no-education program group completed a 2-week control program (physical education classes without physical activity or heart health education). Following the educational program, children in the 2 intervention groups completed 2 weeks with heart rate feedback and 2 weeks without heart rate feedback (counterbalanced). The No-education Program Group were not given any information about the heart rate signal or its meaning, but were informed of the correct position of the chest belt
Control: no intervention took place


OutcomesDuration of physical activity

Mean systolic blood pressure (mmHg)

Mean diastolic blood pressure (mmHg)

Body mass index (kg/m2)

VO2max (mL/kg/minute)

Pulse rate (beats/min)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskComment: does not tell us exactly how they generated the sequence but rather how they selected schools from lists and kept allocation concealed

Allocation concealment (selection bias)Low riskComment: opaque envelopes were utilized to maintain allocation concealment

Blinding (performance bias and detection bias)
All outcomes
High riskComment: partial blinding was implemented only

Incomplete outcome data (attrition bias)
All outcomes
High riskComment: incomplete outcome data was not adequately addressed

Selective reporting (reporting bias)High riskComment: data collected on other outcomes that were not reported (e.g. secondary outcomes blood pressure and body mass index)

Confounders controlled?Low riskComment: all relevant confounders were controlled for

Data collection methods valid and reliable?Low riskComment: data collection methods were shown to be valid and reliable

Neumark-Sztainer 2009

MethodsDesign: cluster randomized controlled trial
Theoretical framework: Social Cognitive Theory
Number of intervention groups: 1
Number of control groups: 1
Follow-up: immediately post-intervention


ParticipantsN (intervention): 51
N (control): 45

Age (mean): 10.3 years
Sex: male and female
Ethnicity: African-American


InterventionsCountry: US
Setting: school, community, theatre, urban
Provider: unstated
Duration: approximately 16 weeks
Intervention: the intervention included 3 components: 1) 14 x 2-hour after-school theatre sessions; 2) 8 weekly after-school booster sessions; and 3) family outreach to enhance home support for behavioral changes through positive reinforcement of health behaviors, parent-child participation in physical activities, and availability of healthy foods. Each theatre session included: 1) a 'check-in' in which children were given an opportunity to share any behavioral changes they had made over the past week (e.g. eating more fruits and vegetables) and talk about how take-home packages were received by families; 2) easy-to-prepare healthy snacks; 3) a movement component of fun and easy activities requiring minimal resources (e.g. dancing or walking); and 4) theatrical ACTivities. For the initial sessions, the ACTivities component included exercises to introduce the children to theatre techniques and to build trust and cooperation. In later sessions, the ACTivities focused on enhancing knowledge and skills related to physical activity and healthy eating and promoting a positive body image through interactive activities. Children were asked to share their personal experiences related to being active and eating healthfully. The content of the script for the Ready. Set. ACTION! play was developed through these activities. During the final sessions, children were introduced to the script and began to rehearse for the final play performance. The booster sessions included activities such as: creating advertisements for fruits and vegetables; painting positive affirmations (e.g. I am special) on a mirror to take home; brainstorming ways to be active while watching television (e.g. doing jumping jacks during commercials); teaching dance and strength training exercises to their classmates; learning exercises to do at home with their families; and rehearsals for the school performance of the Ready. Set. ACTION! play. For the family outreach component, Weekly Fun and Fitness packs (i.e. a healthy food with a simple recipe or fitness incentives for the family) and a CD of the Ready. Set. ACTION! songs were sent home (each pack also had a parent postcard with information and interactive activities on a topic addressed in the after-school program). There were also 2 family events: 1) the students' performance of the play; and 2) a 'Ready. Set. ACTION! DVD Release Party' (i.e. a family viewing of the DVD recording of the play production, a short performance by the children, and a communal family dinner)
Control: the control group participated in a theater-based intervention involving performing a play focused on environmental health issues using a prepared script


OutcomesDuration of physical activity

Television viewing (minutes spent watching television)

Body mass index (kg/m2)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: randomization process not reported

Allocation concealment (selection bias)Low riskComment: criterion not applicable because all participants were allocated at 1 point in time following recruitment, so at time of recruitment allocation was not known

Blinding (performance bias and detection bias)
All outcomes
Unclear riskComment: no information given, likely not done

Incomplete outcome data (attrition bias)
All outcomes
High riskComment: authors should have used intention-to-treat analysis. While they did adjust for baseline differences, they only adjusted for certain characteristics like age and sex, and not for any of the outcome variables

Selective reporting (reporting bias)Low riskComment: all outcomes identified a priori were reported on

Confounders controlled?High riskComment: not all relevant confounders controlled for; only age, gender, and race

Data collection methods valid and reliable?Unclear riskComment: survey tool is cited, but reliability and validity not reported

Neumark-Sztainer 2010

MethodsDesign: cluster randomized controlled trial

Theoretical framework: Social Cognitive Theory, Transtheoretical Model

Number of intervention groups: 1

Number control groups: 1

Follow-up: immediately post-intervention


ParticipantsN (intervention): 177

N (control): 159

Age (mean): 15.8 years

Sex: female

Ethnicity: African-American, Causasian, Hispanic, Asian, American-Indian, mixed/other


InterventionsCountry: US

Setting: school, urban

Provider: physical education (PE) teachers, coaches who were trained intervention staff

Duration: 16 weeks

Intervention: the intervention group continued to participate in the all-girls PE class during the first semester of the school year. They also received the New Moves curriculum during their PE class (approximately 16 weeks) and participated in New Moves activities throughout the rest of the school year (maintenance period). This program included: 1) the New Moves PE class - nutrition and social support/self-empowerment sessions (physical activity (Be Fit) 4 days/week taught by school PE teachers (3 days) and community guest instructors (1 day) and nutrition (Be Fueled) or social support/self-empowerment (Be Fab) classes 1 day/week); 2) individual counseling sessions using motivation interviewing techniques (to set personal goals for behavioral change based on eight New Moves objectives); 3) lunch get-togethers ("lunch bunches") once a week during the maintenance period where participants were served healthy food and engaged in informal discussions on New Moves topics; and 4) minimal parent outreach activities (i.e. 6 postcards sent home to reinforce New Moves messages and a parent-daughter retreat day focused on New Moves messages during the maintenance period). PE teachers attended full-day training before the intervention and half-day training during the intervention. They also received regular, ongoing support from New Moves staff throughout the program. New Moves intervention staff ran all program components aside from the PE class. These staff received training and ongoing support in motivational interviewing techniques
Control: the control group continued to participate in the all-girls PE class during the first semester of the school year. Teachers were free to conduct their PE classes as they desired during the study period and did not receive training on New Moves until after the study period


OutcomesDuration of physical activity

Television viewing (minutes spent watching television)

Body mass index (kg/m2)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: no description of the randomization process given

Allocation concealment (selection bias)Low riskComment: criterion not applicable because all participants were allocated at 1 point in time following recruitment, so at time of recruitment allocation was not known

Blinding (performance bias and detection bias)
All outcomes
High riskComment: self-reported; unclear if trained staff taking measurements were blinded to intervention allocation

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: less than 10% drop-out rate in intervention group; no details provided on reasons for drop-outs

Selective reporting (reporting bias)Unclear riskComment: not discussed in report

Confounders controlled?High riskComment: only considered baseline age, weight, and race

Data collection methods valid and reliable?Unclear riskComment: did not provide details on reliability and validity of measures

Peralta 2009

MethodsDesign: randomized controlled trial
Theoretical framework: Social Cognitive Theory
Number of intervention groups: 1
Number of control groups: 1
Follow-up: immediately post-intervention


ParticipantsN (intervention): 16
N (control): 16

Age (mean): 12.5 years

Sex: male
Ethnicity: unstated


InterventionsCountry: Australia
Setting: school, unstated if urban or rural
Provider: research worker, lay person, physical education (PE) teacher
Duration: 16 weeks
Intervention: the intervention program was primarily based on Social Cognitive Theory, with 16 program weeks, with each week comprising 1 x 60-min curriculum session and 2 x 20-min lunchtime physical activity sessions. Each 60-min curriculum session included practical and/or theoretical components focused on promoting physical activity through increasing physical self-esteem and self-efficacy, reducing time spent in small screen recreation on weekends, decreasing sweetened beverage consumption, and increasing fruit consumption and the acquisition and practice of self-regulatory behaviors such as goal setting, time management, and identifying and overcoming barriers. Behavior modification techniques (e.g. group goals converting time spent in physical activity to kilometers to reach a specified destination, and the use of incentives) were used. The practical component included modified games and activities. The researcher primarily facilitated the intervention with staff and parents' involvement. A Program Champion (PE teacher) liaised with School Executive and other staff to promote the program within the school and assist with logistical requirements. Eleventh grade students peer facilitated lunchtime sessions, based on their potential to be positive role models and had one 20-min training session. Parents were emailed 6 newsletters throughout, informing them of the program content, motivating them, and suggesting strategies to engage the family in healthy behaviors, creating a stronger connection between parents and the school
Control: participated in 16 x 60-min physical activity curriculum at the same time as the intervention group, with a school PE teacher facilitating the control group


OutcomesDuration of physical activity

Television viewing (minutes spent watching television)

Body mass index (kg/m2)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskComment: participants were randomized, using a computer-based number producing algorithm, to either the intervention or active comparison group

Allocation concealment (selection bias)Low riskComment: criterion not applicable because all participants were allocated at 1 point in time following recruitment, so at time of recruitment allocation was not known

Blinding (performance bias and detection bias)
All outcomes
Low riskQuote: "trained independent assessors, blind to group allocation, conducted the measurements" (Peralta 2009, p538)

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: outcome data complete

Selective reporting (reporting bias)Low riskComment: all outcomes identified a priori were reported on

Confounders controlled?Low riskComment: all relevant confounders were controlled for

Data collection methods valid and reliable?High riskComment: although reliability and validity were discussed with some of the data collection methods, not all were discussed

Petchers 1988

MethodsDesign: randomized controlled trial
Theoretical framework: Health Behavior Model
Number of intervention groups: 2
Number of control groups: 1
Follow-up: 1 year post-intervention


ParticipantsN: 325

Age (mean): 11.1 years
Sex: male and female
Ethnicity: unstated


InterventionsCountry: US
Setting: school, mixed (urban, suburban and residential)
Provider: teachers
Duration: 1 school year (40 weeks)
Intervention: Chicago Heart Health Curriculum Program called "Body Power" is a 1-year-long curriculum with modules on 5 topics: 1) cardiovascular system, anatomy, and physiology; 2) smoking; 3) nutrition; 4) exercise; and 5) risk factors review. Curriculum materials and activities emphasize the inter-relationship between students' feelings, behavior, and relationships and the risk factors of cardiovascular disease. The curriculum was implemented by classroom teachers with each module taught during at least 3 x 45-min sessions per week for 4 to 6 weeks. The Northeast Ohio Affiliate of the American Heart Association provided training for teachers. In total, 14 training covered relevant content and humanistic education teaching techniques. Training was supplemented by a comprehensive teachers' manual with specific objectives for each module, suggested time frames and alternative activities for teachers to select those most compatible with their own teaching styles.
Control: control classes received the traditional curriculum with approximately the same amount of teaching time. Control group teachers were provided an alternative experience to the training sessions for the intervention group in the form of a separate in-service training day (general literature and lectures by a cardiologist and an educator


OutcomesPhysical activity rates (% of sample physically active)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: no description of the randomization process was given

Allocation concealment (selection bias)Low riskComment: criterion not applicable because all participants were allocated at 1 point in time following recruitment, so at time of recruitment allocation was not known

Blinding (performance bias and detection bias)
All outcomes
Unclear riskComment: no information given, likely not done

Incomplete outcome data (attrition bias)
All outcomes
High riskComment: incomplete outcome data assessment

Selective reporting (reporting bias)Low riskComment: all outcomes identified a priori were reported on

Confounders controlled?High riskComment: all relevant confounders were not accounted for

Data collection methods valid and reliable?Low riskComment: data collection tools shown to be valid and reliable

Reed 2008

MethodsDesign: cluster randomized controlled trial
Theoretical framework: unstated
Number of intervention groups: 2
Number of control groups: 1
Follow-up: immediately post-intervention


ParticipantsN: 288

Age (mean): 10 years
Sex: male and female
Ethnicity: predominately White and Asian


InterventionsCountry: Canada
Setting: school, community, home, urban
Provider: research staff, teachers
Duration: 11 months
Intervention: the Action Schools! BC model was consistent with the 'active school' framework and emphasized an integrated whole-school approach rather than traditional classroom-based health education, targeting 6 Action Zones: i) School Environment, ii) Scheduled Physical Education, iii) Extracurricular, (iv) School Spirit, v) Family and Community and vi) Classroom Action. Classroom Action was the only prescriptive component of the AS! BC model in which teachers delivered 15 min of moderate to intense physical activity daily to achieve 75 min of extra physical activity per week (in addition to 2 x 40 min physical education (PE) classes). Teachers provided opportunities to 'snack on physical activities' such as skipping, dancing, and resistance exercises throughout the day. A school Action Team – comprised of the school principal, teachers, or both - was convened in each school and an AS! BC facilitator worked with Action Teams to design a program with activities across the 6 Action Zones. A 1-day training workshop was held for INT teachers, who were provided a Classroom Action Bin with resources to support their Action Plan with the goal for each school to provide students with 150 min of physical activity per week (2 x 40 min PE classes and 15 x 5 min per day of Classroom Action)
Control: teachers in usual practice schools continued their regular program of PE and school-based physical activity


OutcomesMean systolic blood pressure (mmHg)
Mean diastolic blood pressure (mmHg)
Mean blood cholesterol level (mg/dL)

Body mass index (kg/m2)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "schools were then remotely randomized to either Usual Practice or Intervention by an epidemiologist not involved in the trial" (Reed 2008, p527)

Comment: although it is stated who allocated schools, it does not state how schools were randomized

Allocation concealment (selection bias)High riskComment: it was reported that it was not possible for schools to be blinded to random assignment and therefore concealment not attained

Blinding (performance bias and detection bias)
All outcomes
Unclear riskComment: no information given, likely not done

Incomplete outcome data (attrition bias)
All outcomes
High riskComment: incomplete outcome data not adequately addressed

Selective reporting (reporting bias)Low riskComment: all outcomes identified a priori were reported on

Confounders controlled?Low riskComment: all relevant confounders controlled for

Data collection methods valid and reliable?High riskComment: reliability and validity of the physical activity measure was not discussed

Robinson 1999

MethodsDesign: cluster randomized controlled trial
Theoretical framework: Social Cognitive Theory
Number of intervention groups: 1
Number of control groups: 1
Follow-up: immediately post-intervention


ParticipantsN (intervention): 92
N (control): 100

Age (mean): 9 years
Sex: male and female
Ethnicity: unstated


InterventionsCountry: US
Setting: school, unstated if urban or rural
Provider: teachers
Duration: 6 months
Intervention: limited access to television (TV) use and budgeting TV time. Based on Bandura's Social Cognitive Theory it involved 18 lessons of 30 to 50 min as part of standard curriculum, taught by regular classroom teachers trained by research staff. Most lessons occurred in the first 2 months of the year and early lessons included self-monitoring and self-reporting for TV and video game use followed by a 10-day TV turnoff challenge after which students were encouraged to follow a 7-h per week budget. Newsletters designed to help parents motivate students and regulate time spent on TV and video games for the entire family were distributed. Each household received 1 (or more if requested) TV time master to regulate TV and video use
Control: not specified


OutcomesDuration of physical activity
TV viewing (minutes spent watching TV)
Body mass index (kg/m2)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: randomization process not reported

Allocation concealment (selection bias)Low riskComment: criterion not applicable because all participants were allocated at 1 point in time following recruitment, so at time of recruitment allocation was not known

Blinding (performance bias and detection bias)
All outcomes
Low riskQuote: "participants and school personal including classroom teachers, were informed of the intervention but were unaware of the primary hypothesis. Measurements were done by trained staff blinded to the experimental design" (Robinson 1999, p1562)

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: outcome data complete

Selective reporting (reporting bias)Low riskComment: all outcomes identified a priori were reported on

Confounders controlled?Low riskComment: all relevant confounders were accounted for

Data collection methods valid and reliable?Low riskComment: data collection tools valid and reliable

Salmon 2008

MethodsDesign: cluster randomized controlled trial
Theoretical framework: Social Marketing Theory, Behavioral Choice Theory
Number of intervention groups: 3
Number of control groups: 1
Follow-up: 1 year post-intervention


ParticipantsN (intervention): 213
N (control): 55

Age (mean): 10 years

Sex: male and female
Ethnicity: unstated


InterventionsCountry: Australia
Setting: school, urban
Provider: specialist physical education (PE) teacher
Duration: 1 school year
Intervention: students were assigned to 1 of 4 conditions: a behavioral modification group (BM; N = 69); a fundamental motor skills group (FMS; N = 73); a combined BM and FMS group (N = 90). Components of the intervention program were developed by the study team, with others adapted from previous interventions (SPARK), concepts outlined in Robinson's study, from Planet Health, and from the Victorian Fundamental Motor Skills program. BM condition: included 19 sessions of 40 to 50 min' duration over 3 school terms by the intervention specialist teacher, with different aims for each set of lessons (e.g. increasing awareness of time-use, health benefits of physical activity, self-monitoring time spent in sedentary behaviors and physical activity, raising awareness of the home and community environments in relation to choices and opportunities, decision-making skills, developing their own physical activities and games, 'intelligent viewing', a 'Switch-off Challenge', and intermittent reinforcement schedule with a small reward). FMS condition: 19 sessions of 40 to 50 min over 3 school terms taught by the same intervention specialist teacher who delivered the BM intervention. The FMS intervention focused on 6 skills, including 3 object control skills and 3 locomotor skills. Skills were taught with an emphasis on fun through games and maximum involvement for all the children. Most lessons focused on at least 2 skills, and each skill was a focus lesson in at least 6 or more sessions
Control: usual classroom lessons


OutcomesDuration of physical activity

Television viewing (minutes spent watching television)

Body mass index (kg/m2)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High riskComment: participants selected a ticket from a container which specified group allocation

Allocation concealment (selection bias)Unclear riskComment: it was not stated if allocation was adequately concealed

Blinding (performance bias and detection bias)
All outcomes
High riskComment: Two trained staff members not blinded to group assignment took measurements

Incomplete outcome data (attrition bias)
All outcomes
High riskComment: incomplete outcome data was not adequately addressed

Selective reporting (reporting bias)Low riskComment: all outcomes identified a priori were reported on

Confounders controlled?Low riskComment: all relevant confounders were accounted for

Data collection methods valid and reliable?Low riskComment: data collection tools valid and reliable

Simon 2004

MethodsDesign: cluster randomized controlled trial
Theoretical framework: unstated
Number of intervention groups: 1
Number of control groups: 1
Follow-up: immediately post-intervention


ParticipantsN (intervention): 475
N (control): 479

Age (mean): 11.7 years
Sex: male and female
Ethnicity: White


InterventionsCountry: France
Setting: community, school, urban
Provider: teachers, physical activity (PA) instructors, peers, community groups
Duration: 4 school years (40 weeks per year)
Intervention: the ICAPS program was implemented over 4 academic years to promote PA inside and outside. The intervention includes an educational component focusing on PA and sedentary behaviors, new opportunities for PA during school hours (lunch break, recess), and after-school hours. Activities implemented are either informal or academic with emphasis on fun and pleasure, well-being, noncompetitiveness. Sporting events, bicycle, and on-foot transport are organized, with teachers, parental organizations, and sport associations encouraged to participate in meetings and regular contact. Intervention staff are informed of study objectives and work in collaboration with the different partners. The ICAPS coordinators regularly visit intervention school members to inquire about difficulties and help resolve material or personnel needs
Control: not specified


OutcomesPA rates (% of sample physically active)
Duration of physical activity

Television viewing (minutes spent watching televisions)

Body mass index (kg/m2)

Mean systolic blood pressure (mmHg)

Mean diastolic blood pressure (mmHg)

Mean cholesterol level (mg/dL)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: randomization process not reported

Allocation concealment (selection bias)Low riskComment: criterion not applicable because all participants were allocated at 1 point in time following recruitment, so at time of recruitment allocation was not known

Blinding (performance bias and detection bias)
All outcomes
Unclear riskComment: no information given, likely not done

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: outcome data complete

Selective reporting (reporting bias)Low riskComment: all outcomes identified a priori were reported on

Confounders controlled?Low riskComment: all relevant confounders were accounted for

Data collection methods valid and reliable?Low riskComment: data collection tools were shown to be valid and reliable

Singh 2009

MethodsDesign: cluster randomized controlled trial
Theoretical framework: Intervention Mapping Protocol
Number of intervention groups: 1
Number of control groups: 1
Follow-up: 1 year post-intervention


ParticipantsN: 875

Age (mean): 12.7 years
Sex: male and female
Ethnicity: : White


InterventionsCountry: Netherlands
Setting: school, unstated whether urban or rural
Provider: teachers although unclear
Duration: 8 months
Intervention: an interdisciplinary program with adapted curriculum including an individual component (11 lessons in biology and physical education) and environmental change component including encouragement for schools to increase physical education and provision of advice for schools related to cafeteria changes
Control: regular curriculum


OutcomesBody mass index (kg/m2)

Television viewing (minutes spent engaged in inactivity)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: randomization process not reported

Allocation concealment (selection bias)Low riskComment: criterion not applicable because all participants were allocated at 1 point in time following recruitment, so at time of recruitment allocation was not known

Blinding (performance bias and detection bias)
All outcomes
High riskQuote: "all measurements were performed within a 6-week period according to a standardized protocol by a trained research team, which was not blinded to the group assignment" (Singh 2009, p310)

Incomplete outcome data (attrition bias)
All outcomes
Low riskQuote: "all analyses were performed according to the intention-to-treat principle" (Singh 2009, p311)

Selective reporting (reporting bias)Low riskComment: all outcomes identified a priori were reported on

Confounders controlled?Low riskComment: all relevant confounders were accounted for

Data collection methods valid and reliable?Low riskComment: more detail on reliability and validity could be given

Singhal 2010

MethodsDesign: cluster randomized controlled trial

Theoretical framework: unstated

Number of intervention groups: 1

Number of control groups: 1

Follow-up: immediately post-intervention


ParticipantsN (intervention): 99

N (control): 102

Age (mean): 16 years

Sex: male and female

Ethnicity: Indian


InterventionsCountry: India

Setting: school, urban

Provider: trained nutritionist, teachers, student volunteers

Duration: 42 weeks

Intervention: multicomponent intervention with 7 components related to nutrition and lifestyle education, including the following activities: dissemination of health-related information through lectures and focused group discussions (24 weeks (6 months) of nutrition education), promotion of physical activity (encouragement to participate in physical activity periods in school every week for at least 30 min), other promotion of healthy lifestyle (a consecutive 8 weeks (30 min 5 days per week), with meal planning and discussion of healthy alternatives and quizzes), individual counseling (1 h per week per child, in groups of 4 or 5), policy-level changes in schools (school canteen serving offering healthier choices), involvement of teachers and parents (health camp for parents and telephone follow-up with counseling of 5 to 7 min per month), training of student volunteers for program sustainability (1-h session each week with 40 eleventh-grade student volunteers)
Control: no intervention


OutcomesBody mass index (kg/m2)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: no description of the randomization process given

Allocation concealment (selection bias)Low riskComment: criterion not applicable because all participants were allocated at 1 point in time following recruitment, so at time of recruitment allocation was not known

Blinding (performance bias and detection bias)
All outcomes
Unclear riskComment: not reported if assessors were blinded

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: participant loss minimal, reasons given in Figure 1

Selective reporting (reporting bias)Unclear riskComment: not clear if all a priori outcomes were reported on

Confounders controlled?High riskComment: not all confounders adequately controlled

Data collection methods valid and reliable?High riskComment: do not provide details on how body mass index was measured, only state who measured outcome

Stephens 1998

MethodsDesign: cluster randomized controlled trial
Theoretical framework: unstated
Number of intervention groups: 1
Number of control groups: 1
Follow-up: immediately post-intervention


ParticipantsN (intervention): 45
N (control): 45

Age (mean): 8 years
Sex: male and female
Ethnicity: African-American


InterventionsCountry: US
Setting: school, urban
Provider: medical students
Duration: 15 weeks
Intervention: 18 medical students were assigned to classrooms and given a 2-day orientation session. Each class received 3 activity sessions per week, with the fitness intervention consisting of 5 min of warm-up and stretching, followed by 20 min of aerobic activity. Activities were selected from a roster defined by the Centers for Disease Control and Prevention and incorporated repetitive movements of large muscle groups, designed to elevate the pulse rate 40 to 60 beats over resting level. Sessions ended with a 5– to 10-min cool-down when medical student teams presented educational material about nutrition, exercise, and disease prevention
Control: students in the control classroom received no additional physical activity beyond regular physical education classes


OutcomesMean systolic blood pressure (mmHg)
Mean diastolic blood pressure (mmHg)
Pulse rate (beats/minute)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: randomization process not reported

Allocation concealment (selection bias)Low riskComment: criterion not applicable because all participants were allocated at 1 point in time following recruitment, so at time of recruitment allocation was not known

Blinding (performance bias and detection bias)
All outcomes
Unclear riskComment: no information given, likely not done

Incomplete outcome data (attrition bias)
All outcomes
High riskComment: incomplete outcome data assessment

Selective reporting (reporting bias)Low riskComment: all outcomes identified a priori were reported

Confounders controlled?Low riskComment: all relevant confounders were accounted for

Data collection methods valid and reliable?Unclear riskComment: insufficient data to determine reliability and validity

Stone 2003

MethodsDesign: cluster randomized controlled trial
Theoretical framework: Social Learning Theory, incorporating Cultural Heritage of American-Indians
Number of intervention groups: 1
Number of control groups: 1
Follow-up: immediately post-intervention


ParticipantsIntervention: 644

Control: 653

Age: grade 3 (mean age not provided)
Sex: male and female
Ethnicity: American-Indian


InterventionsCountry: US
Setting: school, unstated if urban or rural
Provider: teacher, nutritionist (for nutritional support)
Duration: 3 years (12 weeks per year)
Intervention: the intervention program was implemented during third through fifth grades, with 4 components including: food service, skills-based classroom curricula, family, and physical education (PE). The intervention combined Social Learning Theory and principles of American Indian culture and practices with indigenous learning modes (e.g. story telling) incorporated. Classroom component: 2 x 45-min lessons delivered by teachers weekly for 12 weeks during grades 3 and 4, decreased to 8 weeks in grade 5. Food service component: nutrient guidelines and tools for reducing fat content of school meals while meeting nutrient requirements. Food service staff provided skill-building for planning, purchasing, and preparing lower-fat school meals. PE component: a minimum of 3 x 30-min sessions per week of moderate to vigorous physical activity based on SPARK. Family component: assistance creating a supportive environment with an interactive forum to discuss Pathways and additionally, 1) family action packs, and 2) family events at schools
Control: not specified


OutcomesDuration of physical activity
Body mass index (kg/m2)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: randomization process not reported

Allocation concealment (selection bias)Low riskComment: criterion not applicable because all participants were allocated at 1 point in time following recruitment, so at time of recruitment allocation was not known

Blinding (performance bias and detection bias)
All outcomes
Unclear riskComment: no information given, likely not done

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: outcome data complete

Selective reporting (reporting bias)Low riskComment: all outcomes identified a priori were reported

Confounders controlled?Low riskComment: all relevant confounders were accounted for

Data collection methods valid and reliable?Low riskComment: data collection tools shown to be valid and reliable

Trevino 2004

MethodsDesign: randomized controlled trial
Theoretical framework: Social Cognitive Theory, Social Ecological Theory
Number of intervention groups: 1
Number of control groups: 1
Follow-up: immediately post-intervention


ParticipantsN (intervention): 619
N (control): 602

Age (mean): 9.8 years
Sex: male and female
Ethnicity: Hispanic


InterventionsCountry: US
Setting: school, urban
Provider: teachers
Duration: 7 months
Intervention: 50 sessions of health programing across 7 months to transmit to children 3 health behavior messages associated with diabetes mellitus control (decreased dietary saturated fat intake, increase dietary fiber intake, increase physical activity). Taught and reinforced through classroom, home, school cafeteria, and after-school care educational activities. Physical education teachers, parents, school cafeteria staff, and after-school care staff were asked to encourage less dietary saturated fat, more fiber intake and more physical activity, to have less saturated fat and more fiber available, and more physical activity available. Children were asked to set goals aimed at accomplishing the targeted behaviors and to keep records of their accomplishments. Children were also asked to encourage their peers and adult caretakers to practice 3 health behaviors. Children and parents who practiced the 3 health behaviors were rewarded with coupons (worth a $$ amount) from a store set up in the school. Students could purchase merchandise with the coupons
Control: not specified


OutcomesVO2max (mL/kg/minute)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskComment: randomization took place using a random number table

Allocation concealment (selection bias)Low riskComment: methods ensured that no one could foresee intervention assignment

Blinding (performance bias and detection bias)
All outcomes
Low riskQuote: "principals of schools were informed and asked not to inform students, parents or school staff of the intervention assignment" (Trevino 2004, p912)

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: outcome data complete

Selective reporting (reporting bias)Low riskComment: all outcomes identified a priori were reported on

Confounders controlled?Low riskComment: all relevant outcomes were accounted for

Data collection methods valid and reliable?Unclear riskComment: reliability and validity of data collection methods not specifically stated

Verstraete 2006

MethodsDesign: cluster randomized controlled trial
Theoretical framework: unstated
Number of intervention groups: 1
Number of control groups: 1
Follow-up: immediately post-intervention


ParticipantsN (intervention): 122

N (control): 113

Age (mean): 10.8 years
Sex: male and female
Ethnicity: White


InterventionsCountry: Belgium
Setting: school, urban
Provider: research staff
Duration: 3 months
Interventions: intervention: classes received a set of game equipment and 'activity cards' including examples of games and activities that can be performed with the equipment. Children were allowed to play outdoors with the equipment during recesses and lunch break. Before providing the game equipment, the different play toys and 'activity cards' were presented to the children of each class group by a research staff member. Teachers were asked to stimulate the children to play with the game equipment and agreed on rules with the children about the use and the loss or damage of the game equipment to assure its endurance. The teachers were advised to divide the game equipment into different sets and to exchange those sets regularly to prevent children losing interest in the equipment. Children were only allowed to play with the equipment of their own class. The set of game equipment for each class group included 2 jump ropes, 2 double Dutch ropes, 2 scoop sets, 2 flying discs, 2 catchballs, 1 poco bal, 1 plastic bal, 2 plastic hoops, 2 super grips, 3 juggling scarves, 6 juggling rings, 6 juggling beanballs, 1 diabolo, 1 angel-stick, 4 spinning plates, 2 sets of badminton racquets and 2 sets of oversized beach paddles.
Control: not specified


OutcomesPhysical activity rates (% of sample physically active)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: randomization process not reported

Allocation concealment (selection bias)Low riskComment: criterion not applicable because all participants were allocated at 1 point in time following recruitment, so at time of recruitment allocation was not known

Blinding (performance bias and detection bias)
All outcomes
Unclear riskComment: no information given, likely not done

Incomplete outcome data (attrition bias)
All outcomes
High riskComment: incomplete outcome data was not adequately addressed

Selective reporting (reporting bias)Low riskComment: all outcomes identified a priori were reported on

Confounders controlled?High riskComment: not stated therefore likely not done

Data collection methods valid and reliable?Unclear riskComment: reliability and validity of data collection methods not specifically stated

Walter 1988

MethodsDesign: cluster randomized controlled trial
Theoretical framework: PRECEDE, Health Belief Model, Social Learning Theory

Number of intervention groups: 2
Number of control groups: 2
Follow-up: immediately post-intervention


ParticipantsN (intervention in lower income inner city area): 1590 (14 schools)
N (intervention in middle/upper income suburb): 485 (8 schools)
N (control in lower income inner city area): 693 (8 schools)
N (control in middle/upper income suburb): 620 (7 schools)

Age (mean): 9 years
Sex: male and female
Ethnicity: White, Hispanic, African-American


InterventionsCountry: US
Setting: school, community, urban
Provider: teachers
Duration: 6 years
Intervention: special curriculum targeting voluntary changes in risk behavior in the area of diet, physical activity, and smoking. Curriculum content was designed to provide the information and motivation necessary for behavioral changes, as well as training in the skills necessary to make such changes. The intervention foci (perceived susceptibility to, and severity of health problems, perceived benefits of and barriers to adopting and maintaining risk-reduction types of behavior) were derived from the Health Belief Model, skills training strategies were derived from Social Learning Theory. Cognitive-development theory provided a framework for the appropriate tailoring of these constructs to the children's changing maturational stages ad the study progressed over a 5-year period. The physical activity component of the intervention fostered the adoption of a regular program of endurance exercise. The special curriculum was taught in classrooms by specially trained regular teachers for approximately 2 hours per week throughout each school year.
Control: not specified


OutcomesMean systolic blood pressure (mmHg)
Mean diastolic blood pressure (mmHg)
Mean blood cholesterol level (mg/dL)
Body mass index (kg/m2)
Pulse rate (beats/minute)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment randomization process not reported

Allocation concealment (selection bias)Low riskComment: criterion not applicable because all participants were allocated at 1 point in time following recruitment, so at time of recruitment allocation was not known

Blinding (performance bias and detection bias)
All outcomes
Unclear riskComment: no information given, likely not done

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: analyses were done to see if bias would be introduced due to attrition and average values of the risk values were imputed

Selective reporting (reporting bias)Low riskComment: all outcomes identified a priori were reported on

Confounders controlled?Low riskComment: all relevant confounders controlled for

Data collection methods valid and reliable?Unclear riskComment: reliability and validity of data collection methods not specifically stated

Walther 2009

MethodsDesign: cluster randomized controlled trial
Theoretical framework: unstated
Number of intervention groups: 1
Number of control groups: 2
Follow-up: immediately post-intervention


ParticipantsN (intervention): 109
N (control): 73

Age (mean): 11.1 years
Sex: male and female
Ethnicity: White


InterventionsCountry: Germany
Setting: school, unstated if urban or rural
Provider: unstated
Duration: 1 year
Intervention: classes assigned to 1 unit of physical exercise (45 min) with at least 15 min of endurance training per school day. In addition, lessons on healthy lifestyle were included in the regular schedule once monthly for all pupils. 2 additional sixth-grade classes from a school focusing on competitive sports and physical education were selected to serve as a reference group.
Control: according to German standards, 2 units (each 45 min) of physical education per week are mandatory in all schools. The nonrandomized sport students (reference group) received 12 units (45 min per unit) of high-level endurance exercise training per week and frequently participated in competitive sporting events, thus representing a maximum of physical fitness attainable under reasonable conditions in school-age children


OutcomesMean systolic blood pressure (mmHg)

Mean diastolic blood pressure (mmHg)

Mean blood cholesterol level (mg/dL)

VO2max (mL/kg/minute)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: randomization process not reported

Allocation concealment (selection bias)Low riskComment: criterion not applicable because all participants were allocated at 1 point in time following recruitment, so at time of recruitment allocation was not known

Blinding (performance bias and detection bias)
All outcomes
Unclear riskComment: no information given, likely not done

Incomplete outcome data (attrition bias)
All outcomes
High riskComment: incomplete outcome data was not adequately addressed

Selective reporting (reporting bias)Low riskComment: all outcomes identified a priori were reported on

Confounders controlled?High riskComment: not all relevant confounders controlled for

Data collection methods valid and reliable?Low riskComment: data collection methods were reported to be valid and reliable

Wang 2008

MethodsDesign: cluster randomized controlled trial
Theoretical framework: unstated
Number of intervention groups: 1
Number of control groups: 1
Follow-up: immediately post-intervention


ParticipantsN (intervention): 168
N (control): 148

Age (mean): 8.5 years
Sex: Male and female
Ethnicity: African-American


InterventionsCountry: US
Setting: school, urban
Provider: physical education (PE) teachers, classroom teachers, paraprofessionals
Duration: 3 school years
Intervention: 'FitKid' after-school program was offered 5 days a week (not offered during holidays and vacation periods). Certified school teachers and paraprofessionals implemented the program, following established guidelines that included reinforcement and teaching techniques, safety measures, evaluation procedures, and monthly activity plans that accommodate local weather conditions (i.e. more outdoor-based activities in spring, winter, and late fall and more indoor activities in summer and early fall when it is often too hot and humid to play outside). 2-hour intervention sessions began with a 40-min period during which the youths were provided with a healthy snack and academic enrichment activities. The snacks were provided through the US Department of Agriculture's National School Lunch and Child and Adult Care Food Programs in cooperation with the school nutrition service. The academic enrichment activities were incorporated into the program to ensure that participation in the FitKid intervention during the after-school hours would not damage the academic progress of the children. The 80 min of physical activity included a variety of activities designed to improve sport skills, aerobic fitness, strength, and flexibility; 40 min were devoted to vigorous physical activity
Control: not specified


OutcomesMean systolic blood pressure (mmHg)

Mean diastolic blood pressure (mmHg)

Mean cholesterol level (mg/dL)

Body mass index (kg/m2)

VO2max (mL/kg/minute)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: randomization process not reported

Allocation concealment (selection bias)Low riskComment: criterion not applicable because all participants were allocated at 1 point in time following recruitment, so at time of recruitment allocation was not known

Blinding (performance bias and detection bias)
All outcomes
Unclear riskComment: no information given, likely not done

Incomplete outcome data (attrition bias)
All outcomes
High riskComment: incomplete outcome data was not adequately addressed

Selective reporting (reporting bias)Low riskComment: all outcomes identified a priori were reported on

Confounders controlled?Low riskComment: all relevant confounders were taken into account

Data collection methods valid and reliable?High riskComment: not all methods were shown to be valid or reliable

Webber 2008

MethodsDesign: cluster randomized controlled trial
Theoretical framework: Social Cognitive Theory, Diffusion of Innovation, Operant Learning Theory
Number of intervention groups: 1
Number of control groups: 1
Follow-up: immediately post-intervention


ParticipantsN (intervention): 18 schools
N (control): 18 schools

Age (mean): 12 years
Sex: female
Ethnicity: White


InterventionsCountry: US
Setting: community, school, unstated whether urban or rural
Provider: research staff, community groups, teachers
Duration: 2 years
Intervention: TAAG health education included 6 lessons in each of the 7th and 8th grades designed to enhance behavioral skills known to influence physical activity participation. Activity challenges associated with the lessons reinforced the contents, encouraged self-monitoring, and set goals for behavior change. To meet the varying formats in which health education was taught at the school, TAAG health education was offered in 2 forms: 1 for a traditional classroom setting and 1 for physical education (PE) class. TAAG PE class promoted moderate to vigorous physical activity (MVPA) for at least 50% of class time and encouraged teachers to promote physical activity outside of class. Activities targeted to create (1) environmental and organizational changes supportive of physical activity and (2) cues, messages, and incentives to be more physically active. Specifically, the intervention was designed to establish more opportunities, improve social support and norms, and increase self-efficacy, outcome expectations, and behavioral skills to foster greater MVPA. 35 to 40 girls were the focus of the intervention; however, health and PE classes were part of the usual school curriculum and most included boys as well. An innovative feature of the intervention was linking school and community agencies to develop and promote physical activity programs for girls. These programs were delivered both on and off school property, in most cases either before or after school
Control: not specified


OutcomesDuration of physical activity

Television viewing (minutes spent watching television)

Body mass index (kg/m2)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: randomization process not reported

Allocation concealment (selection bias)Low riskComment: criterion not applicable because all participants were allocated at 1 point in time following recruitment, so at time of recruitment allocation was not known

Blinding (performance bias and detection bias)
All outcomes
Low riskQuote: "TAAG staff was blinded to the study outcomes until the 2006 data collection was complete. Also, separate intervention and measurement staff were employed" (Webber 2008, p174)

Incomplete outcome data (attrition bias)
All outcomes
High riskComment: incomplete outcome data was not addressed adequately.

Quote: "in a study such as TAAG, efforts to obtain a complete set of measurements on the girls assigned to each treatment condition would require considerable resources, as it is expensive to track and measure students who have left a school. Furthermore, despite extraordinary efforts, ascertainment of measurements in every girl in the cohort is unlikely" (Stevens 2005, p226)

Selective reporting (reporting bias)Low riskComment: all outcomes identified a priori were reported on

Confounders controlled?High riskComment: all relevant confounders were not controlled for

Data collection methods valid and reliable?Unclear riskComment: data collection methods were not discussed or shown to be valid or reliable

Weeks 2008

MethodsDesign: randomized controlled trial
Theoretical framework: unstated
Number of intervention groups: 1
Number of control groups: 1
Follow-up: immediately post-intervention


ParticipantsN (intervention): 43
N (control): 38

Age (mean): 13.8 years
Sex: male and female
Ethnicity: unstated


InterventionsCountry: Australia
Setting: school, unstated whether urban or rural
Provider: research staff
Duration: 8 months
Intervention: 10 min of directed jumping activity at the beginning of every physical education (PE) class (twice per week). Activities designed to apply loads to the skeleton at high strain magnitude, frequency, and rate, and included: jumps, hops, tuck-jumps, jump-squats, stride jumps, star jumps, lunges, side lunges, and skipping. Jumps were occasionally supplemented with upper body strengthening activities, including push-ups and exercises with resistive latex bands (AusBand; Ausmedic Australia).
Control: regular PE warm-ups and stretching directed by their usual PE teacher at the beginning of every PE class (twice per week). Activities focused on improving flexibility and general preparedness for physical activity without specifically loading the skeleton at higher rates than normal, including: brisk walking, light jogging, and stretching


OutcomesDuration of physical activity

Body mass index (kg/m2)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: no description of the randomization process given

Allocation concealment (selection bias)Low riskComment: criterion not applicable because all participants were allocated at 1 point in time following recruitment, so at time of recruitment allocation was not known

Blinding (performance bias and detection bias)
All outcomes
Unclear riskComment: no Information given, likely not done

Incomplete outcome data (attrition bias)
All outcomes
High riskComment: intention-to-treat analysis was not completed on the outcomes of interest

Selective reporting (reporting bias)Low riskComment: all outcomes identified a priori were reported on

Confounders controlled?Low riskComment: all relevant outcomes were accounted for

Data collection methods valid and reliable?Unclear riskComment: reliability and validity were not discussed

Williamson 2007

MethodsDesign: cluster randomized controlled trial
Theoretical framework: unstated
Number of intervention groups: 2
Number of control groups: 0
Follow-up: immediately post-intervention


ParticipantsN (intervention): 282

N (control): 304

Age (mean): 9.2 years
Sex: male and female
Ethnicity: White


InterventionsCountry: US
Setting: school, unstated if urban or rural
Provider: classroom teachers
Duration: 2 academic years
The Healthy Eating and Exercise (HEE) and Alcohol/Tobacco/Drug abuse prevention (ADT) programs were developed as environmental approaches for weight gain. The primary components of the programs were to alter the physical and social environment of the schools. Both programs were rationally linked to a “Wise Mind” concept, which was a central feature of both programs, thus allowing the use of Wise Mind as the name for the program (as a whole), as opposed to just one intervention arm of the study. The Wise Mind concept represents the idea that with knowledge and environmental changes, students can make wise decisions about nutrition, physical activity, and substance use/abuse. The environmental changes were designed to alter the ecology of the school environments, including policy, personal, social, cultural, and physical environmental changes.
Intervention: Healthy Eating and Exercise (HEE) program, designed with the goal of preventing inappropriate weight gain by modifying the school environment to improve healthy eating habits, increase physical activity, and decrease sedentary behavior at school and to encourage these same behavioral changes outside the school environment. The goal of the physical activity program was to increase physical activity during the school day and at home. Teachers were provided with containers filled with indoor play supplies (e.g. balloons, bean bags) and outdoor play supplies (e.g. balls, jump ropes) to promote active play during class time and recess. Posters encouraged the use of these physical activity centers (PACs), and brief lesson plans provided academic games that used the supplies contained in the PACs
Control: Alcohol/Tobacco/Drug abuse prevention (ADT) program, designed with the goal of modifying children's beliefs and attitudes regarding the use and abuse of tobacco, alcohol, and illicit drugs so that they reflected "healthier" values


OutcomesDuration of physical activity

Television viewing (minutes engaged in inactivity)

Body mass index (kg/m2)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: randomization process not reported

Allocation concealment (selection bias)Low riskComment: criterion not applicable because all participants were allocated at 1 point in time following recruitment, so at time of recruitment allocation was not known

Blinding (performance bias and detection bias)
All outcomes
Unclear riskComment: no information given, likely not done

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: missing values were replaced with calculated estimates

Selective reporting (reporting bias)Low riskComment: all outcomes identified a priori were reported on

Confounders controlled?High riskComment: more confounders should have been assessed and controlled for

Data collection methods valid and reliable?Low riskComment: data collection methods were shown to be valid and reliable

Wilson 2011

MethodsDesign: cluster randomized controlled trial

Theoretical framework: Social Cognitive Theory, Self-Determination Theory

Number of intervention groups: 1

Number of control groups: 1

Follow-up: 2 weeks post-intervention


ParticipantsN (intervention): 673

N (control): 635

Age (mean): 11.3 years

Sex: male and female

Ethnicity: African-American (73%), other


InterventionsCountry: US

Setting: Grade school, unstated if urban or rural, home

Provider: trained team leader

Duration: 17 weeks

Intervention: ACT, a 17-week program implemented on Mondays, Tuesdays, and Thursdays for 2 hours after school. On Wednesdays students practiced what they had learned in the after-school program in their home environment. A trained team leader, with expertise in implementing physical activities (PA) in youth, provided the structure for the ACT intervention program implementation. The program had 3 main components: homework/snack (30 min), moderate to vigorous physical activities (MVPA) (60 min) that students selected each week, and a behavioral skills and motivational component (30 min) during which intervention staff worked with participants on developing strategies for increasing their MVPA in their home environment. The ACT intervention specifically targeted development of behavioral skills (communication, reciprocity of social support, group goal setting, and behavioral competence) for increasing PA outside of program days. In addition, the ACT after-school program social environment (autonomy, choice, participation, belongingness, fun, enjoyment, support) was designed to have a positive impact on cognitive mediators (self-confidence, perceived competence) and motivational orientation (intrinsic motivation, commitment, positive self-concept) to promote long-term PA behavior.
Control: the General Health Education Program (comparison program) focused on nutrition, stress management, drug prevention, and drop-out prevention (with no PA component). The program consisted of a homework/snack (30 min) and 3 hands-on activities related to general health (30 min each). The comparison program was held on the same days and times as the ACT intervention program.


OutcomesDuration of PA


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: no description of the randomization process given

Allocation concealment (selection bias)Low riskComment: criterion not applicable because all participants were allocated at 1 point in time following recruitment, so at time of recruitment allocation was not known

Blinding (performance bias and detection bias)
All outcomes
Low riskComment: used accelerometers to measure outcome

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: did intention-to-treat analysis, also provided details on drop-outs

Selective reporting (reporting bias)Unclear riskComment: no Information given, likely not done

Confounders controlled?Low riskComment: adjusted for important confounders before randomization

Data collection methods valid and reliable?Low riskComment: data collection tools reliable (accelerometers)

Young 2006

MethodsDesign: randomized controlled trial

Theoretical framework: Social Action Theory

Number of intervention groups: 1

Number of control groups: 1

Follow-up: immediately post-intervention


ParticipantsN (intervention): 111

N (control): 99

Age (mean): 13.8 years

Sex: female

Ethnicity: African-American (83%)


InterventionsCountry: US

Setting: school, urban

Provider: teacher hired by project

Duration: 1 year (school year)

Intervention: the intervention was taught by a teacher hired by the project. Intervention content included information to make an informed decision about the personal benefits of a physically active lifestyle, develop problem-solving skills, and obtain support from others. Specific strategies that were taught and reinforced included goal setting, problem-solving barriers, communication skills, reinforcement of goal achievement through internal and external rewards, and learning from relevant role models. Skills were taught using class lectures and discussions, small-group discussions, and homework activities. Physical activity self-monitoring was given a strong focus. Students were encouraged to keep weekly exercise logs from which the teacher provided feedback on progress toward goal attainment and reward strategies. All students in class received the intervention, irrespective of whether they were trial participants. The intervention was also designed to maximize physical activity during physical education (PE) class. The format was congruent with the school's PE curriculum - 1 semester of individual sports and 1 semester of team sports - taught 5 days per week. Classes were optimized for physical activity by teaching units that were active in nature (e.g. soccer instead of softball (personal fitness unit)), breaking skills training into small-group activities, and playing games in small groups (e.g. 3-on-3 basketball). Skills training was limited to that needed for competency rather than proficiency. Written tests focused on health-related physical activity and fitness concepts and behavioral skills. The family support component consisted of a family workshop, monthly newsletters, and adult-child homework assignments. A 2-hour family workshop, scheduled shortly after randomization, featured tips on how parents could provide support to their daughters. As an in-class activity, students worked on skits illustrating support strategies that were videotaped and viewed at the workshop. Families who did not attend were mailed copies. Families also received a 2-page family support newsletter each month that contained an article on ways families can support physical activity with their daughter
Control: standard PE class was a curriculum in which students were taught skills in individual and team sports. For example, during the basketball unit, students were taught how to dribble, shoot, and pass, and were tested on concepts such as game rules and defense strategies. Similar to the intervention structure, 1 semester focused on individual sports and the other on team sports. Classes were taught by certified PE teachers employed by the school. Parents of participants in the standard PE class also received monthly newsletters. Topics were of general health interests and included an article about PE class content that month


OutcomesMean systolic blood pressure (mmHg)

Mean diastolic blood pressure (mmHg)

Mean blood cholesterol level (mg/dL)

Body mass index (BMI) (kg/m2)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: no description of the randomization process given

Allocation concealment (selection bias)Low riskComment: criterion not applicable because all participants were allocated at 1 point in time following recruitment, so at time of recruitment allocation was not known

Blinding (performance bias and detection bias)
All outcomes
Unclear riskComment: no Information given, likely not done

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: less than 10% drop-out rate and reasons given (for blood pressure and BMI outcomes)

Selective reporting (reporting bias)Unclear riskComment: no Information given, likely not done

Confounders controlled?High riskComment: while controlled for baseline outcomes and race, they did not account for other important confounders

Data collection methods valid and reliable?Unclear riskComment: reliability and validity of data collection methods were not stated

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Abbott 1989Weak methodological rating

Aburto 2011Data on relevant outcomes for children aged 6 to 18 years not reported

Adeniran 1988Not relevant to public health or health promotion

Aganovic 2002Not relevant to public health or health promotion

Agron 2002No control group

Al-Nakeeb 2007Not a randomized controlled trial

Alexandrov 1988Not a randomized controlled trial

Alexandrov 1992Intervention not aimed at promoting physical activity

Alhassan 2007Data on relevant outcomes for children aged 6 to 18 years not reported

Allensworth 1997Not relevant to public health or health promotion

Allison 1999Not relevant to public health or health promotion

Allison 2000Not a randomized controlled trial

Andersen 1998No control group

Andersen 2003Not a randomized controlled trial

Andersen 2006No control group

Anderson 1999Not relevant to public health or health promotion

Andreacci 2008No control group

Annesi 2004Data on relevant outcomes for children aged 6 to 18 years not reported

Ara 2006Not a randomized controlled trial

Arau jo-Soares 2009Not a randomized controlled trial

Arborelius 1988Intervention not aimed at promoting physical activity. Data on relevant outcomes for children aged 6 to 18 years not reported

Ardoy 2010Not a randomized controlled trial

Armstrong 2000Not a randomized controlled trial

Babin 2001Data on relevant outcomes for children aged 6 to 18 years not reported

Bal 1990Intervention not school based. Intervention not aimed at promoting physical activity

Baquet 2001Weak methodological rating

Baquet 2002Weak methodological rating

Baranowski 2002Not a randomized controlled trial

Baranowski 2005Not a randomized controlled trial

Barthold 1993Data on relevant outcomes for children aged 6 to 18 years not reported. No control group

Baxter 1997Intervention not aimed at promoting physical activity

Beighle 2006No control group

Belansky 2006Weak methodological rating

Benson 2008Intervention not school based

Berenson 1993Not a randomized controlled trial

Berenson 1993aData on relevant outcomes for children aged 6 to 18 years not reported

Berenson 2001Data on relevant outcomes for children aged 6 to 18 years not reported. No control group

Berg-Kelly 1997Not relevant to public health or health promotion

Bergmann 2010Not a randomized controlled trial

Biddle 2004Not a randomized controlled trial

Bindler 2000Not relevant to public health or health promotion

Bischoff 1987No control group

Blank Sherman 1992No control group

Blessing 1994No control group

Bonhauser 2005Weak methodological rating

Booth 2001Not a randomized controlled trial

Boreham 2001Not a randomized controlled trial

Boyd 1997Weak methodological rating

Boyle-Holmes 2010Not a randomized controlled trial

Briancon 2010Data on relevant outcomes for children aged 6 to 18 years not reported

Brown 2004Data on relevant outcomes for children aged 6 to 18 years not reported

Brownell 1982Intervention not aimed at promoting physical activity

Buchan 2011Intervention duration less than 3 months

Bungum 1997Not relevant to public health or health promotion

Burgeson 2001Not a randomized controlled trial

Burgess 2006Intervention not school based

Bush 2010Intervention not school based

Butcher 2007Data on relevant outcomes for children aged 6 to 18 years not reported

Byrd-Williams 2010Not a randomized controlled trial

Cale 2000Not a randomized controlled trial

Calfas 1991Intervention not aimed at promoting physical activity. Data on relevant outcomes for children aged 6 to 18 years not reported. No control group

Calfas 1994Not relevant to public health or health promotion

Caravella 1996Not relevant to public health or health promotion

Cardon 2002Not a randomized controlled trial

Cardon 2004Not a randomized controlled trial

Carlson 2008Not a randomized controlled trial

Carrel 2005bWeak methodological rating

Carrel 2005aIntervention not aimed at general population (overweight/obese-only sample)

Casazza 2007Not a randomized controlled trial

Cass 2006No control group

Castelli 2007Not a randomized controlled trial

Cawley 2007No control group

Chad 1999Data on relevant outcomes for children aged 6 to 18 years not reported. No control group

Challener 1990Not relevant to public health or health promotion

Chatzisarantis 2009Intervention duration less than 3 months

Chavarro 2005Intervention not aimed at general population (only girls not menstruating were included in the study)

Chomitz 2003Weak methodological rating

Choudhuri 2002Not relevant to public health or health promotion

Chow 2001Data on relevant outcomes for children aged 6 to 18 years not reported

Ciccomascolo 2008Intervention not school based

Cirignano 2010Intervention duration less than 3 months

Clark 2008Data on relevant outcomes for children aged 6 to 18 years not reported

Coe 2005Not relevant to public health or health promotion

Coe 2006Data on relevant outcomes for children aged 6 to 18 years not reported

Cohen 1991No control group

Colchico 2000No control group

Collins 1988Not relevant to public health or health promotion

Collins 1995Not relevant to public health or health promotion

Connor 1986Weak methodological rating

Contento 2010Intervention duration less than 3 months

Cornelius 1991Not relevant to public health or health promotion

Cottrell 2005Weak methodological rating

Cox 2006Intervention not school based

Crawford 1997Not relevant to public health or health promotion

Dale 2000Weak methodological rating

Davis 1995Weak methodological rating

de Barros 2009Data on relevant outcomes for children aged 6 to 18 years not reported

De Bourdeaudhuij 2010Intervention duration less than 3 months

De Meij 2010Data on relevant outcomes for children aged 6 to 18 years not reported

DeBar 2006Data on relevant outcomes for children aged 6 to 18 years not reported

Deforche 2004Not relevant to public health or health promotion

Dehar 1991Data on relevant outcomes for children aged 6 to 18 years not reported. No control group

Del Ben 1991No control group

Dellinger 2002Data on relevant outcomes for children aged 6 to 18 years not reported. No control group

DeMarco 1989Not relevant to public health or health promotion

Dempsey 1993Not relevant to public health or health promotion

Dencker 2006Not a randomized controlled trial

Dennison 2004Data on relevant outcomes for children aged 6 to 18 years not reported

Derri 2004Intervention not school based

DeVault 2009Data on relevant outcomes for children aged 6 to 18 years not reported

Devis 1992No control group

Diaz 1997Data on relevant outcomes for children aged 6 to 18 years not reported

Diehl 1998Data on relevant outcomes for children aged 6 to 18 years not reported. Intervention not school based

Dishman 2005Weak methodological rating

Dishman 2010Data on relevant outcomes for children aged 6 to 18 years not reported

Donnelly 1996Weak methodological rating

Dowda 2001Not relevant to public health or health promotion

Drews 2009Data on relevant outcomes for children aged 6 to 18 years not reported

Dudley 2010Intervention not aimed at general population (only girls who expressed low enjoyment of physical activity were included in the study)

Dunbar 1998Intervention not school based. Data on relevant outcomes for children aged 6 to 18 years not reported. No control group

Duncan 1983Study published prior to inclusion date of 1985

Duncan 2004Not a randomized controlled trial

Duncan 2009Intervention duration less than 3 months

Duncan 2010Intervention duration less than 3 months

Dunn 2006No control group

DuShaw 1984Study published prior to inclusion date of 1985

Dwyer 1979Study published prior to inclusion date of 1985

Dwyer 1983Study published prior to inclusion date of 1985

Dwyer 1991Data on relevant outcomes for children aged 6 to 18 years not reported. No control group

Dwyer 2003Not a randomized controlled trial

Dyson 1998Not relevant to public health or health promotion

Dzewaltowski 2002Data on relevant outcomes for children aged 6 to 18 years not reported

Dzewaltowski 2007Not a randomized controlled trial

Dzewaltowski 2009The type of outcome data collected for physical activity outcomes is this study is too different from how it was measuered by included studies, therefore cannot be synthesized with the included

Economos 2007Not a randomized controlled trial

Edwards 2005Data on relevant outcomes for children aged 6 to 18 years not reported

Eisenmann 2007Not a randomized controlled trial

Ekelund 2004Not a randomized controlled trial

Eliakim 1996Intervention duration less than 3 months

Eliakim 1997Data on relevant outcomes for children aged 6 to 18 years not reported

Epstein 2000Not relevant to public health or health promotion

Ericsson 2011Data on relevant outcomes for children aged 6 to 18 years not reported

Ernst 1999Weak methodological rating

Ernst 2003Weak methodological rating

Errecart 1991No control group

Erwin 2011Not a randomized controlled trial

Escobar 2010Intervention not school based

Everhart 2002Weak methodological rating

Ewart 1998Intervention not aimed at promoting physical activity

Ezendam 2007Data on relevant outcomes for children aged 6 to 18 years not reported

Faigenbaum 1999Intervention not school based

Faigenbaum 2001Data on relevant outcomes for children aged 6 to 18 years not reported

Faigenbaum 2003Data on relevant outcomes for children aged 6 to 18 years not reported

Faigenbaum 2007Intervention not school based

Faigenbaum 2009Data on relevant outcomes for children aged 6 to 18 years not reported

Fairclough 2002Not relevant to public health or health promotion

Fairclough 2005Intervention duration less than 3 months

Faludi 1999Data on relevant outcomes for children aged 6 to 18 years not reported

Fardy 1996Intervention duration less than 3 months

Fisher 2011Not a randomized controlled trial

Fitzgibbon 2005Data on relevant outcomes for children aged 6 to 18 years not reported

Fitzgibbon 2011Data on relevant outcomes for children aged 6 to 18 years not reported

Fleming 2000Data on relevant outcomes for children aged 6 to 18 years not reported. No control group

Flores 1995Weak methodological rating

Foster 1985Not relevant to public health or health promotion

Foster 2008Data on relevant outcomes for children aged 6 to 18 years not reported

Fox 2004Not a randomized controlled trial

Francis 2010Intervention duration less than 3 months

Frauhiger 2002Weak methodological rating

Frenn 2003Not a randomized controlled trial

Frenn 2005Not a randomized controlled trial

Fuchs 2002Intervention not school based. Intervention not aimed at promoting physical activity. Data on relevant outcomes for children aged 6 to 18 years not reported

Fullerton 2007Intervention not aimed at general population (overweight/obese-only sample)

Gallotta 2009Data on relevant outcomes for children aged 6 to 18 years not reported

Giralt 2011Data on relevant outcomes for children aged 6 to 18 years not reported

Goldfine 1993Weak methodological rating

Goran 1999Not relevant to public health or health promotion

Goran 2005Weak methodological rating

Gore 1996Intervention not aimed at promoting physical activity. Data on relevant outcomes for children aged 6 to 18 years not reported

Gortmaker 1999aWeak methodological rating

Gortmaker 1999bWeak methodological rating

Graf 2005Not a randomized controlled trial

Graf 2008Not a randomized controlled trial

Grafner 1987Weak methodological rating

Graham 2008Not a randomized controlled trial

Graham 2008aData on relevant outcomes for children aged 6 to 18 years not reported

Greene 1995Intervention not school based

Greening 2011Not a randomized controlled trial

Grey 2004Data on relevant outcomes for children aged 6 to 18 years not reported

Grey 2009Intervention not aimed at general population (overweight/obese-only sample)

Grund 2001Not relevant to public health or health promotion

Guldbrandsson 2009Not a randomized controlled trial

Gunter 2008Data on relevant outcomes for children aged 6 to 18 years not reported

Gutin 1993Not relevant to public health or health promotion

Gutin 1995Not relevant to public health or health promotion

Gutin 1999Not relevant to public health or health promotion

Gutin 2002Intervention not school based

Gutin 2005Not a randomized controlled trial

Haerens 2007Intervention duration less than 3 months

Haines 2006Not a randomized controlled trial

Halfon 1988Intervention not aimed at promoting physical activity

Hansen 1991Weak methodological rating

Hansen 2005Not relevant to public health or health promotion

Hardman 2011Weak methodological quality (low participation rate; high drop-out rate; less than half of sample included in the final analysis)

Hardy 2007Not a randomized controlled trial

Harrell 1998Weak methodological rating

Harris 1998No control group

Hart 2003Data on relevant outcomes for children aged 6 to 18 years not reported. No control group

Hartmann 2010Data on relevant outcomes for children aged 6 to 18 years not reported

Hasselstrom 2008Data on relevant outcomes for children aged 6 to 18 years not reported

Hastie 2007Data on relevant outcomes for children aged 6 to 18 years not reported

Heale 2008Intervention not school based

HEALTHY Study Group 2010Intervention not aimed at general population (overweight/obese-only sample)

Henaghan 2008Intervention not school based

Hipsky 2002Intervention not school based

Hoelscher 2010Not a randomized controlled trial

Holcomb 1998Weak methodological rating

Hollar 2010Not a randomized controlled trial

Hopper 1992Data on relevant outcomes for children aged 6 to 18 years not reported

Hopper 1996Weak methodological rating

Hopper 2001No control group

Hopper 2005Weak methodological rating

Howard 1996Weak methodological rating

Howe 2003Data on relevant outcomes for children aged 6 to 18 years not reported

Huang 2007Intervention not aimed at general population (overweight/obese-only sample)

Huberty 2011Not a randomized controlled trial

Huguet 1997Data on relevant outcomes for children aged 6 to 18 years not reported

Ingle 2006Intervention not school based

Irwin 2010Intervention duration less than 3 months

Jackson 2001Data on relevant outcomes for children aged 6 to 18 years not reported

Jago 2009Data on relevant outcomes for children aged 6 to 18 years not reported

James 2007Intervention not aimed at promoting physical activity

Jamner 2004Weak methodological rating

Jansen 2008Data on relevant outcomes for children aged 6 to 18 years not reported

Janz 2002Not relevant to public health or health promotion

Jekal 2009Intervention not school based

Jemmott 2011The type of outcome data collected for physical activity outcomes is this study is too different from how it was measuered by included studies, therefore cannot be synthesized with the included

Jiang 2007Intervention not aimed at general population (overweight/obese-only sample)

Johns 1999Not a randomized controlled trial

Johnson-Down 1997Not relevant to public health or health promotion.

Johnston 2007Intervention not aimed at general population (overweight/obese-only sample)

Jones 1988Data on relevant outcomes for children aged 6 to 18 years not reported

Jones 2007Data on relevant outcomes for children aged 6 to 18 years not reported

Jordan 1995Weak methodological rating

Jurg 2006Weak methodological rating

Kain 2004Not a randomized controlled trial

Kain 2008Not a randomized controlled trial

Kann 2000Not a randomized controlled trial

Kaplan 1996Not relevant to public health or health promotion

Karabourniotis 2002Data on relevant outcomes for children aged 6 to 18 years not reported

Katz 2010Not a randomized controlled trial

Kawabe 2000Not relevant to public health or health promotion

Keays 1995Not relevant to public health or health promotion

Kelder 1995aWeak methodological rating

Kelder 2004Not a randomized controlled trial

Kijboonchoo 1999Not a randomized controlled trial

Killen 1989Weak methodological rating

Kimm 1997Not relevant to public health or health promotion

Kimm 2005 Not a randomized controlled trial

Kiran 2010Data on relevant outcomes for children aged 6 to 18 years not reported

Kirkcaldy 2002Data on relevant outcomes for children aged 6 to 18 years not reported. No control group

Klein-Platat 2005Not a randomized controlled trial

Klepp 1994Not a randomized controlled trial

Knox 2009Data on relevant outcomes for children aged 6 to 18 years not reported

Kolbe 1995Data on relevant outcomes for children aged 6 to 18 years not reported. No control group

Kong 2009No control group

Kouli 2009Data on relevant outcomes for children aged 6 to 18 years not reported

Koutedakis 2003Not relevant to public health or health promotion

Kovacs 2009Data on relevant outcomes for children aged 6 to 18 years not reported

Kremers 2005Not a randomized controlled trial

Kriemler 2011Not a randomized controlled trial

Kristensen 2010Data on relevant outcomes for children aged 6 to 18 years not reported

Kwon 2007Intervention not aimed at general population (overweight/obese-only sample)

La Torre 2006Not a randomized controlled trial

Lal 1991Intervention not aimed at promoting physical activity. Data on relevant outcomes for children aged 6 to 18 years not reported. No control group

Lawman 2011Data on relevant outcomes for children aged 6 to 18 years not reported

Lazarus 2000Not a randomized controlled trial

Le Masurier 2005Not a randomized controlled trial

Lee 2010Data on relevant outcomes for children aged 6 to 18 years not reported

LeMura 2000Not relevant to public health or health promotion

Levin 2002Data on relevant outcomes for children aged 6 to 18 years not reported

Lien 2010Data on relevant outcomes for children aged 6 to 18 years not reported

Lindstrom 2010Not a randomized controlled trial

Lionis 1991Not a randomized controlled trial

Liskova 2002Not relevant to public health or health promotion

Lubans 2006Intervention not school based

Lubans 2010aIntervention duration less than 3 months

Lubans 2010bData on relevant outcomes for children aged 6 to 18 years not reported (baseline data only)

Lubans 2011Intervention not aimed at general population (only low active boys were included in the study)

Ludwig 2004No control group

Luepker 1999Not relevant to public health or health promotion

Lungo 1994Weak methodological rating

Macaulay 1997Data on relevant outcomes for children aged 6 to 18 years not reported

MacConnie 1991Data on relevant outcomes for children aged 6 to 18 years not reported

Macdonald 1999Data on relevant outcomes for children aged 6 to 18 yearsnot reported.

Macdonald 2007Data on relevant outcomes for children aged 6 to 18 yearsnot reported

MacKelvie 2001Data on relevant outcomes for children aged 6 to 18 yearsnot reported

MacKelvie 2002Data on relevant outcomes for children aged 6 to 18 yearsnot reported

MacKelvie 2004Data on relevant outcomes for children aged 6 to 18 yearsnot reported

MacLean 2003Data on relevant outcomes for children aged 6 to 18 yearsnot reported.

Mahar 2006Data on relevant outcomes for children aged 6 to 18 yearsnot reported

Mahon 1993Weak methodological rating

Mandigo 2003Not relevant to public health or health promotion

Manios 1999Not a randomized controlled trial

Marcus 1987Not a randomized controlled trial

Marcus 2009The type of outcome data collected for physical activity outcomes is this study is too different from how it was measuered by included studies, therefore cannot be synthesized with the included

Marks 2006Intervention not school based

Martin 2010Not a randomized controlled trial

Matsudo 1999No control group

Mauriello 2010Intervention not school based

McAuley 2010Intervention not school based

McKay 2003Data on relevant outcomes for children aged 6 to 18 yearsnot reported

McKenzie 1993Data on relevant outcomes for children aged 6 to 18 yearsnot reported

McKenzie 2002Weak methodological rating

McManus 1997Intervention not school based

McManus 2005Not relevant to public health or health promotion

McManus 2008aIntervention not school based

McMurray 2002Weak methodological rating

McMurray 2009Data on relevant outcomes for children aged 6 to 18 yearsnot reported

McNeil 2009Intervention not school based

McWhannell 2008Intervention not school based

Mecredy 1993Data on relevant outcomes for children aged 6 to 18 yearsnot reported

Meininger 2000Not relevant to public health or health promotion

Mellin 1987Intervention not school based

Melnyk 1994Not relevant to public health or health promotion

Melnyk 2007Intervention not aimed at general population (overweight/obese-only sample)

Melnyk 2009Intervention not aimed at general population (overweight/obese-only sample)

Meredith 1991Not relevant to public health or health promotion

Mettler 2000Data on relevant outcomes for children aged 6 to 18 yearsnot reported

Metzker 2000Weak methodological rating

Meunnich Cowell 1989No control group

Mier 2002No control group

Missouri 2003Not relevant to public health or health promotion

Mo-suwan 1998Data on relevant outcomes for children aged 6 to 18 yearsnot reported

Moberg 1990Intervention not aimed at promoting physical activity. Data on relevant outcomes for children aged 6 to 18 yearsnot reported

Monness 2009Not a randomized controlled trial

Moodie 2011Intervention not school based.

Moon 1999Weak methodological rating

Morris 1997Intervention not aimed at promoting physical activity

Motlagh 2009Data on relevant outcomes for children aged 6 to 18 yearsnot reported

Mott 1991Data on relevant outcomes for children aged 6 to 18 yearsnot reported

Moya 2011Intervention not school based

Muller 2001Weak methodological rating

Muller 2005Not a randomized controlled trial

Muth 2008Not a randomized controlled trial

Nabipour 2004Intervention not aimed at promoting physical activity

Nader 1992Intervention not aimed at promoting physical activity

Nahas 2009Data on relevant outcomes for children aged 6 to 18 yearsnot reported

Naylor 2006Data on relevant outcomes for children aged 6 to 18 yearsnot reported

NCCDP 1997Intervention not aimed at promoting physical activity. Data on relevant outcomes for children aged 6 to 18 yearsnot reported. No control group

Nelson 2011Not a randomized controlled trial

NeumarkSztainer 2003Weak methodological rating

Newton 2010Not a randomized controlled trial

Niederer 2009Data on relevant outcomes for children aged 6 to 18 yearsnot reported

Nielsen 2010Data on relevant outcomes for children aged 6 to 18 yearsnot reported

Nyberg 2011Data on relevant outcomes for children aged 6 to 18 yearsnot reported

O'Loughlin 1999Data on relevant outcomes for children aged 6 to 18 yearsnot reported. Intervention not school based

Okely 2010Intervention not aimed at general population (overweight/obese-only sample)

Ostbye 2011Data on relevant outcomes for children aged 6 to 18 yearsnot reported

Owen 1995No control group

Oxizoglou 2005Weak methodological rating

Palmer 2005Weak methodological rating

Pangrazi 2003Not a randomized controlled trial

Parcel 1989Weak methodological rating

Park 2007Intervention not school based.

Parlee-Hirth 2002Data on relevant outcomes for children aged 6 to 18 yearsnot reported. No control group

Pate 1987Not relevant to public health or health promotion

Pate 1994Not relevant to public health or health promotion

Pate 1995aNot relevant to public health or health promotion

Pate 1995bNot relevant to public health or health promotion

Pate 1996Not relevant to public health or health promotion

Pate 1999Not a randomized controlled trial

Pate 2003Weak methodological rating

Pate 2006Not a randomized controlled trial

Pena 2004Weak methodological rating

Peralta 2009aIntervention not aimed at general population (overweight/obese-only sample)

Perry 1987No control group

Petkevicius 1985Weak methodological rating

Phillipp 1989Weak methodological rating

Piper 1993No control group.

Plachta-Danielzik 2007Not a randomized controlled trial.

Plotnikoff 1999Not a randomized controlled trial.

Pollatschek 1989Weak methodological rating

Prochaska 2002Data on relevant outcomes for children aged 6 to 18 yearsnot reported

Prusak 2010Data on relevant outcomes for children aged 6 to 18 yearsnot reported

Racette 2010Data on relevant outcomes for children aged 6 to 18 yearsnot reported

Raitakari 1994aIntervention not school based

Rakovi 2008Not a randomized controlled trial

Ramsay 1990Intervention not school based

Ransdell 2003Intervention not school based

Reilly 2006Data on relevant outcomes for children aged 6 to 18 yearsnot reported

Reinhardt 2002No control group

Renaud 1997Data on relevant outcomes for children aged 6 to 18 yearsnot reported. No control group

Resaland 2011Not a randomized controlled trial

Resnick 2009Intervention not school based

Resnicow 1992Weak methodological rating

Resnicow 1993Not relevant to public health or health promotion

Resnicow 1996Not relevant to public health or health promotion

Resnicow 1997Not relevant to public health or health promotion

Resnicow 2000Not relevant to public health or health promotion

Resnicow 2002Data on relevant outcomes for children aged 6 to 18 yearsnot reported. Intervention not school based

Reybrouck 1990Not relevant to public health or health promotion

Rezvanian 2010Intervention not aimed at general population (overweight/obese-only sample)

Ridgers 2010Not a randomized controlled trial (although children from schools were randomly selected to participate in the study, the schools were not randomly allocated to intervention or control: 15 schools from the low SES area were chosen, and then matched to similar schools)

Rimmer 1997Weak methodological rating

Robbins 2006Intervention not school based

Robinson 1999Not relevant to public health or health promotion

Robinson 2003Intervention not school-based

Robinson 2007Intervention not school based

Robinson 2008Intervention not school based

Rodgers 2001Not a randomized controlled trial

Rosenbaum 2007Weak methodological rating

Rowland 1991No control group

Ruiz 2006Not a randomized controlled trial

Saakslahti 2004Intervention not school based

Sabet-Sarvestani 2008Data on relevant outcomes for children aged 6 to 18 yearsnot reported

Sacher 2003Intervention not school based

Sadowsky 1999Weak methodological rating

Sahota 2001aWeak methodological rating

Sahota 2001bData on relevant outcomes for children aged 6 to 18 yearsnot reported

Saksvig 2003Data on relevant outcomes for children aged 6 to 18 yearsnot reported

Sakuragi 2009Not a randomized controlled trial

Sallis 1993aNot relevant to public health or health promotion

Sallis 1993bNot relevant to public health or health promotion

Sallis 1997Not a randomized controlled trial

Salmon 2005Data on relevant outcomes for children aged 6 to 18 yearsnot reported

Salmon 2010Data on relevant outcomes for children aged 6 to 18 yearsnot reported

Samples 2010Data on relevant outcomes for children aged 6 to 18 yearsnot reported

Santiago 2007Intervention not aimed at promoting physical activity

Sasaki 1987Intervention not aimed at promoting physical activity

Schneider 2007Weak methodological rating

Schneider 2009Data on relevant outcomes for children aged 6 to 18 yearsnot reported

Schofield 2005Weak methodological rating

Schuldheisz 1998No control group

Schwarzer 2010Not a randomized controlled trial

Scott 1988Intervention not aimed at promoting physical activity. Data on relevant outcomes for children aged 6 to 18 yearsnot reported. No control group

Sharma 2009Not a randomized controlled trial

Shaw 1989Data on relevant outcomes for children aged 6 to 18 yearsnot reported. Intervention not school based. Intervention not aimed at promoting physical activity. No control group

Shea 1996Data on relevant outcomes for children aged 6 to 18 yearsnot reported

Shek 2008Intervention not aimed at promoting physical activity

Shephard 1992Not relevant to public health or health promotion

Shephard 1996Weak methodological rating

Shimon 2009Data on relevant outcomes for children aged 6 to 18 yearsnot reported

Shingo 2002Not relevant to public health or health promotion

Siegel 1984Intervention not school based

Siegrist 2011Data on relevant outcomes for children aged 6 to 18 yearsnot reported

Simonetti 1986Intervention not aimed at promoting physical activity

Singh 2007Weak methodological rating

Skybo 2002Weak methodological rating

Slawta 2004No control group

Slootmaker 2010Intervention not aimed at whole school population (only low active children were included in the study)

Smith 2009Not a randomized controlled trial

Smith 2011Intervention not school based

Sobczyk 1995Data on relevant outcomes for children aged 6 to 18 yearsnot reported

Sollerhed 2008Not a randomized controlled trial

Soong 1997Not relevant to public health or health promotion

Sothern 1993Not relevant to public health or health promotion

Sothern 1999Not relevant to public health or health promotion

Sothern 2001Not relevant to public health or health promotion

Spence 1997Not relevant to public health or health promotion

Speroni 2007Not a randomized controlled trial

Spiegel 2006Weak methodological rating

Standage 2005Not a randomized controlled trial

Stergioulas 1998Not relevant to public health or health promotion

Stewart 1997Data on relevant outcomes for children aged 6 to 18 yearsnot reported

Stewart 2004Data on relevant outcomes for children aged 6 to 18 yearsnot reported

Stock 2007Not a randomized controlled trial

Stone 1998Not relevant to public health or health promotion

Stone 1989Not relevant to public health or health promotion

Stone 1995Not relevant to public health or health promotion

Stratton 2000Weak methodological rating

Stratton 2005Not a randomized controlled trial

Strazzullo 1988Not relevant to public health or health promotion

Strong 2005Not a randomized controlled trial

Tak 2007Intervention not aimed at general population (overweight/obese-only sample)

Tamir 1990Weak methodological rating

Tavener 1993No control group

Taylor 2006Not a randomized controlled trial

Taylor 2007Not a randomized controlled trial

Taymoori 2008Intervention not school based

Taymoori 2008aIntervention not school based.

Teerarungsikul 2009Not a randomized controlled trial.

Telford 2009Not a randomized controlled trial

Thakor 2004Not relevant to public health or health promotion

Theodorakis 2008Data on relevant outcomes for children aged 6 to 18 yearsnot reported

Thomas 2007Not a randomized controlled trial

Tolfrey 1998Intervention not school based

Tolfrey 2004Intervention not school based

Toruner 2010Not a randomized controlled trial

Trevino 1998Not a randomized controlled trial

Trost 1997Not relevant to public health or health promotion

Trost 1999aNot relevant to public health or health promotion

Trost 1999bNot relevant to public health or health promotion

Trudeau 1999Not a randomized controlled trial

Trudeau 2008Not a randomized controlled trial

Tsai 2009Not a randomized controlled trial

Tsorbatzoudis 2005Weak methodological rating

Tuckman 1986Weak methodological rating

Tudor-Locke 2001Not relevant to public health or health promotion

Tudor-Locke 2006Not a randomized controlled trial

Turnbull 2004Not a randomized controlled trial

Uzunovic 2008Intervention not school based

Vaccaro 1989Not relevant to public health or health promotion

Valverde 1998Not relevant to public health or health promotion

van Beurden 2003Weak methodological rating.

van Mil 1999Not relevant to public health or health promotion.

Velez 2010Outcome data on outcomes relevant to this review not reported

Venditti 2009Data on relevant outcomes for children aged 6 to 18 yearsnot reported

Verderber 2001Not relevant to public health or health promotion

Verstraete 2007Weak methodological rating

Verstraete 2007aThe type of outcome data collected for physical activity outcomes is this study is too different from how it was measuered by included studies, therefore cannot be synthesized with the included

Veugelers 2005Weak methodological rating.

Vissers 2008Intervention not aimed at general population (overweight/obese-only sample)

Walton 1999Not relevant to public health or health promotion

Wang 2006Data on relevant outcomes for children aged 6 to 18 yearsnot reported

Wang 2006aData on relevant outcomes for children aged 6 to 18 yearsnot reported

Warren 2003Data on relevant outcomes for children aged 6 to 18 yearsnot reported

Watts 2004Data on relevant outcomes for children aged 6 to 18 yearsnot reported

Weber 1989Data on relevant outcomes for children aged 6 to 18 yearsnot reported

Weber Cullen 1999Data on relevant outcomes for children aged 6 to 18 yearsnot reported

Wechsler 2000Not a randomized controlled trial

Weintraub 2008Intervention not aimed at general population (overweight/obese-only sample)

Wen 2008Data on relevant outcomes for children aged 6 to 18 yearsnot reported

Werch 2005Weak methodological rating

Werner 1988Weak methodological rating

Westcott 1995Not relevant to public health or health promotion

Wharf Higgins 2001Intervention not aimed at promoting physical activity. Data on relevant outcomes for children aged 6 to 18 yearsnot reported. No control group

Williden 2006Not a randomized controlled trial

Wilson 2005Weak methodological rating

Wilson 2006Not a randomized controlled trial

Wilson 2008Data on relevant outcomes for children aged 6 to 18 yearsnot reported

Wing 1998Data on relevant outcomes for children aged 6 to 18 yearsnot reported. Intervention not school based.

Winters 2003No control group

Wong 2008Intervention not aimed at general population (overweight/obese-only sample)

Yin 2005Weak methodological rating

Yopp Cohen 1989Not relevant to public health or health promotion

Young 2006aWeak methodological rating

Young 2007Not a randomized controlled trial

Zahner 2006Data on relevant outcomes for children aged 6 to 18 yearsnot reported

Zeelie 2010Intervention duration less than 3 months

Zizzi 2006Weak methodological rating

Zonderland 1994Weak methodological rating

Zuckerman 1989No control group

 
Summary of findings for the main comparison. School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6 to 18 years

School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6 to 18

Patient or population: children and adolescents aged 6 to 18 years

Settings: primarily within the school setting

Intervention: educational, health promotion, counseling, and management strategies focused on the promotion of physical activity and fitness

Comparison: standard, currently existing physical education programs in schools

OutcomesRange of effectsNo of participants
(studies)
Quality of the evidence
(GRADE)

Television viewing
(minutes spent watching TV)
[follow-up: end of intervention to 4 years]
Intervention: 85 to 285 

Control: 89 to 288
9372

(16)
⊕⊕⊝⊝

lowa

Physical activity rates
(% of participants physically active)
[follow-up: end of intervention to 1 year]
Intervention: 53 to 92 

Control: 44 to 91
4123

(5)
⊕⊕⊝⊝

lowa

Physical activity duration
(minutes engaged in physical activity)
[follow-up: end of intervention to 4 years]
Intervention: 3 to 158 

Control: 3 to 143
15743

(23)
⊕⊕⊝⊝

lowa

Mean systolic / diastolic blood pressure
(mm Hg)
[follow-up: end of intervention to 4 years]
Intervention: 96 to 138 / 50 to 73 

Control: 97 to 139 / 50 to 76
13,739

(16)
⊕⊕⊝⊝

lowa

Body mass index (BMI)
(kg/m2)
[follow-up: end of intervention to 4 years]
Intervention: 11.3 to 26.0 

Control: 12.0 to 26.1
27,567

(32)
⊕⊕⊝⊝

lowa

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 aSubstantial heterogeneity between trials regarding type of intervention and measured outcomes; wide and overlapping range of effects.
 
Table 1. Overview of study populations

Characteristic

Study ID
Intervention(s) and
control(s)
[n] randomized[n] finishing study[%] of randomized participants
finishing study

Angelopoulos 2009I: 12-month program integrated into the existing curriculum including: student workbook, teacher manual; covering themes: self-esteem, body image, nutrition, PA, fitness, environmental issues. Implemented for 1 to 2 hours per week with motivational methods used for increasing knowledge, skills and self-efficacy and improving self-monitoring and social influence. School teachers trained by the research team delivered the intervention. Parental involvement (reinforcement) was required to complete some (unspecified) home activities

C: not specified
-I: 321

C: 325

T: 646
-

Araujo-Soares 2009I: 2 x 90-min PA sessions with related homework. A trained psychologist delivered the intervention, assisted by a sports education teacher. A research team member supervised preparation for each session, before which each student was asked to keep a diary for a period of 1 week. After the intervention they were asked to keep the diary for an additional 2 weeks. Worksheets and a 3-min film were used, and each student received a leaflet with main topics

C: not specified
I: 157
C: 134
T: 291
I: 105

C: 90

T: 195
I: 67

C: 67

T: 67

Barbeau 2007I: 10-month after-school PA program on body composition and CV fitness in young black girls. The program consisted of 30 min of homework time with a healthy snack, and 80 min of PA (25 min skill development, 35 min MVPA, and 20 min of toning and stretching). Activities during the MVPA included games such as basketball, tag, softball, relay races, etc., all of which were modified to keep all of the subjects active throughout the 35-min period. Subjects received small weekly prizes (e.g. bouncy balls, slinkies, pencils, note pads, lip gloss, play jewelry) for maintaining good behavior and attitude and at most 1 unexcused absence. Absences were discussed with parents. Teachers providing the intervention were trained on childhood obesity, PA, and CV risk factors, the goals of the study, the specific protocol to be followed, and the types of activities appropriate for each segment of the intervention and manuals were provided to schools

C: not specified
--I: 81

C: 84

T: -

Bayne-Smith 2004I: the intervention (PATH program) consisted of 30-min classes conducted 5 days per week for 12 weeks. Classes included: 1) brief lecture/discussion on featured topics (CV health and fitness, health behaviors); and 2) 20 to 25 min of vigorous PA (e.g. resistance exercise, endurance or aerobic exercise, alternated each day)

C: the frequency/duration of PE classes were the same as PATH classes (but without lecture/discussion, so 5 extra min of PA each class)
-I: 310
C: 132
T: 442
-

Burke 1998I1: standard PA and nutrition program (WASPAN). Classroom lessons, 20-min fitness sessions daily (minimum 4/week). Nutrition program built around 4 comic books to teach children and parents how to improve diets, plus 1 h/week nutrition classes

I2: standard WASPAN program plus a PA enrichment program for higher-risk children. Incoprorated teacher-parent-student triad, moved PA activities outside of the class and focused on the individual. Children kept weekly diaries

C: no program
I: -
C: -
T: 800 
I: -

C: -

T: 720
I: -

C: -

T: 90

Bush 1989I1: 'Know Your Body' curriculum focusing on nutrition, fitness, and prevention of smoking. Students also receive a personalized health screening and results on a 'health passport'. Parents are mailed copies of their child's results and kept informed by a quarterly newsletter and an introductory Parent-Teacher meeting

I2: 'Know Your Body' curriculum and health screening, but students do not receive the results of their screening, only their parents receive the results

C: health screening only, parents only receive results of screening
I:-
C: -
T: 892 
I: -

C: -

T: 431
I: -

C: -

T: 48

Colin-Ramirez 2010I: RESCATE program, included PA and nutritional components. PA addressed at individual (curriculum), school (PE sessions) and family level (homework and recommendations for parents)

C: no PA/nutrition program
I: -
C: -
T: 619
I: 245

C: 253

T: 498
I: -

C: -

T: 81

Dishman 2004I: Lifestyle Education for Activity Program (LEAP). Aimed to increase girls' self efficacy for PA, via: PE, school environment, health education, school health services, faculty or staff health promotion, and parent and community involvement

C: standard PE as part of school curriculum
I: 1523
C: 1221
T: 2744
I: -

C: -

T: 2111
I: -

C: -

T: 77

Donnelly 2009I: Physical Activity Across the Curriculum (PAAC), 90 min/week of moderate to vigorous physically active academic lessons delivered intermittently throughout the school day

C: regular classroom instruction without physically active lessons
I: 814
C: 713
T: 1527
I: 792

C: 698

T: 1490
I: 97

C: 98

T: 98

Dorgo 2009I1: PE MRT program. 80-min classes 3 times per week plus 10 to 15 min warm-up and 20 to 30 min of MRT-specific activities conducted by trained research assistants

I2: PE MRT program plus a CV endurance training segment in every session including: walking, jogging, step aerobics, and aerobic kickboxing

C: a regular PE program that followed the usual school curriculum. 80-min classes 3 times per week
I: 141
C: 232
T: 373
I: 93

C: 129

T: 222
I: 66

C: 56

T: 60

Ewart 1998I: 50-min 'Project Heart' aerobic exercise classes including didactic instruction.

C: 50-min standard PE classes
I: 45
C: 54
T: 99
I: 44

C: 44

T: 88
I: 99

C: 82

T: 89

Gentile 2009I: 'Switch' program, promoted healthy active lifestyles including: being active for 60 min or more per day, limiting total screen time to 2 hours or fewer per day, and eating 5 fruits/vegetables or more per day. Included 3 ecologic levels (family, school, community)

C: no intentional exposure to the Switch program
I: 670
C: 653
T: 1323
I: -

C: -

T: 1029
I: -

C: -

T: 78

Haerens 2006I1: PA and nutrition intervention to increase levels of MVPA to at least 60 min a day, increase fruit consumption, increase water consumption, and reduce fat. A computer-tailored intervention assessed children's PA activities and provided tailored feedback

I2: PA and nutrition intervention (same as I1 group) plus parental involvement, including: an interactive meeting on healthy food and PA, a newsletter 3 times/year, and a CD with an adult computer-tailored intervention (same as the children's computer-tailored intervention) for use at home

C: no PA and nutrition intervention
I: 2105
C: 735
T: 2840
I: -

C: -

T: 2434
I: -

C: -

T: 86

Haerens 2009I: computer-tailored PA program consisting of a demographic questionnaire, a PA questionnaire and a questionnaire on psychosocial determinants followed by tailored feedback that related students' PA levels to the PA guidelines

C: generic information on the benefits of PA, public health recommendations, differences between moderate and vigorous intensity activities and tips on how to become more active
I: 563

C: 608

T: 1171
I: 433
C: 448
T: 881
I: 77

C: 74

T: 75

Jones 2008I: included: 1) a health curriculum (classroom lessons and behavioral journalism - during 6th grade, 16 sessions during PE classes, 3 times per week; during 7th grade, science-based lessons during science class); 2) a PE program; and 3) a school food service component, emphasizing calcium-rich food

C: the control group participated in the usual health program
I: 347
C: 371
T: 718
I: 291

C: 315

T: 606
I: 84

C: 85

T: 84

Kipping 2008I: included: 16 lessons on healthy eating, increasing PA and reducing television viewing taught over 5 months by 10 specifically trained teachers. Materials provided to the schools included: lesson plans for 9 PA lessons, 6 nutrition lessons and 1 lesson about screen viewing

C: the control schools were given the materials only after the completion of the study
I: 331
C: 348
T: 679
I: 304

C: 300

T: 604
I: 92

C: 86

T: 89

Kriemler 2010I: the intervention was a multicomponent PA program that included: 1) 3 existing 45-min PE lessons per week; 2) 2 additional 45-min PE lessons per week; 3) daily short activity breaks; and 4) PA homework

C: the control group participated in the usual, mandatory PE lessons (45-min, 3 times/week)
I: 305

C: 235

T: 540
I: 297
C: 205
T: 502
I: 97

C: 87

T: 93

Li 2010I: the intervention (TAKE 10! Program) included 2 daily 10-min PA sessions: 1) the teacher or student selected 1 to 3 activity cards; 2) several children modeled the exercises, the other students followed along; 3) cool-down period; and 4) the students were taught a health message

C: no intervention took place
I: 2371
C: 2329
T: 4700
I: 2092

C: 2028

T:4210
I: 88

C: 87

T: 88

Lubans 2009I: included: 1) 10-week school sport program and exercise program booklet; 2) information sessions; 3) PA and dietary monitoring using pedometers and diaries; 4) program X weekly messages and parent information leaflets; and 5) email support

C: the control group attended a 10-week school sport program and received an exercise program booklet
I: 58
C: 66
T: 124
I: 53

C: 53

T: 106
I: 91

C: 80

T: 86

Luepker 1996I1: group received a school-based program consisting of school food service modifications, PE interventions, and the CATCH curricula

I2: group received the same school-based program plus a family-based program

C: group received the usual health curricula, PE, and food service programs, but none of the CATCH interventions
I: 3651

C: 1455

T: 5106
I: 3297

C: 722

T: 4019
I: 90

C: 50

T: 79

Martinez 2008I: received: 1) the standard, compulsory PE curriculum (3 hours per week of low-to-moderate intensity activity); 2) recreational, noncompetitive, after school PA program (3 x 90-min sessions per week, for 24 weeks)

C: received the standard, compulsory PE curriculum: 3 hours per week of PA at low-to-moderate intensity
I: 691
C: 718
T: 1409
I: 465

C: 579

T: 1044
I: 67

C: 81

T: 74

McManus 2008I1: Educational Program Group completed a 2-week education program, taught using an active game approach, that included: information about heart health, the use of heart rate feedback to attain an activity target, goal-setting and role-play. They then completed 2-weeks with heat rate feedback and 2-weeks without heart rate feedback

I2: No-education Program Group completed a 2-week control program of standard PE classes without PA or heart health education. They then completed 2-weeks with heart rate feedback and 2-weeks without heart rate feedback but were not given any information about the heart rate signal or its meaning

C: no intervention took place
I: 128
C: 69
T: 197
I: 125

C: 68

T: 193
I: 98

C: 99

T: 98

Neumark-Sztainer 2009I: included: (i) 14 x 2-hour after-school theater sessions (which included: check-in, snack, movement component, theatrical activity - the final sessions focused on rehearsing for a play performance (script developed throughout intervention)); (ii) 8 weekly after-school booster sessions (activities related to healthy eating and PA, rehearsals for play); and (iii) family outreach component (to enhance home support for behavioral changes through positive reinforcement of healthy behaviors, parent–child participation in PAs and availability of healthy foods) - take home materials, family events

C: a theater-based control condition (i.e. children participated in a play focused on environmental health issues using a prepared script)
I: 56
C: 52
T: 108
I: 51

C: 45

T: 96
I: 91

C: 87

T: 89

Neumark-Sztainer 2010I: participation in the standard all-girls PE class that was supplemented with the New Moves curriculum (nutrition and self-empowerment components, individual sessions using motivational interviewing, lunch meetings, and parent outreach)

C: participation in all-girls PE class (during first semester of school year)
I: 182
C: 174
T: 356
I: 177

C: 159

T: 336
I: 97

C: 91

T: 94

Peralta 2009I: intervention ran over 16 weeks, with each week including 1 x 60-min curriculum session and 2 x 20-min lunchtime PA sessions. Each 60-min curriculum session included practical or theoretical (or both) components focused on promoting PA and increasing fruit consumption and the acquisition and practice of self-regulatory behaviors. Behavior modification techniques were used. The practical component included modified games and activities. The researcher primarily facilitated the intervention with staff and parents' involvement. Eleventh grade students peer facilitated lunchtime sessions. Parents were emailed 6 newsletters throughout, informing them of the program content, motivating them, and suggesting strategies to engage the family in healthy behaviors

C: participated in 16 x 60-min PA curriculum at the same time as the intervention group, with a school PE teacher facilitating the control group
I: 16
C: 17
T: 33
I: 16

C: 16

T: 32
I: 100

C: 94

T: 97

Petchers 1988I: Chicago Heart Health Curriculum Program called "Body Power": a 1-year-long curriculum with modules on 5 topics: 1) CV system, anatomy, and physiology; 2) smoking; 3) nutrition; 4) exercise; and 5) risk factors review. The curriculum was implemented by classroom teachers during at least 3 x 45-min sessions per week for 4 to 6 weeks, with training provided for teachers and supplemented by a comprehensive teachers' manual

C: traditional curriculum with approximately the same amount of teaching time. Control group teachers were provided an alternative experience to the training sessions for the intervention group in the form of a separate in-service
I: -
C: -
T: 452
I: -
C: -
T: 325
I: -
C: -
T: 72

Reed 2008I: The Action Schools! BC model was consistent with the 'active school' framework and emphasized an integrated whole-school approach rather than traditional classroom-based health education, targeting 6 Action Zones: i) School Environment, ii) Scheduled Physical Education, iii) Extracurricular, (iv) School Spirit, v) Family and Community, and vi) Classroom Action. Classroom Action included 15 min of moderate to intense PA daily (75 min of extra PA per week in addition to 2 x 40 min PE classes). Teachers provided opportunities to 'snack on physical activities' such as skipping, dancing, and resistance exercises throughout the day. A school Action Team was convened in each school with a facilitator who helped to design a program with activities across the 6 Action Zones. INT teachers received a 1-day training workshop and a Classroom Action Bin with resources, with the goal for each school to provide students with 150 min of PA/week (2 x 40 min PE classes + 15 x 5 min/day Classroom Action)

C: teachers in usual practice schools continued the regular program of PE and school-based PA
I: 178
C: 90
T: 268
I: 156
C: 81
T: 237
I: 88
C: 90
T: 73

Robinson 1999I: limited access to television use and budgeting television time and involved 18 lessons of 30 to 50 min as part of standard curriculum, taught by regular classroom teachers trained by research staff. Most lessons occurred in the first 2 months of the year and included self-monitoring and self-reporting for television and video game use followed by a 10-day television turnoff challenge after which students were encouraged to follow a 7-h per week budget. Newsletters designed to help parents motivate students and regulate time spent on television and video games for the entire family were distributed. Each household received television time master(s) to regulate television and video use

C: not specified
I: 106
C: 121
T: 227
I: 92

C: 100

T: 192
I: 87

C: 83

T: 85

Salmon 2008I: students were assigned to 1 of 4 conditions: a behavioral modification group (N = 69); a fundamental motor skills group (N = 73); a combined behavioral modification and fundamental motor skills group (N = 90)

C: usual classroom lessons
I: 233

C: 62
T: 295
I: 213

C: 55

T: 268
I: 91

C: 89

T: 91

Simon 2004I: the ICAPS program was implemented over 4 academic years to promote PA inside and outside. The intervention includes an educational component focusing on PA and sedentary behaviors, new opportunities for PA during and after school hours. Activities implemented are either informal or academic with emphasis on fun, well-being, noncompetitiveness. Sporting events, bicycle, and on-foot transport are organized

C: not specified
I: -

C: -

T: 1046
I: 475

C: 479

T: 954
I: -

C: -

T: 91

Singh 2009I: an interdisciplinary program with adapted curriculum including an individual component (11 lessons in biology and PE) and environmental change component including encouragement for schools to increase PE and provision of advice for schools related to cafeteria changes

C: regular curriculum
I: -

C: -

T: 1053
I: -

C: -

T: 875
I: -

C: -

T: 83

Singhal 2010I: multicomponent intervention with 7 components related to nutrition and lifestyle education, including the following activities: dissemination of health-related information through lectures and focused group discussions (24 weeks (6 months) of nutrition education), promotion of PA, other promotion of healthy lifestyle, individual counseling, policy-level changes in schools, involvement of teachers and parents, training of student volunteers for program sustainability

C: no intervention
I: 101
C: 108
T: 209
I: 99

C:102

T: 201
I: 98

C: 94

T: 96

Stephens 1998I: 18 medical students delivered 3 activity sessions per week, consisting of 5 min of warm-up and stretching, plus 20 min of aerobic activity. Activities incorporated repetitive movements of large muscle groups, designed to elevate the pulse rate 40 to 60 beats/min over resting level. Sessions ended with a 5 to 10 min cool-down with presentation of educational material about nutrition, exercise, and disease prevention

C: students in the control classroom received no additional PA beyond regular PE classes
I: 45
C: 44
T: 89
--

Stone 2003I: intervention program was implemented during third through fifth grades, with 4 components including: food service, skills-based classroom curricula, family, and PE

C: not specified
I: 879
C: 825
T: 1704
I: 644

C: 653

T: 1297
I: 73

C: 79

T: 76

Trevino 2004I: 50 sessions of health programming re: 3 health behavior messages associated with diabetes mellitus control (decreased dietary saturated fat intake, increase dietary fiber intake, increase PA). Children were asked to set goals and keep records of their accomplishments and were rewarded with coupons from a store set up in the school

C: not specified
I: 969
C: 1024
T: 1993
I: 619

C: 602

T: 1221
I: 64

C: 59

T: 61

Verstraete 2006I: classes were provided game equipment (jump ropes, scoop sets, flying discs, balls, plastic hoops, juggling rings and beanballs, badminton racquets, beach paddles) and 'activity cards' demonstrating use of the equipment for use outdoors during recesses and lunch break

C: not specified
-I: 122
C: 113
T: 235
-

Walter 1988I: special curriculum targeting voluntary changes in risk behavior in the area of diet, PA, and smoking, taught in classrooms by specially trained regular teachers for ˜2 hours per week

C: not specified
I: 2075

C: 1313

T: 3388
I: 961

C: 871

T: 1769
I: 46

C: 66

T: 53

Walther 2009I: 1 unit of PE (45 min) with at least 15 min of endurance training per school day, plus lessons on healthy lifestyle 1 per month

C: according to German standards, 2 units (each 45 min) of PE per week are mandatory in all schools. 12 units (45 min per unit) of high-level endurance exercise training per week plus participation in competitive sporting events
I: 112

C: 76

T: 188
I: 109

C: 73

T: 182
I: 97

C: 96

T: 97

Wang 2008I: 'FitKid' after-school program, 2-h intervention sessions (40-min academic enrichment activities and a healthy snack provided; 80 min of PA designed to improve sport skills, aerobic fitness, strength, and flexibility with a minimum of 40 min were devoted to vigorous PA), offered 5 days a week, instructed by certified school teachers and paraprofessionals

C: not specified
I: 603

C: 584

T: 1187
I: 260

C: 265

T: 525
I: 43

C: 45

T: 44

Webber 2008I: six TAAG health education lessons per school year to enhance behavioral skills known to influence PA participation (self-monitoring, setting goals for behavior change). Offered in 2 forms: 1 for a traditional classroom setting and 1 for PE class. Girls were the focus of the intervention; however, health and PE classes were part of the usual school curriculum and most included boys as well

C: not specified
I: -
C: -

T: 3502
I: -
C: -

T: 3378
I: -
C: -

T: 97

Weeks 2008I: 10 min of directed jumping activity at the beginning of every PE class (twice per week), designed to apply loads to the skeleton at high strain magnitude, frequency, and rate, including: jumps, hops, tuck-jumps, jump-squats, stride jumps, star jumps, lunges, side lunges, and skipping

C: regular PE warm-ups and stretching at the beginning of every PE class (twice per week), including: brisk walking, light jogging, and stretching
I: 52
C: 47
T: 99
I: 43

C: 38

T: 81
I: 83

C: 81

T: 82

Williamson 2007I: Healthy Eating and Exercise (HEE) program; goal was to increase PA during the school day and at home. Teachers were provided with containers filled with indoor play supplies (e.g. balloons, bean bags) and outdoor play supplies (e.g. balls, jump ropes) to promote active play during class time and recess. Posters encouraged the use of these PACs, and brief lesson plans provided academic games that used the supplies contained in the PACs

C: Alcohol/Drug/Tobacco abuse prevention (ADT) program, designed with the goal of modifying children's beliefs and attitudes regarding the use and abuse of tobacco, alcohol, and illicit drugs so that they reflected "healthier" values
I: 313
C: 348

T: 661
I: 282

C: 304

T: 586
I: 90

C: 87

T: 89

Wilson 2011I: ACT, a 17-week program implemented for 2 hours, 3 days/week by a trained instructor. Three main components: homework/snack (30 min), MVPA activities (60 min) that students selected each week, and a behavioral skills and motivational component (30 min)

C: The General Health Education Program (comparison program) focused on nutrition, stress management, drug prevention, and drop-out prevention (with no PA component), and consisted of a homework/snack (30 min) and 3 hands-on activities related to general health (30 min each). The comparison program was held on the same days and times as the ACT intervention program
I: 729
C: 693
T: 1422
I: 673

C: 635

T: 1308
I: 92

C: 94

T: 92

Young 2006I: included information to make an informed decision about the personal benefits of a physically active lifestyle, develop problem-solving skills, and obtain support from others. Specific strategies taught by a trained teacher included: goal setting, problem-solving barriers, communication skills, reinforcement of goal achievement through internal and external rewards, and learning from relevant role models. The PA portion of the intervention was congruent with the school's PE curriculum - 1 semester of individual sports and 1 semester of team sports - taught 5 days per week. The family support component consisted of a family workshop, monthly newsletters, and adult-child homework assignments

C: standard PE class in which students were taught skills in individual and team sports. Similar to the intervention structure, 1 semester focused on individual sports and the other on team sports. Classes were taught by certified PE teachers employed by the school. Parents of participants in the standard PE class also received monthly newsletters
I: 116
C: 105
T: 221
I: 111

C: 99

T: 210
I: 96

C: 94

T: 95

TotalI: 20,930

C: 15,897

T* : 45,191
I: 13,358

C: 10,163

T* : 36,593

 C: control; CV: cardiovascular; I: intervention; MRT: manual resistance training; MVPA: moderate to vigorous physical activity; PA: physical activity; PAC: physical activity center; PE: physical education; T: total.
"-" denotes not reported.
*T does not equal the sum of I and C as some studies did not report the breakdown of participants in each group.