Appendix Extensive Summary Tables of Included Studies (Including Information About Study

Appendix Extensive summary tables of included studies (including information about study design, participants, setting, intervention description, underlying theory, duration of study and follow-up, measurements, instruments used for measurements, results, extra information about parental participation)

Study name /author (year) / country / Study design / Participants / Setting / Description of the intervention / Underlying theory / Duration of the intervention (I)+ follow-up period(FU)
CATCH
1991
US / Three arm randomized controlled trial (RCT): a school + family intervention, a school intervention and control intervention group
Unit of randomization: school (cluster) / 5106 children grades 3 – 5
Mean age: 8.75 ±0.487
Mostly 50% females
69% Caucasian,
13% African-American,
13% Hispanic,
4% other / 56 Intervention and 40 Control schools in California, Louisiana, Minnesota, Texas
S+P: n=28
S: n=28
C: n=40 / The Child and Adolescent Trial for Cardiovascular Health (CATCH) study, a school-based cardiovascular health promotion program focusing on diet, PA and smoking (limited)
The CATCH intervention consisted of school-based (school food service, physical education, curricula) and family-based (home curricula, fun nights) components. School food service changes and physical education enhancement were continuous programs over the 3 school years. The classroom and home curricula were implemented by classroom teachers over a defined time period during each school year, and addressed eating habits (3rd through 5th grades), physical activity (4th and 5th grades), and cigarette smoking (5th grade only).
A school-based intervention arm (S), in which a behavioral cardiovascular health education program is added to the curriculum, the cafeteria food service is modified to provide lunches with less fat and salt, the physical education program is modified to promote more vigorous physical activity, and a nonsmoking policy is introduced into the school,
Eat Smart was the food service intervention and the goal was to provide children with tasty meals that were lower in fat (to 30% of energy), saturated fat (to 10% of energy), and sodium (600-1000mg/serving), while maintaining recommended levels of essential nutrients and child participation in the school meal programs. Food service personnel participated in a 1-day training session at the beginning of each school year. Monthly follow-up visits to the schools and booster sessions provided further information, help in planning, and support.
CATCH Physical education (PE) was the physical education intervention. It was implemented in third grade, and sought to increase the amount of enjoyable moderate and vigorous physical activity during physical education classes at school, and had the goal to increase the amount of moderate to vigorous physical activity to 40% of the physical education class. Physical education specialists and teachers had 1 to 1,5 days of CATCH training each school year. At least 90 min of CATCH PE per week spread over a minimum of three sessions per week. Materials used: CATCH PE Guidebook, the Activity Box, and supplementary materials.
The classroom curricula included the Adventures of Hearty Heart and Friends, Go for Health-4 and Go for Health-5, for the 3rd through 5th grades, respectively. They consisted of 15, 24 an 16 lessons over 5, 12 and 8 weeks in the 3rd, 4th, and 5th grades, respectively. Each lesson was 30 to 40 minutes in length. The curricula targeted specific psychosocial factors and involved skills development focused on eating behaviors and physical activity patterns. Additionally, F.A.C.T.S. for Five was a four-session tobacco use prevention curriculum implemented in the 5th grade. Classroom teachers attended 1 to 1,5 days of training each year to implement the curricula using standardized protocols at all sites to insure comparable implementation.
A combined school-based and family-based intervention arm (S+F), in which the intervention comprises all of the elements of intervention S plus a program of family involvement in cardiovascular health education activities that complement and are conducted concurrently with the classroom curriculum.
The family program was the home curricula and involved activity packets that complemented the classroom curricula. These packets were sent home with the students and required adult participation to complete. There were 19 activity packets (a take home packet of learning materials and activities) over the course of 3 school years. Score cards to record points for completing home activities were used for giving small rewards (pencils, memo pads, and certificates) to encourage family participation. In addition, during the third and fourth grades, students invited their family members to a family fun night to culminate the classroom activities. The fun nights (1.5-2 hr. events) consisted of dance performances by the students, food booths (prizes, games and activities in the format of a fair, in either gym/auditorium or school play area), healthy snacks, recipes, and games. These fun nights followed a standardized protocol across all sites. The purpose of the event was to raise awareness of the goals and skills contained in CATCH.
Four home-based curricula were implemented. These included, in 3th grade, Hearty Haert Home Team (5 activity packets distributed weekly), in the 4th grade, Stowaway to Planet Stronghaert (6 weekly activity packets), in 5th grade, Health Trek… The Journey continues (four tip sheets), and at the end of the 5th grade, The Unpuffables (4 weekly activity packets about smoking). The activity packets were distributed each week to students and differed in format and content, depending on the grade level. The activity packets contained a story to be read by all household members followed by a series of activities to be completed at home: healthy recipes, family physical activities, myths about smoking, games, and goal-setting. The refrigerator tip sheets, which were distributed with magnets for refrigerator display, had summaries of health diets and activities to complete. Students brought back to school cards on which parents and students indicated the activities they had completed.
A control arm (C), in which the usual curriculum, food service, and physical education program are provided in the school. / Social cognitive theory and organizational change models including both institutional and individual-level strategies / Baseline: fall 1991
Intervention from January 1992 till spring 1994
FU: each year at the end of the school year in grades 3, 4 and 5 for psychosocial determinants and behaviours
And 1 FU (after three years) for anthropometrical outcomes
Haerens
2003
Belgium / Cluster RCT with three conditions:school-plus-family intervention (S+F), school-based intervention (S) and control group (C)
Unit of randomization: school (cluster) / Random sample of 15 schools, assigned to 3 conditions (5 per condition), 7th and 8th graders
Baseline (n=2840):
S+F: n=1226
S: n=1006
C: n=759
Age: mean=13,1±0,8
%Girls: 36,6±48,2
%Overweight: 18,5 ±38,8
%Higher Socio-economic status (SES): 32,6±46,9
From each of the 15 schools, one class of 7th graders was randomly selected for more in-depth measurement of PA with accelerometers (subsample n=258) / Schools with technical and vocational education in West Flanders (Belgium) / A school-based intervention programme to promote healthy food and physical activity over 2 school was developed. The intervention was designed to be implemented by the school staff itself with only minimal external support to make later implementation in all Flemish schools feasible. During the first intervention year, schools were guided and supported by the research staff to get started; during the second intervention year, schools had to continue with implementation more independently.
Physical activity
The physical activity intervention focused on increasing levels of moderate to vigorous physical activity (MVPA) to at least 60 min a day.
-  Schools were encouraged to create more opportunities to be physically active during breaks, at noon or during after school hours. Schools were encouraged to vary content of physical activities offered in order to reach all pupils. Organization of non-competitive activities was encouraged to increase engagement of less talented children.
-  Additionally, extra sports materials were made available. Every school received an intervention box with sports materials like ropes, balls and beachball sets. Schools were encouraged to make these sports materials available during breaks, at noon and during after school hours.
-  Schools were also stimulated to encourage active transportation.
-  Children received a physical fitness test and an adaptation of the adult computer-tailored intervention for physical activity. The physical fitness test took place once, at the beginning of the second intervention year. During classes, all children had to cycle for 10 min on a computerized cycle ergometer. By means of folders, information was given on their fitness levels and possible ways to improve it. By using CDs, the computer-tailored intervention was completed once each school year during one class hour. The first part of questions concerned demographic factors, physical activity, psychosocial determinants of physical activity behaviours. After completing all questions, tailored feedback was displayed immediately on the screen. First, a general introduction and normative feedback was presented. Overall, an active lifestyle and participation in sports activities was promoted in an advice of five to six pages. Children could either save the advice on the computer or in some cases immediately print feedback. Afterwards, they had to complete a task with questions concerning their advice.
Food
The food intervention focused on three behavioural changes:
(i) increasing fruit consumption to at least two pieces a day,
(ii) reducing soft drink consumption and increasing water consumption to 1.5 l a day and
(iii) reducing fat intake.
-  To facilitate fruit consumption, schools were asked to sell fruit at school at very low price or for free at least once a week. It was also suggested to offer fruit for dessert during lunch break. Furthermore, schools tried to promote drinking water as opposed to soft drinks, by offering it for free by means of drinking fountains or at lower price than soft drinks in shops or vending machines. All children received a free water can to make it possible to bring water to school.
-  Children received additional information about health consequences of eating fruit as opposed to snacks and of drinking water rather than soft drinks by means of folders and posters.
-  Every school year, children got an adaptation of the adult computer-tailored intervention for fat and fruit intake during one class hour. Questionnaires concerning demographics, fat intake, fruit intake and psychosocial determinants of fat intake lead to a tailored fat advice and normative feedback for fruit intake.
Parent involvement
The goal of parent involvement was to create a supportive environment for healthy behaviours outside school. Schools were asked to invite parents at school for an interactive meeting on healthy food, physical activity and the relationship with overweight and health. Three times a year, information on healthy food and physical activity was published in school papers and newsletters for parents. In addition, parents received a free CD with the adult computer-tailored intervention for fat intake and physical activity for use at home. Through an informative folder, parents were informed that their child completed the same computer-tailored programme. They were asked to discuss results together and to give their child support to create a healthier lifestyle, if necessary. / Transtheoretical model and Theory of planned behaviour / Intervention duration of 2 school years (October 2003-June 2005)
Pretest: September 2003
Posttest 1: May - June 2004
Posttest 2: May - June 2005
Hopper 1991
US / RCT with three conditions, one school-and-home condition, one school only condition and one control condition / One 5th and one 6th grade (n=132)
one school-and-home condition (n=45),
one school only condition (n=43),
and one control condition (n=44)
Children mean age: 11.6±0.7
42 parents participated in the S+H condition
Mean age parents: 37.8±6.8 / Rural county, economically depressed area / School only intervention: children were provided with in-class instruction and activities relating to developing healthy nutritional and exercise habits
-  Physical fitness education: children received instruction in physical fitness for three 40-min, in-school sessions per week for 6 weeks. This is taught by regular classroom teachers assisted by an elementary school PE specialist. This were standardized lessons for all classes, with the same number of lessons and same lesson content for all classes. Content was based on the Superkids-Superfit program. All programs combined concepts and activities, f.e. children were taught about pulse rate and implications for fitness while participating in activities. Activities emphasized cardiovascular fitness, flexibility and muscular endurance. The content of the program included non competitive games, educational gymnastics, dance and rhythmic activities, low organizational games, gymnastics stunts, and fundamental movement skills. The following concepts were included during the I: warm-up and cool-down, counting the pulse, threshold of training, calories expended in exercise, evaluating cardiovascular fitness, aerobic and anaerobic exercise, strength and flexibility evaluation, determination of desirable body weight, sports for physical fitness, and contraindicated exercises.
-  Nutrition education: two 30 min in-school sessions per week for 6 weeks (same content and instructions for both groups), taught by regular classroom teacher and assisted by a nutrition education specialist. Main focus of curriculum was reducing saturated fat, but also the following topics were included: preparing snacks using fruits and vegetables, preparing heart-healthy meals (reducing sugar, salt, saturated fat, and cholesterol), reading food labels, and eating high fiber foods, meat alternatives, and high energy foods. Methods used were hands-on preparation, films, games, group discussion, and role-playing designed to encourage the use of heart healthy foods. Food choices were designated as everyday foods or sometimes foods. Students were taught specific concepts relating to nutrition and its influence on cardiovascular disease, as well as how to discuss nutritional topics at home with their parents and how eating habits could be improved within the family.
Home+school intervention: same school intervention + parents were asked to participate by engaging in specific nutritional and exercise activities at home with their family as a home team.
-  Family exercise and nutrition: each week children were given packets to take home and read with their families in order to learn together about healthy nutrition and exercise habits. Families received directions for preparing healthy foods and completing exercise activities as a family. The packets provided guidelines for setting eating and exercise goals and developing healthy nutrition and exercise habits through activities and games. For the family to receive points, activities had to be completed jointly by one home team member and he child. Each week family members completed the scorecard, and the children returned the scorecard to school where teachers recorded each family’s points. Because of the limitations of self-report measures, both children and parents need to sign the card. If parents did not send a scorecard, a follow-up phone call was made. A point goal was given each week for both exercise and nutrition activities. All participating family members received a T-shirt. Family teams received weekly points for completing nutrition activities such as following recipes, setting nutritional goals, and distinguishing between everyday (low in fat) and sometimes (high in fat) foods. They also received points for completing exercise activities in accordance with Cooper’s system, more point for aerobic activities. Stickers and other rewards were also presented weekly, contingent on family participation (Children received stickers every time they handed in their scorecard on Mondays and received a balloon if they reached the point target). Weekly brochures were sent home with the children with information and suggested activities for family members to do together, along with systematic reinforcements provided in the school contingent on a family’s completion of activities at home. All participating families received a certificate and a door prize